9051"":'.:"APPLICANT TO FILL IN INFORMATI N WITHIN RED LINES - USE BALL•*POINT PEN ONLY
BUILnING PROJECT IDENTI FICAT' 'I PERMITNUMBER
5 D - - ' APPLICATION & PER--.r 9051
J1y���('' BUILDING- ELECTRICAL-PLUMBING-MECHANICAL
DWNE B ��J ' ,1 ':hS "> ;' • ':r< ,, PLAN CHECK VALIDATION
NAME
QTY. ;T ELECTRIC PxERMITs�tPsk
PHONE L1 L L. _
CONTRACTOR'Ss- UTLETS-SWITCHES-•RECEP 10.00/1.00
NAME
(� Q (L)' uc.No. '��� $OLIGHTING FIXTURES 10.00/1.00 /
f.ONTRACTOmS 1��� PP LIANCES-RESIDENTIAL 4.00
AOORESa I' lh'
S rm'�CK-PHONE E(41p - I PANELS 10.00 DATE OF APPLICATION
ARCHITECT PANELS (OVER 200 AMP) 20,00 PLAN CHECK FEE P.C.NO.
on
ENGINEE
JCIVI kiC.No. '�Zl �' SIGNS TRANS. 3.00
ARC
ENG. 5.00 PEEFWjT VALIDATION
AOORIR5,�) - SPECIAL CIRCUIT PAID gD _
`Y IB Irk? - o ZIPCl'U� EMP.METER OR POLE INS. 20.00 rAl
APPLICANT'S - MOTORS SEE FEE SCH.ADDRESS f^1 �r+
'�
SERVICE CHANGE 20.00 /1UU C �.a
W¢O O LICENSED CONTRACTORS DECLARATION TEMP.POLE 30.00 .�Iky I�f CDDe1 lIIIO
U
u I hereby affirm That I am licensed under provisions of Chap6•r 9 ! I BUANCE DATE
a 4 ik (commencing with Section 7000)of Division 3 of the Business and QLDG ELECT. PLG. ECH.
s-N z Professions Code,aiHl my license is in full forcc. fMkiG L_.
0 n G License V Lic.Number JL / ✓
Dalelj` Contractor
_ 2 a BUILDING ERMIT-i";,M,'
¢ "ls ¢ OWNER-BUILDER DECLARATION aT.'h''°
Ie w U REFER TO ORO IN FO %> fe;
I hereby affirm that l am exempt from the Contractor's License MISC.- VALUATION g/FT,
coo¢ Law for the following reason.(Sec.703 L5,Businessland Pml'ussions PERMIT ISSUANCE 10.00
- - Code:Any city or county which requires a permit to construct,alter, / 0
Y w Q G improve,demolish,or repair any structure,prior to its issuance•,also ELEC.CONTR. LIC.NO. ELEC.
DLL requires the applicant for such permit to file a signed statement that TOTAL / PERMIT TO
' 12
um Ile is licensed pursuant to the provisions of the Contractors License ., /
'i La. Chapler9(commencingwith Section 7000)of Division 3 of the v
¢ Business and Professions Code)or Ilial he is exempt therefrom and OTY. ' PLUMBING PERMIT-`,.'.=i;';�?:�` ' FEE,-!.
W r$ the basis for the alleged exemption.Any violation of Section 7031.5 STORI TYPE CONSTR.
w. by any applicant for A permit subjects the applicant tuacivil penaly ALTER-DRAIN -WATER IEA.) 5.00
clam more than five hundred dollars(5500).1:
❑ I,as owner of the properly,or my employees with wages asBACK FLOW PROTECT.DEVICE 4.00 OCC.GROUP RE . 5
their sole compensation,will do the work,and the structure is not
intended or offered for sale (Sac 7044, Business and Professions DRAINS-FLOOR,ROOF,AREA,COND. 5.00
Code:The Contractor's License Law does not apply to an owner of �y
property who builds or improves thereon,and who does such wok 1 6 FIXTURES-PER TRAP 5.00 4 g0,IFT.FLOOR AREA Tor LACPEAGE
himself err through his own employees,provided that such improve.
ments are not intended or offered for sale.If,however,the building 2GAS-EA.SYSTEM•1 (NC.40UTLETS 6.00
or improvement is sold within one year of completion,the owner- GAS,EA.SYSTEM-OVER 4 IEA.1 2.00 Buaowc USE
builder will have the burden of proving that he did not build or int- IND CON PB Omar
prove for purpose ofsale.L INDUSTRIAL WASTE INTER. 30.00
❑ 1,as owner of the property,am exclusively contracting Willi El El 11 ❑
licensed contractors to construct the project(Sea 7044,Business LAWN SPRINKLERS-1 INC 5 V.B. 6.00 ASSESSORS PARCEL NO.
and Professions Code 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 J S-C - O sf_VU
the Contractor',
ons forsuch licensed pursuant to SEWER-SAN ITARY•STORM EA.200ft/10.00
the Contractors s License Law. T ACT NO. PARCEL NO.
❑ tem exempt under Sec. ,B.gsP.C.for thin WATER HEATER W/VENT 6.00
reason
Owner Date WATER SYSTEM 5.064
0 ACC.DATE ACC.FILE NO.
WORK ERS'COMPENSATION DECLARATION WATER TREATING EQUIP. 5.00
1 hereby afltrm Dna[I have a certificme of consent to self-insure. ZONING ENG.SITE NO.
or a certificate of Workers Compensation Insurance,or a certified
copy thereof l Sec.3800,Lab.C.)• I�FS'C7
Policy No. Company
O Certified copy Is hereby furnished. FIRE SPRINK ENERGY TN
Z Z C nifse copy s f d with the city inspection division. MISC.• REFER TO ORD.
0 Ap icnnIN�J Y ❑ Rol Y ❑ No
~ res PERMIT ISSUANCE 10.00 FLOOD ZONE A.L.U.C.
LU CERTIFICATEOFKATIO('INS FROM WORKERS'
W � COMPENSATION INSURANCE PLG.CONTR. LIC ND. PLG.
Z (This section need not be completed if the permit is lin one TOTAL Y ElN❑ Y 11N❑
hundred dollars(SIOO)or less.) - -
Q O I certify that in the performant ce of the work for which this per. OTY. MECHANICAL PERMIT•" FEE ''"s" FEE SUMMARYa.,:;1 r'
U. mit is issued,I shall not employ any person in any manner so as to ry
U become subject to the Workers'Compensation Laws of Culilbrnia.
0 a Date Applicant •� ALTER OR ADD TO MECH. 5.00 BUILDING r
} N NOTICE TO APPLICANT: If,after making this Certificate of Ex.
F. ? emption,you should become subject to the Workers'Compensation - APPLIANCE 5.00 PLAN CHECK
provisions of the tabor Code, you must forthwith comply with FEE
U such provisions or this permit shall be deemed revoked. AIR HANDLING UNIT(TO 1OXOCF.M.) 4.00
CONSTRUCTION LENDING AGENCY AIR HANDLING UNIT(OVER 10j=C.F.M.I 6.00 SEISMIC FEE r •
I hereby affirm that there is a construction lending agency for EXHAUST HOOD(WITH DUCT) 5.00 /
the performance of the work I'or which this permit is issued(Sec. MICROFILM
3097,Civ.C.1. : HEATING UNIT(TO 100,000 B.T.U.) 8.00
Lender's Name P+_ n1
Lender's Addrcav Win^ OE 11 ` HEATING UNIT(OVER 100,000 B.T.U.19.50 ELECTRIC
I certify that I have read this application and stale[hat the above VENTILATION FAN (SINGLE) 4.00
information is correct.1 agree to comply with all city and county PLUMBING
ordinances and state laws relating to building construction, and BOILER-COMM21H.P.or 100,000B.T.U.) 6.00
hereby authorize representatives of this city to carer upon Die BOILER-COMP (Dwr 100,000 BTU(SEE FEE SON. MECHANICAL
L . above-mentioned property for inspection purposes.
(We) agree [o save, indemnify and keep harmless the City of MISC.- REFER TO ORD. rA tr
Cupertino against liabilities,judgments, costs and expenses which PERMIT ISSUANCE 10.00 CONST.TAX V�
may in any way accrue against Said City in consequence of the
granting o is penni[. /'� MECH.CONT. LIC.NO. MECH.
_ a.., S/A _ TOTAL TOTACIntCIq
Sig re of Appliyant Contractor Date �/�'•
OFFICE COPY
POST THIS CARD NEAR FRONT OF BUILDING
PfNA97 NUMBER
CITY- 3F CUPERTINO' �a �
INSPECTION DIVISION 905
JOB INSPECTION RECORD
-�! PERMIT EXPIRATION
JOB ADDRESS PontC/v UNIT# LOT#
PERMIT EXPIRES IF WORK
b6fw
OWNER CONTRACTOR ' IS NOT STARTED WITHIN
INSPECTION DATE INSPECTOR INSPECTION RECORD AN DAYS DF PERMIT
FOUNDATION _�,b V LASTCA 180 DAYS FROM
LASTALLEDINSPECTION.
UFER
PR EGUNITE PEpgr�y�ipATION
yam- 1 �-13-Xb l��u
POUR NO CONCRETE UNTIL ABOVE HAS BE N SIGNED AUG
UNDERGROUND /SLAB
PLUMBING City of CuDertiDo
ELECTRICAL ISSUANCE DATE
SLOG. ELECT. PLG. MECH.
MECHANICAL
DO NOT POUR FLOOR UNTIL ABOVE HAS BEEN SIGNED B I D ND IT
NFORMATION
WOOD FLOOR VALUATION S/FT.
PLUMBING -7/-
MECHANICAL 7—J _ ,
'PERMIT TO
ELECTRICAL _
FRAMING -2.(-
BTORIES.l: VPE CONSTR.
INSUL ION
OCC GROUP RES UNITS
wi
PLACE NO SUBFLOORUNTIL ABDVE HAS BE N SIGNED '
SO.FT.FLOORAREA TOTALACREAGE
e� ROOF
DIAPHRAGM 3-
BUILDING USE
. RES IND CON PB Omer I
APPLY NO ROOFING UNTIL ABOVE HAS BEEN SIGNED ❑ ❑ ❑ 13
ROUGH
ASSESSORS PARCEL NO.
�
PLUMBING
TRACT NO. PARCEL NO
GAS TESTS&61
U I
MECHANICAL iuw
ELECTRICAL - G FINALS DATE INSP. ACC.DATE ACC FILE NO. _
FRAMING — —k7SAN # �� ZONING ENG.SITE NO.
INSULATION PLUMBING
GAS
FIRE SPRINK ENERGY T 24
MECHANICAL Y � NE] Y � NE]COVER NO WORK UNTIL A OV9 HAS BEEN SIGNED HEATING
LONE A.L.u.c.
LATH-INTERIOR .Z. ELECTRICAL _ C-,!r7 FooD z
Yo NFj Y 0 NE]
LATH-EXTE R+OR FIRE DEPT.
SHEETROCK GRADE FEE SUMMARY
SHEAR INTERIOR BUILDING BUILDING
SHEAR EXTERIOR p— TEMPORARY APPROVAL
FIREWALLS -$-F( ELECTRIC PLAN CHECK
FEE
GAS
NO TAPE OR PLASTER UNTIL ABOVE HAS BEEN SIGNED occuPANcv SEISMIC FEE
OCCUPANCYOF BUILDING IS NOT PERMITTED UNTIL BUILDING FINAL ISSIGNED BY BUILDING INSPECTOR. MICROFILM
ARRANGE FOR INSPECTION BY PHONING 252-4505, ELECTRIC
0O
ONE WORKING DAY BEFORE REQUIRED INSPECTION. PLUMBING
Z PLEASE GIVE JOB ADDRESS WHEN PHONING.
— SEE PERMIT FOR EXPIRATION DATE — MECHANICAL
IMPORTANT! CONST.TAX
PLEASE READ REVERSE SIDE BEFORE TOTAL
CALLING FOR FINAL INSPECTION.
OFFICE COPY