13583 APPL)CANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
BUILDING PROJECT IDENTIFICATION ♦' • +•, PERMIT NUMBER
aDILDING - APPLICATION & PERMIT ( .
ADDRESS .• p ^I�^t•S
t_L�n)E E G BUILDING -ELECTRICAL-PLUMBING-MECHANICAL 13ll•�„}J3
�, OWNER'S PLAN CHECK VALIDATION
NAME DTV. ELECTRIC PERMIT FEE
P $ E PHONE `� --�OI3
NAMEOUTLETSUTLETS-SWITCHES-RECEP 10.00/1.00
LIC No. LIGHTING FIXTURES 10.00/1.00
CONTRACTOR'S
ADDRESS APPLIANCES-RESIDENTIAL 4.00
PHONE PANELS 10.00 DATE OF APPLICATION
ORRCHITECT PANELS IOVER 200 AMP) 20.00 PLAN CHECK FEE P.C.NO.
INEE
/�nu^se2S TRO uC.NO.C-22(043 ISIGNS TRANS. 3.00
ADDDRESSG'ENSPECIAL CIRCUIT 5.00 PERMIT VALIDATION
ZIP EMP. METER OR POLE INS. 20.00 n
ADDRESS Ts MOTORS SEE FEE SCH.
SERVICE CHANGE 20.00
H o O LICENSED CONTRACTORS DECLARATION 11131S 7
a is U I hereby affirm that I am licensed under provisions of Chapter 9
m Q y (commencing with Section 7000)of Division 3 of the Business and ISSUANCE GATEBLDG. ELECT. PLG. MECH.
H 7 z Professions Code,and my license is in full force and effect ❑ ❑ ❑ ❑
zw• License Class Lic.Number
O
H rz H J Dare Contractor
at w INFORMATION
4 OWNER-BUILDER DECLARATION BUILDING PERMIT
E
;n H I hereby affirm that I am exempt from the Contractor's License MISC.- REFER TO ORD
F uOa, Law for the following mason.(Sec7031.5,Businessand Professions VALUATION $/FT.
PERMIT ISSUANCE 10.00
f ">f Code:Any city orcoumy which requires a permit to construct,alter,
M K GO improve,demolish,or repair any structure,prior to its issuance,also ELEC.CONTR. LIC.NO. fa e+
ar
ELEC.
O LL requires the applicant for such permit to file a signed statement that TOTAL
n w$ he is licensed pursuant to the provisions of the Contractor's License PERMIT TO
H z a
Law(Chapter 9(commencing with Section 7000).(DiviMon 3offia S`l a �� Q�G
i D Business and Professions Code)or that he is exempt therefrom and OTY. PLUMBING PERMIT FEE •('J
It H the basis for the alleged exemption.Any violation Of Section 7031.5
n3 � by any applicant for a permit Subjects the applicant toacivil penalty STORIES TYPE CONSTR.
ofnot more than five hundred dollars(S5000.): ALTER-DRAIN&VENT-WATER (EA.) 5.00
❑ 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 Contractors License Law does not apply to an owner of
propertywhothrbuilds.r improves does improv"
work FIXTURES-PER TRAP 5.00 SO.FT.FLOOR AREA TOTAL ACREAGE
himself or through his own employees,provided that such ich work
menu a rc not intended or offered for sale.If,however,the building GAS-EA.SYSTEM-l1NC.40UTLETS 6.00
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- GAS-EA.SYSTEM-OVER 4(EA.) 2.00 BUILDING USE
prove for purpose of sale.). INDUSTRIAL WASTE INTER. 30.00 RES IND CON PB Other
❑ 1,as owner of the property,am exclusively contracting with
licensed contractors to construct the project(Sec. 7044,BusinessLAWN 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 pr perty wl builds or improves thereon,and who LAWN SPRINKLERS-OVER 5 (EA.) 1,00
emitructs for such ojems Idl a Cnntont.r(s)licensed porsllum t0
the Cmdc(.r' ien.he SEWER-SANITARY-STORMEA.200ft/10.00 TRACT NO. PARCEL NO.
❑ Ira xm
aI rider c. ,B.&P.C.forthis
reason WATER HEATER W/VENT 6.00
XO WATER SYSTEM 5.00 ACC.DATE ACC.FILE NO.
\ )RKF: 'COMPENSATION DECLARA'T'ION WATER TREATING EQUIP. 5.00
1 hereby affirm t at I have a certificate of consent to self-insure,
or a Certificate of Workers'Compensation Insurance,or a certified ZONING ENG.SITE NO.
copy thereof(Sec.3800,Lab.CJ.
Policy No. Company
C ❑ Certified copy Is hereby furnished.
Z Z ❑ Certified copy is Bled with the city inspection division. FIRE SPRINK ENERGY TQ4
Q Applicant MISC.- - REFER TO ORD. Y N� v ❑ NE]
N CERTIFICATE OF EXEMPTION FROM WORKERS' PERMIT ISSUANCE 10.00 FLOOD ZONE A.L.U.C.
W 7 COMPfiNSA"PION INSURANCEPLG.CONTR. LIC.NO. PLG.
C (This section need not be completed if tee permit is for One TOTAL Y N Y[] N
Z hundred dollars IS 100)or less.) 1.
U O I certify that in the performance of the work for which this per- QTY. MECHANICAL PERMIT FEE FEE SUMMARY
LL f mil is issued,I shall not employ any person in any manner so as to
U O beconne subject to the Workers''Compensation Laws of California.
i Date Applicant ALTER OR ADD TO MECH. 5.00 BUILDING
} N NOTICE 1'0 APPLICANT: If,after making this Certificate of Ex-
F Z emption,you should become subject to the Workeri Compensation APPLIANCE 5.00 PLAN CHECK
provisions of the Labor Code, you must forthwith comply with
U such provisions or this permit shall be deemed revoked. AIR HANDLING UNIT(TO 10,000C.F.M.) 4.00 FEE _
CONSTRUCTION LENDING AGENCY AIR HANDLING UNIT(OVER I0,00DC.F.M.) 6.00 SEISMIC FEE
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.L HEATING UNIT(TO 100,000 B.T.U.) 8.00
Lender's Name
Lender's Address HEATI NG UNIT(OVER 100,000 B.T.U.)9.50 ELECTRIC
I certify that l 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 t0 building construction, and BOILER-COMP(3 H.P,or100,000B.T.U.) 6.00
hereby authorize repre enmtives oI this city to enter upon the BB ER OMP IOver 100,000 BTU)SEE FEE SCH. MECHANICAL
above-mentioned grope y for inspection purposes.
We) ogre to save, indemnify and keep harmless the City in MISC.• REFER TO ORD.
Cu rteino a&c nst liabil ieS,judgments, costs and expenses which CONST.TAX
ma in ay act against said City in consequence of the PERMIT ISSUANCE 10.00
g ing fill permit MECH.CONT. LIC.NO. MECH.
_ $ TOTAL 9 OP
ign men pplmant/C actor Date TOTAL
OFFICE COPY
r
POST THIS CARD NEAR FRONT OF BUILDING
CITY OF CUPERTINO i - - ' RMITNDMhBE}
INSPECTION DIVISION
JOB INSPECTION RECORD
10900 N BLANEY PERMIT EXPIRATION
JOB ADDRESS UNIT# LOT#
PERMIT EXPIRES IF WORK
OWNER PG&E CONTRACTOR IS NOT STARTED WITHIN
INSPECTION DATE INSPECTOR INSPECTION RECORD - 180 DAYS OF PERMIT ISSU-
FOUNDATION - ANCE OR 180 DAYS FROM
LIFER LASTCALLED INSPECTION.
PREGUNITE PERMIT VALIDATION
c.
POUR NO CONCRETE UNTIL ABOVE HAS BEEN SIGNED
UNDERGROUND /SLAB
PLUMBING - ,
ELECTRICAL ISSUANCE DATE
MECHANICAL - BLDG. ELECT. PLG. MECH.
1 .
❑ ❑ ❑ ❑
DO NOT POUR FLOOR UNTIL ABOVE HAS BEEN SIGNED /� _ "'•BUILDING PERMIT
/') ` • a/ _ NFORMATION
WOOD FLOOR C/ ALu TION
PLUMBING � � -t�
c
MECHANICAL /
ELECTRICAL (- PERMIT TO
FRAMING -
STORIES TYPE CONSTR.
INSULATION
OCC.GROUP _ RES.UNITS
PLACE NO SUBFLOOR UNTIL ABOVE HAS BEEN SIGNED
ROOF SO,FTFLOORAREA TOTAL ACREAGE
DIAPHRAGM
BUILDING USE
(� 1G- RES IND CON PB Omer
APPLY NO ROOFING UNTIL ABOVE HAS BEEN SIGNED ❑ ❑ ❑ ❑ ❑
ASSESSORS PARCEL NO,
ROUGH
PLUMBING
GAS TEST TRACT NO; PARCEL NO.
MECHANICAL
ACC.DATE ACC.FILE NO.
ELECTRICAL FINALS DATE INSP.
FRAMING IGAS
N a
INSULATION UMBING zoNlNc ENO,SITE NO.
ECHANICAL FIRE SPRINK ENERGY T-ZA
COVER NO WORK UNTIL ABOVE HAS BEEN SIGNED EATING Y [] NE] Y F] NE]
LATH-INTERIOR LECTRICAL a000 zome A.L.u.c.
LATH-EXTERIOR FIRE DEPT. v N� Y ❑ NE)
SHEETROCK GRADE FEE SUMMARY
SHEAR INTERIOR BUILDING
SHEAR EXTERIOR TEMPORARY APPROVALS BUILDING
FIREWALLS ELECTRIC PLAN CHECK
GAS FEE
NO TAPE OR PLASTER UNTIL ABOVE HAS BEEN SIGNED OCCUPANCY SEISMIC FEE
OCCUPANCYOF BUILDING ISNOT PERMITTED UNTIL BUILDING FINAL ISSIGNEDBY BUILDING INSPECTOR. MICROFILM
ARRANGE FOR INSPECTION BY P=HONING.
ELECTRIC
F ONE WORKING DAY BEFORE REQPLUMBING
PLEASE GIVE JOB ADDRESS WHE
- SEE PERMIT FOR EXPIRAMECHANICAL
IMPORTANT! CONST.TAX
PLEASE READ REVERSE SIDE BEFORE TOTAL -
CALLING FOR FINAL INSPECTION.
OFFICE COPY