12783 (3) APPLICANT-TO FILL IN INFORMATION WITHIN RED LINES - USE'BALI_ POINT PEN ONLY
! PERMIT NUMBER
,. '.,x1U1 LDING PROJECT IDENTIFICATION' APPLICATION $! PERMIT
9u LLOING
ADDRESS oT 12783
' aZS 3S 1caNs 'j BUILDING-ELECTRICAL-PLUMBING-MECHANICAL
OANER'Sy,- V /�.. PLAN CHECK VALIDATION
NAME 4--Y/�11 �„�/�M1 CITY. ELECTRIC PERMIT FEE
PHONE.*20"60
CONTRACTOR'S _"OUTLETS SWITCHES 10.00/1.00
NAME
110s911) nuc.rvo. `"�-LIGHTING FIXTURES 10.00/1.00 As - '
CONTRADDREAEa ORs .Z.) 2: PPLIANCES-RESIDENTIAL 4.00
PHONE 72 I' PANELS 10.00 Q -� ' DATE OF APPLICATION
ARCHITECT . PANELS (OVER 200 AMP) 20;00 PLAN CHECK FEE P.C.NO.
OR
ENGINE
LIC.Na. SIGNS TRANS. 3.00
ARCH.0.ENG. S33 / SPECIAL CIRCUIT 1, 5.00 PERMIT VA 1 M29N
1 CA, zIv EMP.METER OR POUE'INS. 20.00 . nN n• D fl
APPLICANTS
MOTORS SEE.FEE SCH.
"
' SERVICE CHANGE 20,00
o o LICENSED CONTRACTORS DECLARATION " . Ity "' l?dn�tlBG
a ZU U•.. I hereby affirm that 1 am licensed under provisions of Chapter 9 u 'ISSUANCE DATE
y a N (commencing with.Section 7000)of Division 3 of the Business and BLDG. - IELECT. PLG., MECH.
H n z Professions Code,yyd my lliienw is in full for,,E(c and of ec'I MCT.
Z 0 m o License Class_(]_Lic.Number,y Q't(yT Z lxl la; LL
H w, Dote-�?--VQy Contractor �, I
1-'� - J a ,
a.y E J ^ BUILDING PERMIT
¢ ¢ a OWNER-BUILDER DECLARATION -
oa" MISC.-, ' CIEj EPEFt MORD INFORMATION
E:
a. .I hereby affirm that 1 son.(Sec.
7 from the Contractor's License - VALUATION _ $/FT.
F u O ¢ Law for the following reason.(Sec.7031.5,Business and Professions PERMIT ISSUANCE 10.00 �] -
Code:Any city or county which requires a permit to construct,alter,
/Qac
F w Y M improve.demolish,or repair an SlNetafe, rinr 10 Bs ISSIranCe,also ELEC.CONTR. . LIC.NO.
as,
a 0 P P Y p t ELEC. !/� r
-s 0 ¢ requires the applicant for such permit to file a signed statement that TOTAL PERMITTO
w m he is licensed porsilant to the provisions of the Contractor's License
r z r Law(Chapter 9(commencingwith Section 7000)of Division 3 of the
a Business and Professions Code)or that be is exempt therefrom and CITY. PLUMBING PERMIT FEE
IS 1- m the basis for the alleged exemption.Any violation of Section 7031.$ STORIES TYPE CONSTR.
by any applicant for a permit subjects the applicant to a civil penalty ALTEfl-DRAIN&VENT-
WATER (EA.) 5.00
of not more9han five hundred dollars(S500).): V �VIV�
❑ I,as owner of the property,or my employees with wages as - BACKFLOW PROTECT.DEVICE 4.00 OCC.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,AR EA,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 -
a0,FT.FLOOR AREA TOTAL ACREAGE
himself or through his own employees,provided that such.improve-
ments are not intended or offered for sale.If,however,the building GAS-EA.SYSTEM-11NC.40UTLETS 6.00 Q
or improvement is sold within one year of completion, the owner-, GAS EASYSTEM-OVER 4(EA) 200
builder will have tile - . . .
e 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 Omer
❑ 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 does not apply /
to an owner of property who builds or improves thereon,and who LAWN SPRINKLERS-O ER• (EAu
'.) . 1.00 3
contracts for such projects with a contmctor(s)licensed pursuant to , SEWER-SANITAR V-STORM EA.200(1/10.00 -
the Commetor s License Law. L) TRACT NO. PARCEL NO.
❑ l am exempt under Sec. ,B.&P.C.I'or this WATER HEATER W/VE C'1 '.-T Lj 6.00 6 -'
reason �`Q
Owner - Dale WATER SYSTEM 5.00
ACC,DATE ACC:FILE N0,
WORK FHS'CUM P17NSA'F[ON DECLARATION - WATER TREATING EQUIP, )E10 5.00 '
1 hereby atflrn that I ILve a wDineen, of"neem to sel Ginsam,
Lor a certificate of Workers'Cantp4xdm IJ�ns�urmme,urn certified - G� '-ZONING ENG.SITE NO.
copy thereof(Sec. l�$r ,
Policy No. Co r&
❑ Certi1lCd copy is hereby hereby(SNIosht0 FIRE SPRINK ENERGY T-74
Z Z - ❑ Certified copy is filed with the city inspection division. -
O Applicant MISC.- �• REFER TO ORD. -.Y❑ N❑ Y ❑ N❑
W CERTIFICA'I'Ii 017 EXEMPTION PROM WORKERS' PERMIT ISSUANCE 10.00 FLOOD ZONE A.L.U.C.
W C041:NSATION INSURANCE PLG.CONTR. LIC.NO, PLG, I �I
CL Q (This ...loo need not be completed if the permit is for one TOTAL / K- Y❑ N❑ Y❑ N❑,
::) Z hundred dollars 1S 100)or less.) -
U O 1 certify that in the performance of the work for which'this per- QTY. MECHANICAL PERMIT FEE FEE SUMMARY
1L not is issued,I shall not employ any person in any manner so as Io
O W become subject to the Workers'Compensation Laws of CaBfornia.
Q. Date ApplicantALTER OR ADD TOM H. 5.00 ' BUILDING
} wNOTICE'1'0 APPLICANT: If,after making this Certificate of Ex- - - -'1'�®
� Z emplion,you should become subject to the W'orken'Compensation APPLIANCE ^.t 5.00 ' PLAN CHECK
provisions of the Labor Code, you must forthwith Comply with FEE
3 such provisions or this permit shall be deemed revoked. AIR HANDLING UNIT(TO,1OPMr-F.M.)U-4.00
CONSTRUCTION LENDING AGENCY
AIR HANDLING UNIT(OYEFI10,060 C F.M.)•600 SEISMIC FEE 7 < •
1 hereby affirm that there is a construction lending agency for EXHAUST HOOD (WITH DUCT V1)e1 15,. 0
the performance of the work for which this permit is issued(Sec. - MICROFILM
30nder's .am /
HEATING UNIT(TO 100,0 B.T.U.) 8.00
Lender's Name HEATI NG UN IT(OV ER 100,000 B.T.U.)9.50 A/ �
Lender's Address � ELECTRIC
VENTILATION FAN IS 4.00
I certify that I have read this application and state that the above '7./ - •
information is correct. I agree to comply with all city and county PLUMBING
ordinances and state laws relining to building construction, and BOILER•COMPI3 H.P.or 100,000B.T.U.) 6.00 .L
hereby authorize representatives,of this city to enter upon the BOILER-COMP(Over 100,000 BTU)SEE FEE SCH. MECHANICAL 3.
above-mentioned property for inspection purposes.
-G -(We) agree to save, indemnify unit keep harmless the City of MISC. REFER TO ORD. -
Cupertino against liabilities,judge Sets, costs and expenses which pERMIT ISSUANCE 10.00 Q CONST.TAX 73 �B
may in any�svayc•me t aid C/ty in consequence of the 'F
grain I f 11 is Alp,
, Q�/ MECH.CONT, LIC,NO. MECH.
Y5/27� 7 TOTAL '31,�• TOTAL 9� O
Signof A �Contta or ate
s�
r OFFICE COPY �'�
POST THIS CARD NEAR FRONT OF BUILDING
PERMIT NUMBER
' CITY OF CUPERTINO
INSPECTION DIVISION w 1.4455 :
JOB INSPECTION RECORD
PERMIT EXPIRATION
• 11
JOB ADDRESSKINST COURT. UNIT#' _.LOT# '
PERMIT EXPIRES IF WORK
OWNER' KINST COURT CORP CONTRACTOR.' TERRY BROWN IS NOT,STARTED WITHIN ,
INSPECTION. DATE INSPECTOR INSPECTION RECORD 180 DAYS OF PERMIT ISSU-
'FOUNDATION - ANCE OR 180 DAYS FROM
- NOTE: LASTCALLED INSPECTION. :
UFER - ALL GRADING AND DRAINAGE SHALL:BE INSTALLED' ,
.PR EGUNITE .. TO COMPLY WITH THE APPROVED PLANS AND CIN a OF PERKT ,,VAIOAnoN
CUPERTINO STANDARDS.
GARAGE SLABS -
POUR NO CONCRETE UNTIL ABOVE HAS BEEN SIGNED 'M !.,
UNDERGROUND /'SLAB
PLUMBING - _ - AIDjt,�S >•;° .� .
ELECTRICAL NCF.DAN: '
MECHANICAL ' - - yG, cr, -PLG. MECH.•
_ ❑ ❑
OO NOT POUR FLOOR UNTIL ABOVE HAS BEEN SIGNED BUILDING PERMIT
INFORMATION
WOOD FLOOR. - VALUATION SIFT.
PLUMBING
MECHANICAL - •• •h.'.,.
%RMIT TU
' ELECTRICAL
FRAMING. t-..u.L'.. •�M,
INSULATION STORIES. -TYPE CONSTR.
1 ' _ OCC GROUP RES;UNITS
PLACE NO SUBFLOOR UNTIL ABOVE HAS BEEN SIGNED
'Yr �- $II.fT,f'I.00H AREA
ROOF �NOTEi NO FINAL INSP.SHALL BE MADE BEFORE ' TOTAL ACRE AGL
DIAPHRAGM r THE CONSTRUCTION TAX IS PAID -
BUILDING USC
ROOF SHEATHING Ills IND CON .PB O,H" -
APPLY NO ROOFING UNTIL ABOVE HAS BEEN SIGNED FINALS DATE INSP. ❑ ❑ ❑ ❑ ❑ '
-ROUGH SAN.N • ASSESSORS.PARCEL NO.
PLUMBING
ELECT.ENERGY' - -
1RACINO. �PAHCELNO
NUBS&SHOWER PAN '* PLUMBING ENERGY .
MECHANICAL, " MECH.ENERGY
�
ELECTRICAL - BUILDING ENERGYACC.
. - � DATEACC.FILE NO
-
'FRAMING ELECT.FI NAL TEST' C'
INSULATION - PLUMBING ZONING ENG SITE NO.
GAS,TEST+.,- , , - �. . - .. GAS. E .,
" MECHANICAL r .EIRE SPRINK . ENERGY T.24
_COVER NO WORK UNTIL ABOVE HAS BEEN SIGNED HEATING Y ❑ "❑ `❑' "❑
EXTERIOR SHEAR
ELECTRICAL RELEASE FLOOD ZONE - A,L.U
INTERIOR,SHEAR - FIRE DEPT: °❑ N❑ Y ❑ NEI
SHEETROCK 1, GRADE : FEESUMMARY
EXTERIOR LATH - .BUILDING',
INTERIOR LATH - �,TEMPORARYAPPROVALS - � BUILDING 'c' '
SCRATCH COAT ELECTRIC„ - _ �� PLAN CHECK
GAS FEE
NO TAPE OR PLASTER UNTIL ABOVE HAS BEEN SIGNED OCCUPANCY SEISMIC FEE-
OCCUPANCY OF BUILDING ISNOT PERMITTE D UNTIL BUILDING FINAL ISSIGNED BY BUILDING'INSPECTOR. MICROFILM
ARRANGE FOR INSPECTION BY PHONING 252-4505, ELECTRIC` ,
F, 'ONE WORKING DAY BEFORE REQUIRED INSPECTION. P�uMeiNc
o�j PLEASE GIVE JOB ADDRESS WHEN PHONING1..
I• z } SEE PERMIT FOR EXPIRATION DATE MECHANICAL'
dMPORTANTI I, CONST.TAX
PLEASE READ'FIEVERSE SIDE BEFORE I'`
TOTAL
CALLING FOR FINAL INSPECTION.
OFFICE COPY
APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALLPOINT PEN ONLY
BUI LDI NG PROJECT DENTI F1 CATION. PERMIT NUMBER
APPLICATION & PERMIT
BUILDING 1 A A
AooREs. ` BUILDING =ELECTRICAL-PLUMBING-MECHANICAL I ` 4 5
OWNER'S ��y 1��- PLAN CHECK VALIDATION
I• °'.{ `'`'""'0' /s QTY, ELECTRIC PERMIT. - FEE
PHONE (i (/ fol/ .
CO TRACTORs - - "I UTLETS-SWITCHES-RECEP 10.00/1.00 .
uc.No. _ LIGHTING FIXTURES 10.00/1.00
CONTRACTOR'ADDRESS I APPLIANCES-RESIDENTIAL. 4.00 '
'.PHoNE PANELS ' ' 10.00 DATE OF APPLICATION
ARCHITECT - PANELS'IOV ER ZOO AMP) 20.00 PLAN CHECK FEE P.C.N
OR O.
ENGINEER - -
" uc.No. SIGNSTRANS. -3.00 -
ARCH.OREND, PERMIT VALIDATION.
AooREss - • SPECIALCIRCUIT 'F`5.00 �-
` - ZIP TEMP.METER•OR POLE INS. 20.00
APPLICANT 5
ADDRESS - - MOTORS SEE FEE SCH. .• (J N ._ .
ADDRESS
SERVICE CHANGE pAto 20.00
o o LICENSED CONTRACI ORS DECLARATION -
a o U I hereby affirm that I',am licenkd under provisions of Chapter 9 - `1 SSUANCE DATE
'li r (commencing with Section 7000)of Division 3 of the Business and ii Q y } BLDG. ELECT. PLG. MECH.
F N z Professions Code,and my license is in full force and effect
O.I w a,:: License Class Lic.Number (� ® ❑
rw Date � ' Cmitracm, f r Ck. C"Oft, '.
am
¢ ¢ w - OWNER-BUILDER DL'CLA RA I ION• BUILDING PERMIT
X 3 LL H 1 hereby affirm that I,am exempt from the Contractor'sLicense MISC - - REFER TO ORD INFORMATION
FUN¢ law for the following reuson.fSee.7031.5,Business and Professions,
1000b •-PERMIT ISSUANCE . VALUATION $/FT.
Code.Any city or county which requiresa permit to construct,alter,
Jac Q improve,demolish,or repair any struClure,prior la Its issuance,also ELEC.CONTR. -LIC.NO.-
u requires thea licant forsuch permit to file a sighed statement ilial - ELEC:i' //--t/L
9 pP p 6 TOTAL U PERMIT TO
w $a he is licensed pursuant to the provisions of the Contractor's License
F2 >,
Law(Chapter 9(Commeneingwith Section 7000)ofDivision3ofthe
i i o Business and Professions Code)or that he is exempt therefmmand. QTY. PLUMBING PERMIT FEE
¢ H m. the basis for the alleged exemption.Any.violafion of Section 7031.5 , , STORIES TYPE CONSTR.
c- by any appllcaal lora permit suhjecis theappllcanl to a civil penalty ALTER-DRAIN -WATER'1EA.) 5.00 )
Of not more than five hundred dollars($500).);
❑ 1,as owner of theproperty,or my employees with wages as BACK FLOW PROTECT. DEVICE 4.00
their sole compensation,will du the work,and the structure is not OCC.GROUP RES.UNITS
intended or offered for sale (Sec. 7044, Business and Professions DRAINS-FLOOR,ROOF,AREA,COND., 5.00
Code:The Contractor's License Law does nut apply to an owner of - .
property who builds or.improves thereon,and who does such work' _ FIXTURES,,PER TRAP - '5.00 s0.PT.FLOOR AREA TOTAL ACREAGE
himself or through,his awn employees,provided that such imj rovc- -
mentsarenot intituled or offered far sale.If,however,the building GAS-EA.SYSTEM-I INC.4OUTLET$ 6:00 ,
✓ or improvement is sold within one year of completion,the owner- GAS-EA.SYSTEM-OVER 4 (EA.1' „2.00
builder will have the burden of proving that he did not build Or iin- BUILDING USE
prove for purpose of sale.). - - INDUSTRIAL WASTE INTER: 30.00 RES6 IND CON PB Other
❑ I,as owner of- he property,am exclusively Contracting with �.
licensed contractors to con9lrucl the project(Sec. 7044, Business LAWN SPRINKLERS--1 INC 5 V.B., 6.00 - - ASSESSORS PARCEL NO.
and Professions Code'.The Contractor's Licenu 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 will a con tinct NO licensed pursuant tri '
the Contractor' License Law. SEWER-SANITARY-STORM EA.200ft/10.00 TRACT No. PARCEL NO.
❑ lam ex', �r See ,R.&P...for this WATER HEATER W/VENT 6.00
reason -
Owner Date .WATER SYSTEM - 5.00 ' ACC.DATE ACC.FILE No.
W'ORKE RS'COMPENSA'I'ION DECLARATION / WATER TREATING EQUIP. 5.00
I hereby affirm that I have a certificate of consent to self-insure,
or a certificate of Workers'Compensation Insurance,or a certified _ ZONING- ENG.SITE N0,
copy thercol'(See,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. -
O Applicam - MISC.-- REFER TO ORD. YN❑ Y;Q NQ-
CC w CERTIFICATE OF EXEMPTION.FROM WORKERS' PERMIT ISSUANCE 10.00 FLOOD ZONE A.U.UG. ,
'UJ 'COMPP-NSATION INSURANCE PLG.CONTR. - LIC.NO PLG. -
tl a (This section nceJ not be completed it the permit is for one _ TOTAL• Y�' �'N� Y❑ .IN a
7) Z hundred dollars(5100)or less.)
U O . I certify that in the performance of the work for which this per- OTY MECHANICAL PERMIT FEE FEE SUMMARY
LL f- in is issued,I shall not employ any person inany manner so as to ,
- U become subject to the Workers'Compensation Laws of CalifoniaL - - _
y DateApplicant - ALTER OR,ADD•TO MECH. I 5.00 BUILDING
}.tit NOTICE TO APPLICANT: If,aNer making this Certificate of pix- --
F 2 emption,you should become subject to the Workers'Compensation APPLIANCE' 5.00 PLAN CHECK
provisions of [be Labor Code, you must forthwith comply with - FEE '•
U such provisions or this permit shall he deemed revoked AIR HANDLING UNIT(TO�1041MC,F.M.) 4,00
' AIR HANDLING UNIT(OVER 10=C.F.M.) 6.00 SEISMIC FEE
CONST'RUCTION LENDING AGENCY _
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.CA HEATING UNIT(TO 100,000 B.T.U.) , 8.00
Lender's Name HEATING UNIT(OV ER 100,000 B.T.U.)9.50
Lender's Address ' ELECTRIC .'
-
I'certify that I huvarcad this application and state that tireVENTILATION above - N FAN (SINGLE) ,4.00
information is correct. 1 agree to Comply with all city and county - PLUMBING
ordinances and statelows relating to building construction, and BOILER•CO1V1P,(3 H.P.or 100,000 B.T.U.) 6.00
y hereby authorize representatives of this city to enterupon the IBOILER-COMP IOver 100,000 BTU)SEE FEE$CH. MECHANICAL '
r above-mentioned properly for inspection purposes.
,,(We) agree (a Save, mdeglatey and keep harmless the City of MISC.t - REFER TO ORD. -
upertino against li'bili ti ,jud ne s, c is and expenses which PERMIT ISSUANCE 10:00 - CONST.TAX
may in any ay to against r d '1 in consequence of the
ranti of its il. MECH.CONT. - - LIC.NO. MECH.
TOTAL TOTAL
•',p ,
ignature of Appllrnnt/Contractor ;1 Date ' ' I.e' ' .� -
OFFICE COPY