12830APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONI v
BU LD1 NG PROJECT I DENTI FICATI ON
APPLICATION &PERMIT
BUILDING -ELECTRICAL- PLUMBING -MECHANICAL
PERMIT NUMBER
12830Q�
BUILDING
A DRE55
NAME � � Y
G/ �s
PHONE
QTY ELECTRIC,PE' fi FEE
PLAN CHECK VALIDATION
DATE OF APPLICATION
CONTB4CT0
NAME (�L /ty. r�
OUTLETS-SWITCHES-RECEP 10.00/1.00
LIGHTING FIXTURES 10.00/1.00
nooeess TORS r
8. acsysaT �vE
PHONE%/
APPLIANCES - RESIDENTIAL 4.00
PANELS 10.00'
ARCHITECT
DR
ENGINEER
LIC. NO.
PANELS (OVER 200 AMP) 20.00
PLAN CHECK FEE P.C, NO.
SIGNS TRANS. 3.00
ADDRESS ENc.,
ZIP
SPECIAL CIRCUIT 5.00
PERMIT VALIDATION
Fg p
Li 87
gNCE DATE
fASSUBL
TEMP. METER OR POLE INS. 20.00
none SSTS
' .
MOTORS - SEE FEE SCH, -
SERVICE CHANGE 20.00
' LICENSED CONTRACTORS DECLARATION
I hereby affirm that 1 am licensed under provisions of Chapter 9
(commencing wl[b Section 7000) of Division 3 of the Business and
Professions Code, and my license Is in full force and effect.
License Class Lic. Number-
umber
DatContractor
OWNER -BUILDER DECLARATION
I hereby affirm that 1 am exempt from the Contractor's License
Law for the following mason, (Sec. 7031.5, Business and Professions
Code: Any city or county which requiresa permit toconstrod, alter,
improve, demolish; or repair any structure, prior to its issuance, also
requires the applicant for such permit to file a signed statement that
he is licensed pursuant to the provisions of the Contractor's License
Law (Chapter 9 (commencing with Section 7000) of Division 3 ofthe
Business and Professions Code) or that he is exempt therefrom and
the basis for the alleged exemption. Any violation of Section 7031.5
by any applicant for a permit subjects the applicant loacivil penally
of not more than five hundred dollars ($500).):
❑ I, as owner of the property, or on, employees with wages as
their sole compensation, will do the work, and the�struclure is not
intended or offered for sale (Sec. 7044, Business and Professions
Code: The Contractor, License Law does not apply to an owner of
property who builds or improves thereon, and who does such work
himself or through his own employees, provided that such improve -
meats are not intended or offered for sale. It', however, the building
or improvement is sold within one year of completion, the owner-
builder will have the burden of proving that he did not build or im-
prove for purpose of sale. p I -
❑ d as owner " the property, he exclusively . 7044, Bu with
licensed contractors to construct the project (Sec. 7044, Business
and nProfessionsneeof Code: The Contractor's License Law does not apply
to tr owner of property who builds tr improves thereon, and who
contracts for such projects with n conhac[or(s) licensed pursuant ki
the Contractor's License Law.
❑ lam exempt under Sec.., B.&P.C. for this
on
MECH.
11Dalo
1 11 BUILDING PERMIT r
INFGRMATION;,
MISC. - REFER TO ORD
PERMIT ISSUANCE 10.00
VAL I
✓✓//�//
/FT.
ELEC. CONTR. LIC. NO.
ELEC.
TOTAL
PERMIT O
r
QTY.PLUMBING PERMIT r ` FEE
a z -
ALTER -DRAIN -WATER (EA.)5.00
S ORIEs
CC. R
TYPE CO STR
RES. UNITS -
-
- BACK FLOW PROTECT. DEVICE 4.00
DRAINS-FLOORROOFAREA,CON D. 5.00
, ,
FIXTURES - PER TRAP 5.00
GAS EA. SYSTEM -1 INC.4 OUTLETS 6.00
GAS - EA. SYSTEM -OVER 4 (EA.) 2,00
50. FT. FLOOR AREA
TOTAL ACREAGE
BUILDING USE
E ND ON O Other
SSE55ORS PARCEL NO.
INDUSTRIAL WASTE INTER. 30.00
LAWN SPRINKLERS -.1 INC 5 V.B. 6.00
LAWN SPRINKLERS -OVER 5 (EA.) 1.00'
SEWER -SANITARY -STORM EA. 200ft/10.00
- TRACT No.
PARCEL No.
WATER HEATER W/VENT 6.00
Owner Date
WATER SYSTEM - 5.00
WORKERS'COMPENSATION DECLARATION,
1 hereby affirm that I have a certificate of consent to self -insure,
or acern 'c j.o( W�jLrs' C r tfp� ranCC, or a certified
cop FM. -c: 36��1.a��i:C .T.cc/r�-tt --��----��
P Icy Company�k,�.�/�Q ac
It ❑ Cert led copy is hereby furnished.'
❑ Certi lad .filed o e inspecfan division.
Applicant
'RTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(Thissection need not be completed if the permit is for one
hundreddollars ($100)orlCss.)M
I certify that in the performance of uk work for which this per-
mit is issued, I shall not employ :my person in any manner so as [obecome sobjec[ to the Workers' Compenmtion Laws ofCalifornia.-
Date Applicant
ACC. DATE
ACC FILE N0.
WATER TREATING EQUIP. 5.00
-
ZONING
ENG. SITE NO.
MISC. - REFER TO ORD.
FIRE SPRINK
Y N
ENERGY T24
'. 'Y [] N11_�
PERMIT ISSUANCE 10.00
FLOOD ZONE
Y [:]N
q. L. u.C.
Y 0 N[]
PLG. CONTR. LIC. NO.
PLG.
TOTAL
R -
, MEGHANICAL PERMIT' FEE
-
•FEE SUMMARY
BUILDING
OR ADD TO MECH. 5.013
NOTICE TO APPLICANT. If, after making this Certificate of Ex-
emption, you should become subject to the WorkersCompensationNCE
of the Labor Code, you omit forthwith comply withFEE
such provisions or this permit shall be deemed revoked.
CONSTRUCTION LENDING AGENCY
I hereby affirm that there is a construction lending agency forST
performance of the work for which this permit Is issued (SecMICROFILM
3097, Civ C.). i
Name
_ _ 5.00
PLAN CHECKprovisions
DLING UNIT (TO 10=C.F.M.) 4.00
DLING UNIT(OVER IO,ODDGRM.) 6.00
SEISMICFEE
HOOD (WITH DUCT) 5.00the
NG UNIT (T0100,000 B.T.U.) 8.00Lender's
Lender's Address -G
certify that 1 have read this application and state that the aboveLATION
information is correct. 1 agree to comply with'a)l city.and county
ordinances and state laws relating to building construction, and
Denby, authorize representatives of this city to enter upon the
above-mentioned property for inspection purposes.
(We) agree to save, Indemnify and keep harmless the City of
Cupertino against liabilities, judgments, costs and expanses which
may in any way, accrue against said City in consequence of the
gmntin t permit /-yam
Signature of Apphc/Color Data
UNIT (OVER 100,000 B.T,U.19.50'
ELECTRICI
FAN (SINGLE) 4.00
-
BOILER- COMP f3 H.P. or 100,000 B.T.U.) 6.00
-
PLUMBING
BOILER -COMP (Over 100,000 BTU) SEE FEE SCH.
-
MECHANICAL
MISC. - REFER TO ORD.
'- .. PERMIT ISSUANCE 10.00
CONST. TAX
MECH. CONT. LIC. NO. MECH.
TOTAL
'
TOTAL
Q
tJ
__ I vrrRrGbVrT
POST THIS CARD NEAR FRONT OF. BUILDING
., .CITY OF CUPERTINO.
INSPECTION DIVISION,
JOB INSPECTION RECORD
r, ••
JOB ADDRESS '� UNIT# _'LOT#
OWNER CONTRACTOR
PERMIT NUMBER '
1:283
•PERMIT EXPIRATION'' '
..PERMIT EXPIRES IF WORK
'' IS NOTSTARTED WITHIN
180 DAYS OF PERMIT ISSU. '
ANCE OR,180 DAYS FROM,
LASTCALLED INSPECTION.
INSPECTfONI I DATr 11 INSPECTOR
I SPECTION-RECORD -
FOUNDATION
-
LIFER
PREGUNITE
-
PERMIT VALIDATION -
„
.IssuarvcE DATE.
POUR NO CONCRETE UNTIL ABOVE HAS BEEN SIGNED
UNDERGROUND/SLAB .
PLUMBING ..
,.
-
'
ELECTRICAL
MECHANICAL
•
BL
\
ELECT. IPLG.
o I
MECR.
❑ P,
DO NOT POUR FLOOR UNTIL ABOVE HAS BEEN SIGNED
BUILDING PERMIT
INFORMATION
.WOOD FLOOR
PLUMBING' „... .. ..:.
.,frIO
-
VALUATION, /
�s/FT.
MECHANICAL'
ELECTRICAL
•
PER To I
1 sW', tl.i
FRAMING
INSULATION -
- -
Sr RIES
% it�.10'}
TYPE CONSTR.7
f;j `,j
"
OCC. GROUP=
RES.UNITS
PLACE NO SUBFLOOR UNTIL ABOVE HAS BEEN SIGNED
•
ROOF ' -
-
SO. FT, FLOOR AREA
TOTALACREAGE
DIAPHRAGM -+
-
•
BUILDING USE
RES
• IND F'CON PB Other`
It - ❑" ❑ ❑-
APPLY NO ROOFING UNTIL ABOVE HAS BEEN SIGNED
-
ROUGH
-
• •
,ASSESSORS PARCEL NO
PLUMBING -
GAS TEST
- -
TRACT No—'.PARCEL
No
MECHANICAL -
ELECTRICAL -„
=.FINALS DATE INSP.
,Acc DATE
ACC. FILE No.
FRAMING'
SAN
INSULATIONPLUMBING
ZON1NG
ENG. SITE NO.
GAS 7-
MECHANICAL
'FIRE SPRINK
-•° N ❑
ENERGY T 24
Y ❑ N❑
-;_• JCOVER NO WORK UNTIL AB VE HAS BEEN IGNED I
HEATING-" -
LATH—INTERIOR _/6
'ELECTRICAL
FL000 zorvE
Y ❑ ' N❑'
A.L.U.C,
. -Y ❑- N ❑ '
LATH—EXTERIOR. -
FIR6DEPT. -
SHEETROCK —
GRADE
FEE SUMMARY
SHEAR INTERIOR ; - --
BUILDING .,
•,
BUILDING ..
•�
•�,
SHEAR E) TERIOR - _
TEMPOR'P,,RY�APPR V LS
FIREWALLS
ELECTRIC
PLAN CHECK
FEE
GAS ..
NO TAPE OR PLASTER UNTIL ABOVE HAS BEEN SIGNED JOCCUPANCY
SEISMIC FEE
OCCUPANCY OF BUILDING IS NOTPERMITTED UNTIL BUILDING FINAL ISSIGNED BY BUILDING INSPECTOR:
;MICROFILM ,
ARRANGE FOR INSPECTION BY PHONING 252-4505,
o, ONE WORKING DAY BEFORE REQUIRED INSPECTION.
Z PLEASE GIVE JOB ADDRESS WHEN PHONING,
- SEE PERMIT FOR EXPIRATION DATE - . '. '
ELECTRIC `
PLUMBING
MECHANICAL
CONST. TAX
IMPORTANT! 'I
PLEASE READ REVERSE SIDE BEFORE'TOTAL
CALLING FOR FINAL INSPECTION.
)
M J
OFFICE COPY