14094 APPLICANT TO FILL.IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
��- BUILDING PROJECT IDENTIFICATION PERMIT NUMBER
Go1LDIINNGG y /� APPLICATION & PERMIT 14094
All V O y /'E' 1 eVL �/'ILYJI� L- BUILDING —ELECTRICAL—PLUMBING —MECHANICAL
OWNER' , U. PLAN CHECK VALIDATION
NAME OTV. ELECTRIC PERMIT FEE
> e.� �'e�
IA le PHONE?S2-01zi,
' CONTRACTOR OUTLETS-SWITCHES-RECEP 10.00/1.00
No((1('( 0 LIGHTING FIXTURES 10.00/1.00
CONTRACTOR APPLIANCES-RESIDENTIAL 4.00
'AD ESS C /(q J-A I/ '�1y ,
�1� 0. f?J-JC.0 IlaflY PHONE72_�� PANELS 10.00 DATE OF APPLICATION
ARCHITECT (/ PANELS (OVER 200 AMP) 20.00 PLAN CHECK FEE PC NO.
On
ENGINEER
uc.NO. SIGNS TRANS. 3.00
ARCH SPECIALCIRCUIT 5,001 PERMIT VALIDATION
ZIP TEMP.METER OR POLE INS. 20.001
APPLICANT S
AD CASES MOTORS SEE FEE SCH.
SERVICE CHANGE 20.00 Ln2U�
°w DO LICENSED CON TRACTORS DECLARATION ! /}/'Y3/�
a u E, I hereby i fllnn Thal 1 am licensed under provisions of Chapter 9 11 ti ,I � ISS ANCE GATE
H a (commencing with Section 70001 of Deves.on 3 of the Busmess and J . - BLDG. FLECT. J . PEG MECH
H w i Professions C.chl 'a e)licensc Is m lull fogy f,Mt
Z im o�I LicenseC ss /pp!V% Lue Number_(_ V V\,- ❑
N r aa I Dare (jI_Z'�_p�Contructc= o
BUILDING PERMIT
a o a U OWNER-BUILDER DECLARATION INFORMATION
w ; y I hereby affirm that I am exempt from the Contractors License MISC. REFER TO ORD 1
F LL O J Law for the following reason (Sec.703 L5,Business and Professions PERMIT ISSUANCE 10.00 Vol � VALUATION SIFT.
2wle Code Anyeety orcounty which requsresa permit toconstruct,alter,
¢ ¢¢ f
0 Improve,demolish,or repair any structure,prior to Its Issuance,also ELEC.CONTE. LIC.NO. ELEC.
u w m a, requires the applicant for such permit to file a signed statement that TO
ra TAL 3V PERMIT TO
F z he is licensed pursuant to the provisions of the Contractor's License
>
Law(Chapter 9(Commencing with Section 7000)of Divlaton3of
a Business and Professions Code)or that he Is exempt therefrom and OTV. PLUMBING PERMIT FEE
s ¢ o
¢ r by basis for tan alleged exemption.Any applicant of Section penalty 5 STORIES TYPE CONSTR.
by any more fora permit subjects theapplicanl toamvelpenalty ALTER-DRAIN -WATER (EA.) 5.00
of not more than live hundred dollars 1my em):
❑ I,as owner of the property,or my employees with wages as BACK FLOW PROTECT. DEVICE 4.00 OCC GROUP RES UNITS
thin,sole compensation,will do the work,and.the structure Is not 1
Intended or offered for sale(Sec. 7044, Business and Professions I DRAINS-FLOOR,ROOF,AREA,COND. 5.00
Code The Contractor's License Law does not apply to an owner of
properly who builds or improves thereon,and who does such work I FIXTURES-PER TRAP S.00 80.FT,FLOOR AREA TOTAL ACREAGE
himself or through his own employees,provided that such improve-
- marts are not Intended or offered for sale.If,however.the budding) GAS-EA.SYSTEM-1 INC.4 OUTLETS 6.00 .
Or improvement is sold within one year of completion,the owne GAS-EA.SYSTEM-OVER 4 (EA.) 2.00 r-
` builder will have the burden of proving that he did not build or im-I BUILDING USE
prove for purpose of sale.). g INDUSTRIALWASTE INTER. 30.00 RES IND CON PH Other I'
0 1,as owner of the property,am exclusively contracting with I ❑ ❑ ❑ ❑ ❑
licensed contractors to construct the project(Sec. 7044,Busmess I LAWN SPRINKLERS-1 INC 5 V.B. 6.00 ASSESSORS PARCEL NO,
and Professions Code-The Contractor's License Law does not apply �I
to an owner of property who builds or improves thereon,and who I LAWN SPRINKLERS-OVER 5 (EA.) 1.00
contracts for such projects with contractor(s)licensed pursuant to SEWER-SANITARY-STORM EA.200ft/10.00
the Contractor's License Law. I TRACT N0, PARCEL ND.
- ❑on I am exempt under Sec. B&P.C.for this I WATER HEATER W/VENT 6.00
reas
Owner Dale 1 WATER SYSTEM 5.00 ACC.DATE ACC.FILE N0. I J
WORKERS'COMPENSA'fION DECLARATION WATER TREATING EQUIP. 5.001 -
I hereby affirm that I have a certificate ofconsent to self-insure.
or a ce ZONING ENG.SITE N0.
rtfecate of Workers'Compensation Insurance,or a certified _
4E Cupy thereof(Sec.3800,Lab.C.)
Policy No. COmpam -
Q ❑ Certified copy is hereby furnished I I FIRE SPRINK 'ENERGY T-14
Z O O,
Certified copy Is fled with the my inspection division. MISC.- REFER TO ORD. I ❑ ❑ ❑ ❑
.Applicant Y N V N
H �O PERMIT ISSUANCE ' 10.00
— CERTIFICATE 01'EXEMPTION FROM WORKERS' I FLOOD ZONE A LU,C.
LD > COMPENSATION INSURANCE PEG CONTE. LIC NO. PEG.
1 O
(This sect ilia need not be.completed If the permit is for one IT OTAL I V E] N❑ v❑ N❑
=) Z hundred dollars(S 1001 or less I
U O 1 ecrtd'y that m the performance of the work for whmh this per- QTY MECHANICAL PERMIT FEE FEE SUMMARY
LL H,_ mLL is issuetl,(shall not employ anon in any morn P,as to
-OW rbecolq�y b he Workers' na wsyl.rg}I,fp�ormu.
y Dal /i.E�"r°s Anpllnant +C^!i! BUILDING
} rn OTICE TO AI'PLICAN'f: If,after making this C ¢me of Cs ALTER OR ADD TO MECH. 5.001
I_ Z_ a Piton,you should become subject to the Worke Compensation 1 1 APPLIANCE 5.001 PLAN CHECK
Provisions of the Labor Code, you must forthwith comply with
U such provisions or this permit shall be deemed revoked. I AIR HANDLING UNIT(TO 10,000C.F.M.) 4.001 I FEE
CONSTRUCTION LENDING AGENCY I AIR HANDLING UNIT(OVER 10,000C.EM.) 6.00 SEISMIC FEE
I hereby affirm that there Is a construction lending agency for EXHAUST HOOD (WITH DUCT) 5.00 I 'I
the performance of the work for which this permit is issued(Sec. MICROFILM
3097,Civ.0). ' . HEATING UNIT(TO 100,000 B.T.U.) 8.00 I
Lender's Nam-
Lender's Nam-Andre— HEATI N UN IT(OV ER 100,000 B.T.U.)9.50 , ELECTRICo
I certity that I have read thus application and state that Ilan above VENTILATION FAN (SINGLE) 4.00 '
Information Is correct I agree to comply with all city and county g01LER•COMP13 H.P.Or 100,000 B.T.U.) 6.00 ' PLUMBING
I ordinances and slate laws relating to building construction, and
hereby authorize representatives of thus city In enter upon the
(BOILER-COMP (Over 100,000 BTU(SEE FEE SIGH. MECHANICAL
hereby properly for inspection of purposes
(We) agree to save, indemnify and keep harmless the City of MISC.- REFER TO ORD. I
C.Perhl umst liabilities,tadgments, cos s and expenses when PERMIT ISSUANCE , 10.00 ' CONST.TAX
may an a c e'ag' s1 said Q I consequence of the
gran ng d w cm It MECH.CONT, LIC NO. MECH
�rs TOTAL I TOTAL
47 Seg azure PApricier ontraclur Date
OFFICE COPY
POST THIS CARD NEAR FRONT OF BU I LDI'NG : : RnIITNUn,PEIv
. . CITY OF CUPERTINO'•,'
14094
-INSPECTION DIVISION"
JOB INSPECTION RECORD ' ;
i I .PERMIT EXPIRATION
.IOB'ADDRESR' 10789 ALDERBROOK LANE UNIT# _LOT# -
PERMIT EXPIRESAF WORK
OWNER SELTERRECIH CONTRACTOR FIELDS ' • ELECTRIC IS NOT STARTED WITHIN
I
I INSPECTION DATE INSPECTOR I INSPECTION RECORD .180 DAYS OF PERMIT ISSU.ANCE OR 180 DAYS FROM
IUFER FOUNDATION - I LAST•CALLED INSPECTION:
-I PREGUNITE - .. PERMIT VALIDATION
POUR NO CONCRETE UNTIL ABOVE HAS BEEN SIGNED
I ' ' . UNDERGROUND /SLAB ,
IPLUMBING - : t. .. '.
(ELECTRICAL ISSUANCE DATE
(MECHANICAL '' PLUG ELECT PLC,• MECH.
100 NOT POUR FLOOR UNTIL ABOVE HAS BEEN SIGNED( BUILDING PERMIT
INFORMATION
WOOD FLOOR
PLUMBING VALUATION- r &T.
L -I
- I � ,
MECHANICAL
`. -
•
ELECTRICAC' PERMIT TO'
• . . ,. � � � /,:••G.C,;Gf .
IFRAMING rvrE ONSTR.
INSULATION• __C i
OCC GROUP -�RES UNITS
PLACE NO SUBFLOOR UNTIL ABOVE HAS BEEN SIGNED I - II
.- ROOF I - ` $O.FT,FLOOR AREA^ TOTAL ACFIAGE
. iDIAPHRAGM
BUILDING USE
•RES INO CON PP O,mv
J APPLY NO ROOFING UNTIL ABOVE HAS BEEN SIGNED I' ❑ ❑ ❑ ❑ ❑
I ROUGH I ASSESSORS FARCE L NO
IPLUMBING + I'
IGAS TEST ' ' I • 'I TRACT NO PARCEL NO' 'I
;.'I MECHANICAL
ELECTRICAL ♦ACC DATE Ac C,FILE NO. I'
'J ELECTRICAL I FINALS I DATE INSP. I
I FRAMING ' ' ISAN # zoNlNC ENG slrE rvo.
( INSULATION : I • IPLUMBING I
I I I GAS
I I (MECHANICAL I FIRE SPRINK ENERGY T 20
I COVER NO WORK UNTIL ABOVE HAS BEEN SIGNED ,I HEATING I "[] "F]
- ICATH-INTERIOR ELECTRICAL �Q_?v,g.� I FLO 7NE 'A L U C
(LATH-EXTERIOR. (FIRE DEPT. I Y❑ "❑ Yo N❑
ISHEETROCK IGRADE I I FEE SUMMARY
ISHEAR INTERIOR r , IBUILDING 'I I
` ISHEAR EXTERIOR _ _ _ _ _ I TEMPORARY APPROVALS BUILDING
PLAN CHECK
FIREWALLS. I ,•(ELECTRIC
.IGAS• ,
. I .. I ' . fI " FEE
NO TAPE OR PLASTER UNTIL ABOVE HAS BEEN SIGNEO.I000UPANCY I I SeiSMIC FEE .
OCCUPANCY OF BUILDING IS NOT PERMIT TED UNTIL BUILDING FINAL ISSIGNED BY BUILDING INSPECTOR. 'MICROFILM
-ARRANGE FOR INSPECTION BY PHONING 252-4505, ELECTRIC
1� F—� ONE WORKING DAY BEFORE REQUIRED INSPECTION. �• PLUMBING
0 PLEASE GIVE JOB"ADDRESS WHEN PHONINGrx8 "
ZT MECHANICAL
- SEE PERMIT FOR EXPIRATION DATE=
•', ,CONST.TAX
- .. IMPORTANT!, , k'
PLEASE READ REVERSE SIDE BEFORE °'1 TOTAL
• CALLING FOR FINAL INSPECTION. '. ^„
,�. . . - OFFICECOPY. -