17414 (2) fi;APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
BU I LDI NG PROJECT I DENTI FICATION APPLICATION & PERMIT PERMIT NUMBER
}✓�� SoLDING A
Li.I'I ADDRESS �}
80
FJ. D BUILDING-ELECTRICAL-PLUMBING-MECHANICAL
it NAME ✓A 1 tzw PLAN CHECK VALIDATION
IrG .r IsWgbPHONNAL. TV. ELECTRIC PERMIT FEE '
IuIoMAFARAcrons OUTLETS-SWITCHES-RECEP 10.00/1.00 I,C
I-J`k T LIc.NO. LIGHTING FIXTURES 10.00/1.00
CONTRACTOR'S - FAI0
ADDRESS \I,f 818 G PPLIANCES-RESIDENTIAL 4.00
I7504. . �1I�/,I}��1A Fye ONE ✓- PANELS 10.00 DATE OF APPLICATION
ENCR ERr /cam 9i50�, PLAN CHECK FEE P.C.NO.
PANELS IDV ER 200 AMP) 20.00
SIGNS TRANS. 3.00
ADDRRESS ENG. SPECIALCIRCUIT' 5.00 PE IIOnNr�.
ZIP EMP.METER OR POLE INS. 20.00 �`I ILII T io w1c,
ADDRESS MOTORS SEE FEE SCH. Y A i'ra Pf.`R7J
ADDRESS JI
SERVICE CHANGE 20.00
O ¢ i
.02 ICE-NSED CONTRACTORS DECLARATION sf '1�``l yrs. •I
ac u
,w I hereby affirm that I am licensed under provisions of Chapter 9
w <y (conmlencmg with Section 7000)of Division 3 of the Business and I66UANCE DATE
• BLDG. ELECT., PLG. MECH.
H °z Professions C Qe nd license is in full for a LD ® ❑ ❑
z O - License Class Lia Numbe
4 y r w UatcCnntmctar
M M ¢ a OWNER-BUILD 7R DEC' RATION S[,evK BUILDING PERMIT
w ° 'O MISC.- REFER TO ORD INFORMATION
3 U. F I hereby affirm that I am exempt from the Contractor's License VALUATION - $/FT.
F u N 4 Law for the following reason.(Sec.7031.5,Businessand ProfessionI PERMIT ISSUANCE 12
Code:Any city or county which requires permit reconstruct,site,
QQer improve,demolish.or repair any structure,prior to its Issuance,alsoLEG.CONTR. LIC.NO. ELEC. 1�T�J
° requires the applicant for such permit to file a signed statement that
w u$w he is licensed pursuant to the provisions of the Contractors TOTAL License PERMIT TO
zQ
Law(Chapter 9(conmencing with Section 7000)ofDivision 3 ofthe /-J ( I
4 ° Business and Professions Code)or that he is exempt therefrom and DTV. PLUMBING PERMIT FEE vl
W F$ the basis for the alleged exemption.Any violation Uf$ection 7031.5 STORIES TYPE CONSTR.
by any applicant for a permit subjects the applicant to acivil penalty ALTER-DRAIN IEA.) 5.00
of not more than five hundred dollars(S500 -
).): -
❑ I,as owner of the property,or my employees with wages as BACK FLOW PROTECT.DEVICE 4.00 OCC.GROUP RES.UNITS
their sole compensation,will do the work,and the structure is not
intended for offered for sale (See. 7044, Business and Professions DRAINS-FLOOR,ROOF,AREA,COND. 5.00
.. Code:The Contractors License Law does not apply room owner of
YV', property who builds or improves thereon,and who does such work F IXTUR ES-PER TRAP 5.00 S0,FT.FLOOR AREA TOTAL ACREAGE
iii himself or through his own employees,provided that such improve-
yy ments are not intended or offered for sale.If,however,Ole building GAS-EA.SYSTEM-1INC.4 OUTLETS 6.00
} u or improvement is sold within one year of completion,the owner-
�,A builder will have the burden of proving that lie did not build or int- GAS-EA.SYSTEM.-OVER 4 (EA.) 2.00 BUILDING USE
prove for purpose ofsale.). INDUSTRIAL WASTE INTER3000 RES IND CON PB Other
❑ 1: . .
as owner of the property,am exclusively contracting with ❑ ❑ ❑ ❑ ❑
licensed contractors to construct the project(See. 7044,Bismess 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 IEA.) 1.00
contracts for such projects with a conlractods)licensed porsumm In SEWER-SANITARYV-STORM EA.200ft/10.00
lire Contractors License Law. • TRACT NO. PARCEL NO.
❑
e 0 lam exempt uridcr Sec. ,B.&PC.for this WATER HEATER W/VENT 6.00
Owner Date WATER SYSTEM 5,00 ACC.DATE ACC.FILE NO.
'ORKERS'COMPENSATION DECLARATION WATER TREATING EQUIP. 5.00
I hereby affirm that I have a certificate of consent In self-insure,
or a certificate of Workers'Compensation Insurance,or a certified ZONING ENG.SITE NO.
copy thcreo�l�SSSe�,���3'��8""0V� 1,.,t�bpC,
Policy No Cut G1}74' ZCIC tH QrYF,t1cAUZ
Q ❑ Certified copy Is hereby furnished.
z Z ❑ Certified copy is filed with the city inspection division. FIRE SPRINK ENERGY T 24
F O Applicant MISC.- REFER TO ORD. LFLOODZONE
❑ N❑ v [:] N
C ❑
CCERTIFICATE OF EXEMPTION FROM WORKERS' PERMIT ISSUANCE .00 A.L.U.C.
WCOMPENSATION INSURANCE PLG.CONTR. LIC.NO. PLG.
CL O (This section need not be completed if the permit is for one TOTAL ❑ N❑ Y❑ N❑
=) Z hundred dollars(5100)or less.)
U O I certify that in the performance of the work for which this per- OTV MECHANICAL PERMIT FEE I FEE SUMMARY
LL U suit is issued.I shall not employ any person in any manner so as Its
O
become subject to the Workers'Compensation Laws of California.
U-1 Date Applicant ALTER OR ADD TO MECH. 5.00 BUILDING ��
rn NOTICE TO APPLICANT: If,after making this Certificate of Ex-
F 2 emption,you should become subject to the Workers Compensation APPLIANCE 5.00 PLAN CHECK
provisions of the Labor Code, YOU must forthwith comply with FEE
U spch provisions or this permit shall be deemed revoked. AIR HANDLING UNIT(TO 10,ODOC.F.M.) 4.00
CONSTRUCTION L17NDING AGENCY AIR HANDLING UNITIOVER IO,000C.EM.I 6.00 SEISMIC FEE d5
I hereby affirm that there is a construction lending agency for EXHAUST HOOD(WITH DUCT) 5.00
the performance of the work for which this permit is issued(Sec. MICROFILM
3097,Civ C.). HEATING UNIT(TO 100,000 B.T.U.) 8.00
Lender's Name HEATING UNIT ER 100,000 B.T.U.)9.50 ' ELECTRIC
Leader's Atldress �3LZJ
4a' PL-1 certify that I 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 BOILER-COMP(3 H.P.Or 100,000 B.T.U.) 6.00
UMBING
oN inances and state laws relating to building construction, and
hereby authorize representatives of this city to enter upon the BOILER-COMP (Over 100,o00BTU)SEE FEESCH. MECHANICAL
above-mentioned property for inspection purposes.
(We) agree to save, indemnify and keep harmless the City of MISC.- REFER TO ORD.
uperti zgainst liabilities,judgments, costs and expenses whicli PERMIT ISSUANCE CONST.TAX'
may in a way accrue ago' t said City in consequence of the 10.00
,rents of his Emit MECH.CONT. LIC.NO. MECH. ��V
�3 TOTAL TOTAL
signature of Applicant/Contractor Dae 1
OFFICE COPY
r" 1 POST THIS CARD NEAR FRONT OF BUILDING PERN;IT NUMBER
CITY .01"CUPERTIN-0 17414
INSPECTION DIVISION
:
Alt JOB INSPECTION RECORD ' ;
PERMtIT'E XPI RATION
O
JOB ADDRESS " �� '"" UNIT# _LOT# i Y
S C��/ j /� PERMIT EXPIRES IF WORK
owrvER 7 C coNTRACToa IS NOT STARTED WITHIN
INSPECTION DATE INSPECTOR INSPECTION RECORD 180 DAYS OF PERMIT ISSU.
FOUNDATION - - NOTE: ANCE OR 180 DAYS OM
LIFER � ALL GRADING AND DRAINAGE SHALLBE INSTALLED LASTCALLED INSPEC
PREGUNITE TO COMPLY WITH THE APPROVED PLANS AND CITY OF PAW At.CATION
-
CUPERTINO STANDARDS.
GARAGE SLABS -
POUR NO CONCRETE UNTIL ABOVE HAS BEEN SIGNED fl���• ��
UNDERGROUND /SLAB
PLUMBING ryCk wwi�ClUmum
_
ELECTRICAL - ISSUANCE DATE '
MECHANICAL eLDe ELECT. PLc. MecR
Q I ❑' ❑ ❑
DO NOT POUR FLOOR UNTIL ABOVE HAS BEEN SIGNED - BUILDING PERMIT
INFORMATION
WOOD FLOOR
VALUATION S/F T.
PLUMBING
MECHANICAL I '� 1 •�.
RMIT TO
ELECTRICAL' • .
FRAMING
STORIES TYPE CONSTR.
INSULATION
OCC GROUP RES UMTS
%PL'A.CE NO SUBFLOOR UNTIL ABOVE HAS BEEN SIGNED `
$O FT GLOOR AREA TOTAL ACREAGE
t ROOF NOTE:NO FINAL INSP.SHALL BE MADE BEFORE
i
DIAPHRAGM THE CONSTRUCTION TAX IS PAID
auuDlrvc usE
ROOF SHEATHING RES INU CON Pa om.,
APPLY NO ROOFING UNTIL ABOVE HAS BEEN SIGNED- FINALS DATE INSP. El ❑ ❑
ASSESSORS PARCEL NO.
ROUGH SAN.# _-
' PLUMBING - ELECT.ENERGY
TRACT NO. PARCEL NO
TUBS 8 SHOWER PAN PLUMBING ENERGY '
MECHANICAL" - MECH.ENERGY
ELECTRICAL - - (p BUILDING ENERGY I ACC DATE .;ACC.FILE NO
FRAMING ELECT,FINAL TEST
ZONING ENG,SITE NO.
INSULATION .b PLUMBING
GAS TEST - GAS
MECHANICAL FIRE SPRINK ENERGY T24
1 11
-COVER NO WORK UNTIL ABOVE HAS BEEN SIGNED HEATING - Y "� I IN
EXTERIOR SHEAR ELECTRICAL RELEASE FLOOD TONE ALUC
INTERIOR SHEAR FIRE DEPT.
O "O ❑ N❑
SHEETROCK GRADE - FEE SUMMARY
EXTERIOR LATH BUILDING
INTERIOR LATH TEMPORARY APPROVALS BUILDING
SCRATCH COAT ELECTRIC PLAN CHECK.
GAS FEE —'NO TAPE OR PLASTER UNTIL ABOVE HAS BEEN SIGNED OCCUPANCY - SEISMIC FEE I
OCCUPANCY OF BUILDING IS NOT PERMITTED UNTIL BUILDING FINAL IS SIGNED BY BUILDING INSPECTOR. MICROFILM
LU
ARRANGE FOR INSPECTION BY PHONING 252-4505, - ELECTRIC
.= ONE WORKING.DAY BEFORE REQUIRED INSPECTION. PLUMBING
0� PLEASE GIVE JOB ADDRESS WHEN PHONING.
1.� z MECHANICAL
— SEE PERMIT FOR, EXPIRATION DATE =
IMPORTANT! CONST,rnx
PLEASE READ REVERSE SIDE BEFORE TOTAL
CALLING FOR FINAL INSPECTION.
OFFICE COPY