11908 ' -APPLICANT TO'FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
BUILDING PROJECT IDENTIFICATION PERMIT NUMBER
/ EDLOIss APPLICATION & PERMIT ^ ^ 8
r LL � l' 9 BUILDING - ELECTRICAL-PLUMBING-MECHANICAL I I `J'
119.1 1 PLAN CHECK VALIDATION
NAME OTY. ELECTRIC PERMIT ' FEE /O�1
�Ir JM I G a PHONE f0
CONTRACTORS
NAME uµ UTLETS-SWITCHES•RECEP 10.00/1.00
LIC.NO.2 C' • LIGHTING FIXTURES 10.00/1.00
CONTRACTORS '� (+ PPLIANCES-RESIDENTIAL 4.00
-ADDRESS f"l1 IJ J�� �"/
112, ( f J&..NE PANELS 10.00 DATE OF APPLICATION
ARLNrtwT - PANELS (OVER 200 AMP) 2000 PLAN CHECK FEE P.C.NO.
OR
ENGINEER ,��••r-�
1® �t Ic.No. 'L�,U,-7 SIGNS TRANS. 3.00
ARCH.OR ENG. SPECIALCIRCUIT - 5.00 PERMIT VALIDATION
-ADDRESS
2( sQ)yr-neiLu, VC EMP.METER OR POLE INS. 20.00
ASMOTORS ' SEE FEE SCH.
ADDREOREAS
2SOf RiIli+ 3JF ` OD SERVICE CHANGE 20.00 . O v
Dietz LICENSED CONTRACTORS DECLARATION (!s�11nQ1 �0
a u u I hereby affirm that I am licensed under provisions of Chaplet 9 Of YSSUANCE DATE
N Q w (Commencing with Section 70001 of Division 3 o(the Busipnesspnd BLDG. ELECT. PLG. MECH.
H y z rofessions Cod and license is in full f e f 1. j
0 o u, License e 1 Lic.Number) -�A�! ❑ ❑ ❑ ❑
g ate Contractor
y a BUILDING PERMIT
a'w OWNER-BUILDER DECLARATION INFORMATION
soA MISC.- REFER TO ORD
to ; y I hereby affirm that 1 am exempt from the Contract ors License VALUATION
u m J Law far the following reason.(Sec.7031.5,Business and Professions PERMIT ISSUANCE 10.00 eJU S/FT.
~ ,4 Code:Any city or county which requiresa permit to construct,alter,
Q Q Q improve,demolish,or repair any structure,prior to Its issuance,also ELEC.CONTR. LIC.NO. ELEC. 7
DLL requires the applicant for such permit to file a signed statement that TOTAL
n PERMIT TO
w he is licensed pursuant to the provisions of the Contractor's License
rzi Law(Chapter9(commencing with Setlion 7000)of Division 3ofthe a[.OG•\ Gt/A-LL
f 4 c Business and Professions Code)or that he is exempt therefrom and OTY. PLUMBING PERMIT FEE
M f the basis for the alleged exemption.Any violation o(Section 7031.5 STORIES TYPE CONSTR.
by any applicant for a permit subjects the applicant to a civil penally
ALTER-DRAIN&VENT-WATER (EA.) 5.00
ofnot more than five hundred dollars(S500).):
❑ 1,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,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 F IXTUR ES-PER TRAP 5.00 SO.FT.FLOOR ARE-A TOTAL-ACREAGE
himself or through his own employees,provided that such improve- GAS-EA.SVSTEM-11NC.40UTLETS 6.00
menta are not intended or offend for sale.If.however,the building
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 im• 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 the project(Sec.7044,Business LAWN SPRINKLERS-1 INC 5 V.B. 6.00 ASSESSORS PARCEL NO.
and Professions Code:The Contractor's License Law docs not apply
to an owner of property who builds or improves thereon,and who LAWN SPRINKLERS-OVER 5(EA.) 1.00
contracts foroar's h License
with a contractor(s)licenv:d pursuant to SEWER-SANITARY-STORM EA.200ft/10,00 TRACT NO. PARCEL NO.
the Contractor's License Law:
'❑ lam exempt under Sec.-,B.&P.C.For this WATER HEATER W/VENT 6.00
reason
Owner Date WATER SYSTEM 5.00
ACC.DATE ACC.FILE NO.
WORKERS'COMPENSATION DECLARATION WATER TREATING.EQUIP. 5.00
I hereby affirm that I have a certificate of c.nSent to self-insure,
Or a certificate c F Workers'a C.-pens 'on Insurani l ZONING ENG.SITE N0.
copy thereof(Sec.3800,Lan
Policy No. Compun
O ❑ Certified Co y' her Tums c FIRE SPRINK ENERGY T-24
Z Z ❑ CertaIt rs d w' re nspech drviSion. MISC.• REFER TO ORD.
O/ Applican'I Y ❑ N❑ Y ❑ No
F' in PERMIT ISSUANCE 10.00
-
CERTIFICATEOFEXEMPTION PROM WORKERS' FLOOD ZONE A.L.U.C.
aQ COMPENSATION INSURANCE PLG.CONTR., LIC.NO. TPL
OTAL Y❑ N❑ Y❑ N❑
(This dollars
need not he completed if the permit is for one
' D Z hundred dollars($100)or lase,)
U O 1 certify that in the performance of the work for which this par. OTY. MECHANICAL PERMIT FEE FEE SUMMARY
LL F mit is issued,1 shall not employ any person in any manner so as to
U become subject to the Workers'Compensation Laws of California.
O w BUILDING 9a
y Date Applicant ALTER OR ADD TO MECH. 5.00
} N NOTICE TO APPLICANT: 1f,after making this rs'Coicote of Ex-
2 emvisionyou should become
e,subject utothe Workers'Compensation APPLIANCE 5.00 PLAN CHECK
provisions io the Labor Cola, you must forthwith comply with FEE
U such provisions Or this permit shall be deemed revoke). AIR HANDLING UNIT(TO 10,000GF.M.) 4.00
CONSTRUCT ION LENDING AGENCY AIR HANDLING UNIT(OVER 10MC.EM.) 6.00 SEISMIC FEE
1 hereby affirm that there is a construction lendingpgency for EXHAUST HOOD(WITH DUCT) 5.00
the performance of the work for which this permit is issued(Sec. MICROFILM
3097,Civ.C.). I HEATING UNIT(TO 100,000 B.T.U.1 8.00
Lender's Name HEATING UNIT(OV ER 100,000 B.T.U.)9.50 ELECTRIC
Lender's Address
I 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 state laws relating to building construction, and BOILER-COW(3 H.P.Or 100,000 B.T.U.1 6.00
hereby authorize representatives of this city to enter upon the BOILER-COMP(Over 100,0008TU)SEE FEE SCH. MECHANICAL
above-mentioned property for inspection purposes.
(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
may in any way accrue against said 'yin consequence of the PERMIT ISSUANCE 10.00
ing o is a MECH.CONT. LIC.N0. MECH.
f TOTAL TOTAL rl3
\v, Signature ofApplicant/Contrctor 1)
/�-' OFFICECOPY �'
i ` POST THIS-CARD NEAR FRONT OF,BUILDING
-CITY OF CUPERTINO RMITND9F08
9
C � ,
INSPECTION DIVISION' .
JOB INSPECTION RECORD
PERMIT EXPIRATION
r , JOB ADDRESS II/.I�I /.�UNIT 4t LOT#'
( PERMIT EXPIRES IF WORK
r OWNER CONTRACTOR AS "NOT,STARTEO WITHIN
M, INSPECTION DATE INSPECTOR INSPECTION RECORR 180 DAYS OF PERMIT ISSU-
FOUNDATION fbixs (- (I-y,3 ,1 vim, ANCE OR 180 OAYS•FROM .
LAST CAL LED INSPECTI ON.
UFER _
- -
PR EGUNITE,° PERMIT VALIDATION
' . � ,.
I POUR NO CONCR TE UNTIL ABOVE HAS BEEN SIGNED
UNDERGROUND /SLAB
PLUMBING
ELECTRICAL - ISSUANCE DATE
MECHANICAL BLDG. ELECT. PLG. MECR.
❑ ❑ ❑ ❑.
00 NOT POUR FLOOR UNTIL ABOVE HAS BEEN SIGNED BUILDING PERMIT
INFORMATION
-WOOD FLOOR - VALUATION $/FT.
PLUMBING Q.V
MECHANICAL 3 y
ELECTRICAL - - JJ •PERMIT To
•FRAMING
INSULATION " - STORIES TYPE CONSTR.
OCC.GROUP RES.UNITS
fiRwA`GE NO SUBFl00R UNTIL ABOVE HAS BEEN SIGNED
ROOF , - SO.FT.FLOOR AREA TOTALACREAGE
DIAPHRAGM
BUILDING USE
., RES IND CON PB Otne, {'
J'APPLW NA ROOFING UNTIL ABOVE HAS BEEN SIGNED ❑ ❑ E) ❑ ❑
ASSESSORS PARCEL NO.
ROUGH '
PLUMBING - '
TRACT NO. PARCEL NO.
GAS TEST •
.MECHANICAL
ELECTRICAL FINALS DATE INSP. ACC.DATE ACC.FILE NO.
FRAMING SAN # ' ZONING ENG,sIrE.No.
INSULATION - PLUMBING
GAS _
• FIRE
MECHANICAL ]. [ ENERGY T 2
�
T, COVER NO WORWUNTIL`ABOVE HAS BEEN SIGNED HEATING y N Y N�
vLooD ZONE A,L.u.c.
LATH—INTERIOR ELECTRICAL
Yo N� 0 N[3LATH—EXTERIOR FIRE DEPT.
SHEETROCK GRADE FEE SUMMARY
SHEAR INTERIOR BUILDING
SHEAR EXTERIOR TEMPORARY APPROVALS BUILDING
FIREWALLS ELECTRIC PLAN CHECK
GAS 1. - FEE
LNO TAPE OR•PLASTER UNTIL ABOVE HAS BEEN SIGNED'' OCCUPANCY. SEISMIC FEE
OCCUPANCY OF BUILDING ISNOTPERMITTED UNtlLBUILDING FINAL ISSIGNED BY BUILDING INSPECTOR. MICROFILM
' t
ARRANGE FOR INSPECTION'BY P=PHONING.
ELECTRIC
LW��L) ONE WORKING DAY BEFORE REQPLUMBING
IO•Y PLEASE GIVEJOB ADDRESS WHEz1SEE PERMIT FOR EXPIRMECHANICAL
IMPORTANT!
CONST.TAX
1 PLEASE READ REVERSE SIDE BEFORE TOTAL
CALLING FOR FINAL INSPECTION.
OFFICE COPY