16031 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY i
4 Jr BUILDING PROJECT IDENTIFICATION ,PERMIT NUMBER '
APPLICATION & PERMIT 1 CO��
ft rvc I v
ADDRp,£S��^ BUILDING—ELECTRICAL—PLUMBING—MECHANICAL '`,
OWNER'S `� �'`6s PLAN CHECK VALIDATION
I —1 1, DTV. ELECTRIC PERMIT FEE
CONFIPHONE l
RA roll's
NAMEUTLETS-SWITCHES-RECEP 10.00/1.00
LIC.No. LIGHTING FIXTURES 10.00/1.00
CONTRACTOR o '
ADDRESS PPLIANCES-RESIDENTIAL 4.00
PHONE PANELS 10.00 DATE OF AP PLICATION T
on PANELS (OVER 200 AMP) 20.00 PLAN CHECK FEE P.C.NO.
ENGINEER LIC.NO, SIGNS TRANS. 3.00
ANDRESSS E"c' SPECIAL'CIRCUIT 5.00 PERMIT VALIDATION
zIP EMP.METER OR POLE INS, 20.00
APPLICANT
ADDRESS MOTORS SEE FEE SCH. . til/l
(, - SERVICE CHANGE 20.00
w o o LICENSED NTRACTORS DECLARATION
¢z w I hereby affirm that I am licensed under provisions of Chapter 9 ISSUANCE DATE
N a L (commencing with Section 7000)of Division 3 of the Business and BLDG. ELECT. PLG. MECH.
H m z Professions Code,and my license is in full force and effect. El ❑ EI El
0 w License Class Lic.Number
4 z F w Date Contactor
x f
¢ a OWNIiWBUILDER DECLARATION BUILDING PERMIT
- o a u INFORMATION
X ;LL N I hereby affirm that I am exempt from the Contmcror's License MISC.— REFER TO OflD
Le ¢0 j Law for the following reason.(Sec.7031.5,Business and Professions PERMIT ISSUANCE VALUATION $/FT.
y yr y which requires a permit to construeL alter, 10.00
Code:An cit a count
22¢ improve,demolish,or repair any structure,prior to its issuance,also ELEC.CONTR. - LIC.NO.
If ELEC. PP' v
S,
requires the applicant for such permit to file a signed statement that TOTAL ` PERMIT
w m he is licensed pursuant to the provisions of the Contractor's License
z A Law(Chapter 9(commencing with Section 7000)of Division 3 of the wd-w- g�K
4 0 Business and Professions Code)or that he is exempt therefrom and OTY. PLUMBING PERMIT Ur p
the basis for the alleged exemption.Any violation of Section 7031.5 \`RIES TV CONSTR.
w. � ,- by any applicant for a permit subjects the applicant toll civil penalty ALTER-DRAIN&VENT-WATER IEA.) 0 �` h '
of not more than five hundred dollars(55001.1:
❑ I,as owner of the property,or my employees with wages as BACK FLOW PROTECT. DEVICE 4.0q km 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,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 F IXTUR ES-PER TRAP 5.00 SO.FT.FLOOR AREA TOTAL ACREAGE
himself or through his own employees,provided that such improve-
mentsare not intended oroffered for sale.If,however,the building GAS-EA.SYSTEM-11 NC.4 OUTLETS 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 Omer
O I,as owner of the property,am exclusively contracting with 0 D ❑ ❑ ❑
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 ownof property who builds or improves thereon,and who LAWN SPRINKLERS-OVER 5(EA.) 1.00
romans Srfor such projects with a contraaortsl licensed pursuant to
the ConSEWER-SANITARY-STORM EA.200ft/10.00
Contractor's License Law. TRACT NO. PARCEL NO.
❑ Ium exempt under Sec. ,N.&P.C.for this WATER HEATER W/VENT 6.00
reason
Owner Mme WATER SYSTEM 5.00 ACC.DATE ACC.FILE NO.
WORK E RS'COMPENSATION DECLARATION WATER TREATING EQUIP. 5.00
1 hemhy album that I have a certificate of consent to sth&insure,
or a eckific to of Workers'Compensation Insurance,or a certified ZONING ENG.SITE NO.
copy Ihercol'(Sce.3800,I.A.C.).
Policy No. Company
0 O Certified copy is hereby furnished. FIRE SPRINK. ENERGY T 24
Z 2 ❑ Certified copy is fled with the city inspection division.
p Applicant MISC- REFER TO ORD, y� rv❑ Yo No
~ rn PERMIT ISSUANCE 10.00
CC — CERTIFICATE OF I'.XEMPTION FROM WORKERS' FLOOD ZONE A.L.U.C.
W COMPENSATION INSURANCE PLG.CONTR. LIC.NO. DLG,
CL Z This section need not be completed if the permit is for one TOTAL V❑ N� V N❑
hundred dollars(S 1001 or less.)
U O I certify that in the performance of the work for which this per- QTY. MECHANICAL PERMIT FEE FEE SUMMARY
LL F- mit is issued,I shall not employ any person in any manner so as to
O w become subject to the Workers'Compensation Laws of California.
a Dau Applicant ALTER OR ADD TO MECH. 5.00 BUILDING ��`(� -
} 0 NOTICE TO APPLICANT: If,after making this Certificate of.Ex
H Z 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 such provisions or this permit shall be deemed revoked. AIR HANDLING UNIT(TO 10=CF.M.) 4.00
CONSTRUCTION LENDING AGENCY AIR HANDLING UNIT(OVER 10400CRM.) 6.00 SEISMIC FEE ts�
I hereby affirm that there is a construction lending agency for EXHAUST HOOD (WITH DUCT) 5.00
h the performance of the work for which this permit is issued(Sec. HEATING UNIT(TO 100,000 B.T.U.) 8.00 MICROFILM
3097,Civ.C.1.
Lender's someAddy HEATING UNIT(OVER 100,000 B.T.U.)9.50
Lender's Address ' ELECTRIC '
I certify that 1 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 to building construction, and BOILER-COMP(3 H.P.or 100,000 B.T.U.) 6.00
t hereby authorize representatives of this city to enter upon the
above-mentioned property for inspection purposes. BOILER-COMP (Over 100,000 BTU)SEE FEE$GH. MECHANICAL
(We) agree to save, indemnify and keep harmless the City of MISC.- REFER TO ORD.
Cupertino against liabilities,judgments, costs and expenses which rH
RM1T ISSUANCE 10.00 . CONST.TAX
in any way accrue against said City in canseyuence of the
a is pt,( hL T. LIC.NO. MECH.
Sign V TOTAL &-J 1)
Dale
OFFICE COPY
POST THIS CARD NEAR FRONT OF BUILDING i
PERMIT NUMBER
CITY OF CUPERTINO 16031
INSPECTION DIVISION
JOB INSPECTION RECORD
I.
JOB ADDRESS e 0 F7 �Q�N7 �y� PERMIT EXPIRATION
UNIT#) LOT#f
�� ,,// PERMIT EXPIRES IF WORK
OWNER j167;iqq�rtT/T� CONTRACTOR IS NOT STARTED WITHIN
INSPECTION DATE INSPECTOR INSPECTION RECORD 180 DAYS OF PERMIT ISSU.
FOUNDATION NOTE: ANCE OR-180 DAYS FROM
UFER ALL GRADING AND DRAINAGE SHALL BE INSTALLED LASTCALLED INSPECTION.
PREGUNITE TO COMPLY WITH THE APPROVED PLANS AND CITY OF' PERMIT VALIDATION
CUPERTINO STANDARDS.
GARAGE SLABS
POUR NO CONCRETE UNTIL ABOVE HAS BEEN SIGNED
UNDERGROUND /SLAB
i, PLUMBING - ✓ 6 J.
ELECTRICAL _ _
_ ISSUANCE.DALE
MECHANICAL BLDG ELECT I PLG, MECH
DO NOT POUR FLOOR UNTIL ABOVE HAS BEEN SIGNEDA BUILDING PERMIT
I WOOD FLOOR - c .�1 INFORMATION
PLUMBING � t vawn
noN 5/FT.
MECHANICAL ' P,4V fti o I p
ELECTRICAL - ,-.,/ PERAt� ,`•,�
FRAMING
INSULATION STORIES T ECONSTR
• OCC GROUP RES UNITS
i
PLACE NO SUBFLOOR UNTIL ABOVE HAS BEEN SIGNED
ROOFSO IT FLOOR PREA TOTAL ACREAGE
- NOTE:NO FINAL INSP.SHALL BE MADE BEFORE
DIAPHRAGM THE CONSTRUCTION TAX IS PAID
ROQF SHEATHING BUILDING USE
ILS IND 'CON PB ov—
APPLY NO ROOFING UNTIL ABOVE HAS BEEN SIGNED FINALS DATE INSP. ❑ ❑ ❑ ❑ ' ❑
ASSESSORS PARCEL No.,
ROUGH SAN.#
PLUMBING ELECT.ENERGY '
TUBS 8 SHOWER PAN - PLUMBING ENERGY TRACT NO PARCEL NO
MECHANICAL - MECH.ENERGY
ELECTRICAL BUILDING ENERGY ACC DATE. ACC.FILE NO
FRAMING ELECT.FINAL TEST
INSULATION PLUMBING 7NING ENG.SITE NO.
GAS TEST GAS
MECHANICAL FIRE$PRINK ENERGY L3A
COVERNO WORK UNTIL ABOVE HAS BEEN SIGNED HEATING ° ❑ N❑ I Y ❑ N❑
EXTERIOR SHEAR ELECTRICAL RELEASE FL000 zoNE ALUC.
INTERIOR SHEAR FIRE DEPT. �❑ NC] r (1 N[]SHEETROCK _ GRADE FEE SUMMARY
EXTERIOR LATH BUILDING -
INTERIOR LATHTEMPORARY APPROVALS - BUILDING �/�.•
SCRATCH COAT ELECTRIC PLAN CHECK J
GAS FEE
NO TAPE OR PLASTER UNTIL ABOVE HAS BEEN SIGNED OCCUPANCY SEISMIC FEE
OCCUPANCYOF BUILDING IS NOT PERMITTED UNTIL BUILDING FINALIS SIGNED BY BUILDING INSPECTOR. MICROFILM
s7 w ARRANGE FOR INSPECTION BY PHONING 252-4505, ELECTRIC
~O� ONE WORKING DAY BEFORE REQUIRED INSPECTION. PLUMBING
PLEASE GIVE JOB ADDRESS WHEN PHONING.
— SEE PERMIT FOR EXPIRATION DATE — MECHANICAL
IMPORTANT! CONST,TAX-
PLEASE READ REVERSE SIDE BEFORE TOTAL
CALLING FOR FINAL INSPECTION. S .
OFFICE COPY