11740 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
BUI LDItG PROJECT IDENTIFICATION - PERMIT NUMBER
BUILDING' q � QSI"�-f-e� APPLICATION & PERMIT
OR
C. ` T),\ BUILDING-ELECTRICAL-PLUMBING-MECHANICAL 11740
OWNER'5 \ PLAN CHECK VALIDATION
G NAME QTY. ELECTRIC PERMIT FEE
E
CONTRACTORS OUTLETS-SWITCHES-RECEP 10.00/1.00
&ME � p
4Frr_O LIC. .37 .J Yc) LIGHTING FIXTURES 10.00/1.00
CONTRACTOR'S ^ 140 PPLIANCES-RESIDENTIAL 4.00
xp
q J I \TPHONga( � / C PANELS 10.00 DATE OF APPLICATION
ARCHITECT PANELS (OVER 200 AMP) 20.00 PLAN CHECK FEE P.C.NO.
OR
ENGINEER
LIC.No. SIGNS TRANS. 3.00
AT CH
OR ENG. SPECIALCIRCUIT 5.00 PERMIT VALIDATION
ADDESS
ZIP EMP.METER OR POLE INS. 20.00 Oe
AvvucANrs MOTORS SEE FEE SCH. G
ADDRESS ggqU
SERVICE CHANGE 20.00 lY�' 0/ y
woo LICENSED CONTRACTORS DECLARATION VV I/ ,Yye{l1pp
a v w I hereby affirm that 1 am licensed under provisions of Chapter') •l.r 1&eArn DAT
y (commencing with Section 7000)of Division 3 of the Business and
Professions Code,a ul my Urn.is in full ful
¢ m S�'.l
II ELECT. PLG. MECH.
F N z 'FsapI ( ❑' ❑ ❑ ❑
Z O w Licen Lie.Num
I
o w la- Date b Comracto
a r f BUILDING PERMIT
¢ ¢ ¢ OWNER-BUILDER DECLARATION
A o a v INFORMATION
w 3 r 1 hereby affirm that I am exempt from the Contractor's License MISC.- REFER TO ORD
HLL0 Law for the following reason.(Sec.7031.5,Businessand Professions PERMIT ISSUANCE 10.00 VALUATION g/FT.
Vs Code:Any city or county which requires permit to construct,alter, y
p R 4 D improve,demolish,or repair any structure,prior to ds issuance,also ELEC.CONTR. LIC.NO. ELEC.
O u requires the applicant for such permit m lite a signed statement that TOTAL PERMIT T
a. K
m he is licensed pursuant to the provisions of the Contractor's License V5�)_
H z a Law(Chapter 9(commencing with Section 7000)of Division 3 of(he �il/Tt7La v,e / �[19��
f 4 O Business and Professions Code)or that he is exempt therefrom and QTY. PLUMBING PERMIT FEE
ce H$ the basis lot the alleged exemption.Any violation of Section 7031.5 STORIES TYPE CONSTR.
nI-- by any applicant far a permit subjects the applicant o a civil penalty ALTER-DRAIN -WATER IEA.) 5.00
of not more than five hundred dollars(55001.1:
❑ I,as owner of the property,or my employees with wages as BACK FLOW PROTECT.DEVICE 4.00
their sole compensation,will do the work,and the structure is not OCC.GROUP RES.UNITS
intended or offered for sale (Sec. 7044, Business and Professions DRAINS-FLOOR,ROOF,AR EA,COND. 5.00
Code:The Contractor's License Law does not apply to an owner of
. property who builds or improves Dlercon,and who does such work F I XTUR ES-PER TRAP 5.00 SO.FT.FLOOR AREA TOTAL ACREAGE
himself or through his own employees,provided that such improve-
mentsarenotintendedoroll'ered for sale.If,however,the building GAS-EA.SYSTEM-1INC.4 OUTLETS 6.00
or improvement is sold within one year of completion,the owner- GAS-EA.SYSTEM-OVER 4 (EA.) 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
❑ I,as owner of the property,am exclusively contracting with
licensed contractors to construct lie project IS,,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
contracts for such projects with a contractors)licensed pursuant to
the Contractor's License Law. SEWER-SANITARY-STORM EA.200ft/10.00 TRACT NO. PARCEL NO.
O lam exempt under Sec.-,BAP.C.for this WATER HEATER W/VENT 6.00
reason
Owner Date WATER SYSTEM 5.00 ACC.DATE ACC FILE NO.
WORKF.RS'COMPENSATION DECLARATION WATER TREATING EQUIP. 5.00
1 bei-ch,affirm that 1 have a ecrtificateafeonsunt to self-insure.
or a certificate of Workers'Compensation sera ser a certified ZONING ENG.SITE NO.
74 copy thereof(Sec.3800,Lab.CQ>�4�1 N I
Policy No. Companys
(] ❑ fed co00RyyY is hereby furnisI d FIRE SPRINK ENERGY T 29
Z 2 H d (oy.y 'is fled ttt city inspection division.
!- O APNe et ems` MISC.- REFER TO ORD. Y [:] N( v ❑ NF]
y CERTIFICATE OF EXEMPTION FROM WORKERS' PERMIT ISSUANCE 10.00 FLOOD ZONE A.L.U.C.
LU > COMPENSATION INSURANC17 PLG.CONTR. LIC.NO. PLG.'
CL Q (This section need no[ be completed if the permit is for one TOTAL Y[:] N Y[:] N❑
� Z hundred dollars($100)or be
U O 1 certify that in the performance of the work for which this per- CITY MECHANICAL PERMIT FEE FEE SUMMARY
LL l- mit is issued,I shall not employ any person in any manner so as to
O W become subject to the Workers'Compensation Laws of California.
n Date Applicata ALTER OR ADD TO MECH. 5 00 BUILDING ��
T:
} (0 NOTIC17 'f0 APPLICANT: It,after making this Certificate of E.-
emption,you should become subject to the Workers'Compensation APPLIANCE 5.00 PLAN CHECK
provisions of the Labor Code, you must forthwith comply with
C7 such provisions or this permit shall be deemed revoked. AIR HANDLING UNIT(TO 10,000C.F.M.) 4.00 FEE
CONSTRUCTION LENDING AGENCY AIR HANDLING UNIT(OVER IQOOOC.F.M.) 6.00 SEISMIC FEE �O
I hereby affirm that there is a construction lending agency I'or EXHAUST HOOD(WITH DUCT) 5.00
the performance of the work for which this permit is issued(Sec.
3097,Civ.C.). HEATING UNIT(TO 100,000 B.T.U.) 8.00 MICROFILM
Lender's Name
Lender's Address HEATING UNIT(OVER 100,000 B.T.U.)9.50 ELECTRIC
1 certily hall have read this application and state that the above VENTILATION FAN (SINGLE) 4.00
information is correct. 1 agree to comply with allcity and county PLUMBING
ordinances and state laws relating to building construction, and BOILER-COMP13 H.P.or 100,000 B.T.U.1 6.00
.,by authorize representatives of this city to enter upon the BOILER-COMP (Over 100,000 BTUI SEE FEE SCH. MECHANICAL
a ve-mentioned property for inspection purposes.
( e) agree to save, indemnify and keep harmless the City of MISC.- REFER TO ORD.
C p rtino reinst liabilities,judgments, costs and expenses which PERMIT ISSUANCE 10.00 CONST.TAX
m in an way accrue against said City in consequence of the
gr t' g of penniL Q' '� / /meq MECH.CONT. LIC.N0. MECH.
G �' 6 TOTAL TOTAL
nature of pplicant/Contractor Date ♦i
OFFICE COPY
POST THIS CARD NEAR FRONT OF BUILDING
PFRMIF NUMBER
CITY OF CUPERTINO 11 ' 40
INSPECTION DIVISION
JOB INSPECTION RECORD
I Io // /��X"7_ / '\ PERMIT EXPIRATION
JOB ADDR ESS Iowa y1L 6% '��i IF`(J/'!^y ' �U tk LOT# •
' �I- PERMIT EXPIRES IF WORK
OWNER CONTRACTOR IS NOT STARTED WITHIN
INSPECTION DATE INSPECTOR INSP CTI N CORD 180 DAYS OF PERMIT ISSU-
FOUNDATION I�-16-+(Ib SJ 0 L� ANCE OR 180 DAYS FROM
LIFER
LAST CALLED INSPECTION.
PREGUNITE PERMIT VALIDATION
POUR NO CONCRETE UNTIL ABOVE HAS BEEN SIGNED J�
PLUMBING
UNDERGROUND /SLAB
ELECTRICAL
ISSUANCE DATE
MECHANICAL BLDG. ELECT. PLG. MECH,
1:1El ❑
DO NOT POUR FLOOR UNTIL ABOVE HAS BEEN SIGNED BUILDING PERMIT
WOOD FLOOR INFORMATION
VA(JATIr $IRT.
U
PLUMBING Cl
MECHANICAL
ELECTRICAL' PERMIT TO jJ
FRAMING �/ e%z J
INSULATION STORIES TYPE CONSTR.
OCC.GROUP RES.UNITS
_ PLACE NO SUBFLOOR UNTIL ABOVE HAS BEEN SIGNED
S ROOF SO.FT.FLOOR AREA TOTAL ACREAGE
DIAPHRAGM
fiuILD usE
' RES IND CON
PB Go..,
APPLY NO ROOFING UNTIL ABOVE HAS BEEN SIGNED ❑ ❑ ❑ 1:1ASSESSORSPAHCEL NO.
ROUGH
PLUMBING
GAS TEST TRACT No. PARCEL NO,
MECHANICAL
ELECTRICAL FINAL DATE INSP. ACC.DATE Acc.FILE No.
FRAMING I I-,21-� V SAN #
INSULATION PLUMBING - ZONING ENG.SITE NO.
GAS
MECHANICAL EFIRE SPRINK ENERGY T 24
COVER NO WORK UNTIL ABOVE HAS BEEN SIGNED HEATIN ❑ N❑ Y ❑ N❑LATH-INTERIOR ELEVT. .
100020NE A.L.uc.
LATH-EXTERIOR FIR ❑ N❑ Y ❑ N❑
SHEETROCK GRA
FEE SUMMARY
SHEAR INTERIOR BUI SSHEAR EXTERIOR APPROVALS BUILDING
FIREWALLS - ELECTRIC PLAN CHECK.
GAS FEE
NO TAPE OR PLASTER UNTIL ABOVE HAS BEEN SIGNED JOCCUPANCY SEISMIC FEE
OCCUPANCYOF BUILDING ISNOTPERMITTED UNTILBUILDING FINALISSIGNED BY BUILDING INSPECTOR, MICROFILM
ARRANGE FOR INSPECTION BYPHONING 252-4505, , .,; ELECTRIC .
z ONE WORKING DAY BEFORE REQUIRED INSPECTION. PLUMBING
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