C8592 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
BUILDING PROJECT. IDENTIFICATION PERMIT NUMBER
BUILDING APPLICATION & PERMIT
ACONCSS z/ 8592
® I /a(A TQ BUILDING-ELECTRICAL-PLUMBING-MECHANICAL
OWNER'S -I
NAME .Z'-k• N CHECK VALIDATION.
-_ - QTY. ELECTRIC PERMIT FEE
1/Ir . I '� ONE
CONTERACTORS UTLETS
-SWITCHES-RECEP 10.00/1.00
Lm.No. ILIGHTING FIXTURES 10.00/1.00
CO
ADS
NTRAS oR's
DRESPPLIANCES-RESIDENTIAL 4.00
PHONE PANELS 10.00 DATE OF APPLICATION
ARRCHITECT PANELS (OVER 200 AMP) 20,00 PLAN CHECK FEE P.C.NO,
O
ENGINEER
LIC,NO, SIGNS TRANS. 3.00
ADDRRESS eNe. SPECIAL CIRCUIT 5.00 PERMIT VALIDATION
ZIP TEMP.METER OR POLE INS. ' 20.00
Ars
ADDRESS MOTORS SEE FEE SCH.
DRESS Ess
SERVICE CHANGE 20.00 S
IS o LICENSED CONTRACTORS DECLARATION TEMP.POLE 30.00 tC �
SI hereby affirm that I am licensed under provisions oC Chapter 9 1S5AE
wIu (commencing with Section 7000)of Division 3 of the Business and
D Professions Code,and
Q vAi my license is in full force and effect. BLDG. ELECT. PLG. ECH.
Z ❑ ❑ ❑
0=O License Class Lia Number
o
0.@ Contracror M
H F J BUILDING PERMIT
a, w OWNER-BUILDER DECLARATION INFORMATION
w ;A.A. H I hereby affirm that I am exempt from the Contractor'%License MISC.- REFER TO ORD
H u O a Law for the following reason.(Sec.7031.5.Businessand Professions PERMIT ISSUANCE 10.00 VALUATION $/FT.
Code:Any city or county which requiresa permit to construct,alter, ) _
Qimprove,demolish,or repair any structure,prior to its issuance,also ELEC.CONTR. LIC.NO. ELEC. / ro
D LL
requires the applicant for such permit t0 file a signed Statement that TOTAL PERMIT TO
a w m he is licensed pursuant to the provisions of the Contractor's License /
HZQ Law(Chapter 9(commencing with Section 7000)oCDivision 3 of the
4 D [justness and Professions Code)or that he is exempt therefrom and QTY. PLUMBING PERMIT FEE
IS t- $ the basis for the alleged exemption.Any violation of Section 7031.5 STORIES TYPE CONSTR.
n ;
by any applicant for a permit subjects the applicant to a civil penalty ALTER-DRAIN -WATER (EA.) 5.00
of not more than five hundred dollars(S50OL L
❑ 1,as owner of the property,or my employees with wages as BACK F LOW PROTECT. DEV ICE 4.00
their sole compensation,will do the work,and the stincome is not OCC.GROUP RES.UNITS
intended or offered for sale (Sec. 7044, Business and Professions DRAINS-FLOOR,ROOF,AREA,COND. 5.00
Code:The Contractor's License Law does not apply to an owner of
property who builds or Improves thereon,and who does such work FIXTURES-PER TRAP 5.00 SO,FT.FLOOR AREA TOTAL ACREAGE
himself or through bis own employees.provided that such improve- ' GAS-EA.SVSTEM-l 6.00
ments are not intended or offered for sale.It,however,the building
or improvement is sold within one year of completion,the owner- GAS-EA.SYSTEM-OVER 4 IEA.) 2.00 -
builder will have the burden of proving that he did not build or int- BUILDING USE
prove for purpose of sale). INDUSTRIAL WASTE INTER. 30.00 RES IND CON PB Other
0 I,as owner of the property,am exclusively contracting with ❑ ❑ ❑ ❑ ❑
' licensed contractors to construct the project(Sec. 7044,Business LAWN SPRINKLERS- I INC 5 V.B. / 6.00 ASSESSORSPARCEL NO.
and Professions Codi The Contractor's License Law does not apply
to an owner of property who builds or improves
thereon,and who LAWN SPRINKLERS-OVER 5(EA.) 1.00
cmitmctsfiusueh projectswith a contractors)licensed pursuant to SEWER V-STORM EA.200ft/10.00
the Contractor's License L.w. TRACT NO. PARCEL NO.
❑ lam exempt under Sec,-,B&P.C.our this WATER HEATER W/VENT 6.00
reason
'lL\ Ower - 1 Dater+ WATER SYSTEM 5.00
IE E ' ACC.DATE ACC.FILE NO.
I W'ORKGRS'COMPEN'SA'IION DECLARATION WATER TREATING EQUIP. 5.00
I I hereby affirm that I have a certificate of consent to sell-insure, ZONING
or a certificate of Workers'Compensation Insurance,or a certified ENG.SITE NO.
copy thercol'(See 3800.Lab.C.).
f Policy No. Company
Q ❑ Certified copy is hereby furnished. FIRE SPRINK ENERGY T 24
z Z O Certified copy is filed with the city inspection division. MISC.- REFER TO ORD.
O Applicant Y ❑ IN Y ❑ N❑
~1 rnPERMIT ISSUANCE 10.00
L) CERI'l l'IGA'1'EE EXEMPTION PROM\PORKERS' FLOOD ZONE A.L.U.C.
W � COMPIiNSAT10N INSURANCE PLG.CONTR. LIC.NO. PLG,
t`t d O (This section need not be completed if the permit is for one TOTAL YE] N Y ❑ IN
D Z ImmE,d do]]...($100)or less.)
L) O 1 certify that in the performance or 11n,work for which this per- QTY. MECHANICAL PERMIT FEE FEE SUMMARY
mit is issued,I shall not employ any person in uny manna.so us N
Q w become subject to tire Worked Compensation Laws oC Calilbrnia.
Date Applicant BUILDING � QT
' } y NOTICE TO APPLICANT: IL after making this Certificate of lis- ALTER OR ADD TO MECH. 5.00
♦- ? emption,you should become subject to Ore Workers'Compensation APPLIANCE 5.00 PLAN CHECK
1 provisions of the Labor Code, you must forthwith comply with FEE
U ' such provisions or this permit shall be deemed revoked. AIR HANDLING UNIT(TO 10MOC.F.M.) 4.00
C'ONS'TRUC'rIONLIaNDINGAGENCY AIR HANDLING UNIT(OVER 10=C.F.M.) 6.00 SEISMIC FEE 'O
I hereby affirm that there is o construction lending.gency I.. EXHAUST HOOD (WITH DUCT) 5.00
the performance of the work for which this permit is issued(Sec. MICROFILM
3097,Civ.C.L HEATING UNIT(TO 100,000 B.T.U.) 8.00
Lender's Name HEATING UNIT(OVER 100;000 B.T.U.)9.50
Lender's Address ELECTRIC
1 certify that 1 have read this application and state that the above VENTILATION FAN (SINGLE) 4.00
information is correct. I agree to comply with all city and county PLUMBING
ordinances and slate laws relating to building construction, and BOILER-CO MP(3H.P.Or100,000B.T.U.) 6.00
hereby authorize representatives o1' this city to cif upon Ih. BOILER-COMP (Over 100,000 BTU)SEE FEE SCH. MECHANICAL
above-menlioncd property for inspection purpose.
(We) agree to save, indemnify and keep harmless the City of MISC.- REFER TO ORD.
Cupertino against liabilities,judgments, costs and expenses which CONST.TAX
n;ay, in $ny' way accrue hist said City in lonseque or of the PERMIT ISSUANCE 10.00
&Wftirig.8ftihi4,permit 3`'I 1� ✓s, 1 f� MECH.CONT. LIC.NO. MECH.
pl TOTAL
TOTAL �� do
Signature oPApplic:mt/ContracldP' Dale`
INSPECTOR COPY
POST THIS CARD NEAR FRONT OF BUILDING
CITY OF CUPERTINO RA,IT NUMBER
INSPECTION DIVISION VJ�
JOB INSPECTION RECORD '
PERMIT EXPIRATION
JOB ADORES UNIT# LOT# J
PERMIT EXPIRES IF WORK
OWNER CONTRACTORMon IS NOT STARTED.WITHIN
INSPECTION DATE INSPECTOR INSPECTION RECORD 180 DAYS OF PERMIT ISSU-
FOUNDATION ' - - ANCE OR 180 DAYS FROM
LAST CALLED INSPECTION.
UFER - -
PREGUNITE PERMIT VALIDATION
POUR NO CONCRETE UNTIL ABOVE HAS BEEN'SIGNED .'
UNDERGROUND /SLAB - �
r.
PLUMBING > , ,
E LECTRICAL .• Is ANCE TE VVV
MECHANICAL BLDG. ,ELECT. -PLG. MECH,
DO NOT POUR FLOOR UNTIL ABOVE HAS BEEN SIGNED - BUILDING PERMIT
INFORMATION
WOOD FLOOR vnwnnoN RIFT:
PLUMBING -
MECHANICAL'
_ PERMIT TO
.ELECTRICAL- -
FRAMING
INSULATION . . - SJOHIE TYPE CONSTH.
' OCG GROUP RES.UNITS
PLACE NO SUBFLOOR UNTIL ABOVE HAS BEEN SIGNED
ROOF , SO.FT.FLUOR AREA - TOTAL ACREAGE
DIAPHRAGM _ ` • RES 'INDUILOCGN USEONer
APPLY NO,ROOFING UNTIL ABOVE HAS BEEN SIGNED - U ❑
AS ESSORSPAHCEI-NO.
ROUGH
PLUMBING - -
_ rRAcr No. PARCEL No.•
GAS TEST
MECHANICAL - - -
ELECTRICAL ' ACC.DATE ACG FILE NO.
FINALS DATE. INSP.
FRAMING SAN # zoNwc ENG.SITE No.
INSULATION ,, - PLUMBING
GAS
FIRE SPRINK ENERGY 1.24
MECHANICAL YE] NE], Y.❑ NF]
COVER NO WORK UNTIL ABOVE HAS BEEN SIGNED HEATING '
LATH—INTERIOR - ELECTRICAL FLOOD ZONE - A-L.0 C.
LATH—EXTERIOR'
FI RE'DEPT. vNO YI] N❑
SHEETROCK - GRADE FEE SUMMARY
SHEAR INTERIOR BUILDING < BUILDING "
SHEAR EXTERIOR - TEMPORARY APPROVALS
FIREWALLS ELECTRIC - PLAN CHECK -A
GAS FEE r
NO TAPE OR PLASTER UNTIL ABOVE HAS BEEN SIGNED OCCUPANCY - SEISMIC.FEE
OCCUPANCYOF BUILDING IS NOT PERMITTED UNTIL BUILDING FINAL ISSIGNED BY BUILDINGINSPECTOR. MICROFILM
ARRANGE FOR INSPECTION BY PHONING 252-4505,
ELECTRIC
V_-ONE WORKING DAY BEFORE REQUIRED INSPECTION. PLUMBING
O PLEASE GIVE JOB ADDRESS WHEN PHONING.
' Z' - - MECHANICAL
—*SEE PERMIT FOR EXPIRATION DATE —
IMPORTANT! consT.TAX
PLEASE READ REVERSE:SIDE BIEFOREL TOTAL
'CALLING FOR FINAL INSPECTION.,
OFFICE COPY - '
APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
tlUl LD1 NG PROJECT I DENTI FICATION PERMIT NUMBER
BUILDING APPLICATION & PERMIT
ADDRESS BUILDING-ELECTRICAL-PLUMBING-MECHANICAL
o N. �'A ra 8592
OWNER'S - qN CHECK VALIDATION
NA E QTY. ELECTRIC PERMIT FEE
ONE JIL CCA
CONTRACTORS UTLETS-SWITCHES-RECEP 10.00/1.00
LIC.No. LIGHTING FIXTURES 10.00/1.00
DRRAcroRS
ADDRESS PPLIANCES-RESIDENTIAL 4.00
AD
PHONE PANELS 10.00 DATE OF APPLICATION
o nnCHIrECi PANELS (OVER 200 AMP) .20.00 PLAN CHECK FEE .C.NO.
ENGINEER
LIC.No SIGNS TRANS. 3.00 '
ADDRESS ENG. SPECIAL CIRCUIT 5,00 PERMIT VALIDATION
Zip TEMP.METER OR POLE INS. 20.00
APPLICANT'S
ADDRESS MOTORS SEE FEE SCH. S
9�5
SERVICE CHANGE 20.00 IF,
woo LICENSED CONTRACTORS DECLARATION TEMP.POLE 30.00 J�
X i w I hereby'affirm that I am licensed under provisions of Chapter 9 ISSUANCE DATE
(commencing with Section 7000)of Division 3 of the Businets and
< a BLDG. ELECT. PLG. MECH.
F w i Professions Code,and my license, in full force and effect ❑ ❑ ❑
z O vs - Date Class Con Numtrcr
O r Date Contractor
x s BUILDING PERMIT
IS OWNER-BUILDER DECLARATION
IS a a, - INFORMATION
ww I hereby affirm that I am exempt from the Contractor i License MISC.- REFER TO ORD
u o a Law for the following reason.(Sec.7031.5,Businessand Professions PERMIT ISSUANCE 10.00 VAwgTI {/FT.
>-t Code:Any cityor county which requiresa permit toconstruct,alroq
Q O improve,demolish,or repair any structure,prior to ns issuance,also ELEC.CONTR. LIC.NQ ELEC.
-O u requLn S the applicant for such permit to File a signed statement that TOTAL
wso$w he is licensed pursuant to the provisions of the Contractors License p(`
Law(Chapter 9(commencing with Section 7000)of Division 3 ofthe V
a Business and Professions Code)or that he is exempt therefrom and QTY. PLUMBING PERMIT FEE
SE I1$ the basis for the alleged exemption.Any violation of Section 7031.5 STOR 01 CUPWfiNTR.
by any applicant to,a permit subjects the applicant toacivil penalty ALTER-DRAIN -WATER IEA.( 5.00
of not more than Five hundred dollars(5500).1:
D 1,as owner of the property,or my employees with wages ns BACK FLOW PROTECT. DEVICE 4.00 DEC.GROUP RES.UNITS
their sole compensation,will do the work,and the structure is not
intended or offered for sale(Sec..7044, Business and Professions DRAINS-FLOOR,ROOF,AREA,COND. 5.00
Code:The Contractor's License Law don not apply to an owner of
property who builds or improves thereon,and who does such work FIXTURES-PER TRAP 5.00 Sp_FT.FLOORAREA TOTALACAEAGE
O himself re of rote de own employers,provided that such ins prove
-
Dents throuhh is oroffered for employeesale.lf,ed that such
building GAS-EA.SVSTEM-11NC.40UTLET$ 6.00
or improvement is sold within one year of completion, - . .) . .00 the owner. GAS EASYSTEM-OVER 4 (EA2
builder will have the burden of proving that he did not build or ins- BUILDING USE
prove for purpose of sale.). INDUSTRIAL WASTE INTER. 30.00 RES IND CON PB Other
❑ I,as owner of the propsny,am exclusively contracting with ❑ ❑ ❑ ❑ ❑
licensed contractors to construct the project(See. 7044,Business LAWN SPRINKLERS-1 INC 5 V.B. 6.00 ASSESSORS PARCEL NO.
and Professions Code:The Contractor',License Law docs not apply
to an owner of property who builds or improves thereon,and who LAWN SPRINKLERS-OVER 5(EA.) 1.00
contacts forsuch projectswith a conraclons)licensed pursuant to SEWER-SANITARYV-STORM EA.200ft/10.00
the Conracloi s License Law. TRACT NO. PARCEL NO.
❑ lam exempt under Sea ,B.&P.C.for this WATER HEATER W/VENT .6.00
reason
Owner Date . 1r�fgTER SV STEM 5.00 - ACC.GATE ACC.FILE N0.
WORK CRS;COMPENSATION DECLARATION - WATER TREATING EQUIP. 5.00
1 hereby affirm that I have a certificate of consent to self-insure, ZONING ENG.SITE NO.
or a certificate of Workers'Compensation Insurance,or a certified
copy thereof(Sec.3800,Lab.C.).
Policy No. Company
O ❑ Certified copy is hereby furnished. FIRE SPRINK ENERGY T 24
Z Z ❑ Certified copy is riled with the city inspection division. MISC- REFER.TO ORD.
O ApplicantV ❑ N❑ Y ❑ N❑
� y CERTIFICAT17 OF EXEMPTION FROM WORKERS' PERMIT ISSUANCE 10.00 FLOODZONE A.L.U.O.
LU > COMPENSATION INSURANCE - PLG.CONTR. LIC.NO. PLG.
CL O (This section med not be completed it the permit is for one TOTAL Y❑ N❑ Y ❑ N❑
Z) Z hundred dollars IS 100)or Im-)
U O I certify that in the performance of the work for which this pe, QTY MECHANICAL PERMIT FEE FEE SUMMARY
LL F mil is issued,1 shall not employ any person in any manner so as to
Ow become subject to the Workers'Compensation Laws of California. BUILDING
Uate Applicant r 6
a ALTER OR ADD,TO MECH. 5.00
} to NOTICE '1'O APPLICANT: If,after making this CeniImcte.1 Ii
emplion,you should become subject to the Workers'Compensation APPLIANCE 5.00 PLAN CHECK
provisions of the tabor Code, you most forthwith comply with FEE (p
U such provisions or this permit shall be deemed revoked. AIR HANDLING UNIT(TO 10=471F.NL) 4.00 -�
CONSTRUCTION LENDING AGENCY AIR HANDLING UNIT(OVER 10MC.F.M.) 6.00 SEISMIC FEE S�
I hereby affirm that there is a construction lending agency for EXHAUST HOOD (WITH DUCT) 5.00
the er ore ance of(he work fonMICROFILM
which this permit is issued(Sec. HEATING UNIT(TO 100,000 B.T.U.) 8.00
Name
Lender's Add Name
Lender's NHEATI NG UN IT(OVER 100,000 B.T.U.)9.50 ELECTRIC - '
I certify that I have read this application andstar that the above VENTILATION FAN (SINGLE) 4.00
information is correct. I agree to comply with all city and county PLUMBING
ordimmces and state laws relating to building construction, and BOILER-713(H P.or 100,000 B.T.
U.) 6.00
hereby authorize representatives of this city to enter upon the g01 LE R-COMP(Com,100,000 BTU)SEE FEE SCH. MECHANICAL
above-mentioned progeny for inspection purp"H
(We) agree to save, indemnify and keep harmless the City of MISC.- REFER TO ORD.
,44"Iia ,judgments, co is nJ peaces which PERMIT ISSUANCE 10.00 CONST.TAX
arc i®sCilyST cure of the
, aG l MECR.CONT. LIC.NO. MECH.
It
b.� g� TOTAL TOTAL /,7 0�
Signa[ of pOBca ontractor Date
OFFICE COPY