11079't:iCANT TO FILL IN INFOFISTION WITHIN RED LINES - USE Ep`LL POINT PEN ONLY
BU I LDINGPROJECT I DENTIFICATU
-_4'
APPLICATION & PERrib p
BUILDING -ELECTRICAL- PLUMBING -MECHANICAL
PERMIT NUMBER
11079
BUILDING
ADDRESS
OWNER'S.•,
NAME p
l' .S PHONE
�.
NiFr,; TAr .(! WA a'. .:� . ♦ ., '� •eBi' t '1Z -.,
FZ( 14c,ELECTRIC PERMIT " "'I If --.FEE;,
.1
PLAN CHECK VALIDATION
C CTO
all
UTLETS- SWITCHES -RECEP 10.00/1.00
LIGHTING FIXTURES 10.00/1.00
NR's
ADDRESSRESS
APPLIANCES - RESIDENTIAL 4.00
QoPH0N O
DATE OF APPLICATION
PANELS 10.00
ORRDHhrscT
ENGINEER
uC. No.
PANELS (OVER 200 AMP) 20,00
PLAN CHECK FEE P.C. NO.
SIGNS TRANS. 3.00
ADDRESS EN
SPECIAL CIRCUIT 5.00
PERMIT VALIDATION
EMP. METER OR POLE INS. 20.00
ZIP
P
APPLICANT
ADDRESS
MOTORS SEE FEE SCH.
SERVICE CHANGE 20.00
/�
//
AR
'- LICENSED CON ' I' RACfORS DECLARATION
1 hereby affirm chat I am licensed under Provisions of Chapler 9
(commencing with Section 7000) of Division 3 of the Business and
Professions Codc rl m license -is in full fortey'� ..yy��{}fk}j��ffoAPPy/
License Cl's Lic. Number"IJVV`r
Dale Conlradori�%�
Xi
SUANCE GATE
BLDELECT.
I
_-1
�In
PLG. MECH.
\
��
,x}',:,BUILDING PERMIT
>. 6; INFORMATION h
VNERBUILDER DECLARATION
I hereby affirm that I am exempt from the Contractors 'cense
Law for ore following centric. (Sec. 7031.5, Businessand Professions
Code: Any city or county which requiresa permit to construct, 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 Licenses
Law (Chapter 9(commencingwith Section 7000) of Division 3 cities
Business and Professions Code) or that Ire isexe mpc therefrom and
MISC. - REFER TO ORD
VALUATION
'q
S/FT.
PERMIT ISSUANCE 10.00
ELEC. CONTR. LIC. NO.
ELEC.
TOTAL
PERMIT TO
/N7 1,25/1.(0!]��
..
OTY.. PLUMBING PERM_ IT ,FEE'
STORIES
TYPE CONSTR.
lire basis for the alleged exemption. Any violation of Sccfon703I.5
) " -
by any applicant for a permit subjects the applicant to a civil penalty
of not more that, five hundred dollars (5500).1:
ALTER -DRAIN -WATER (EA.) 5.00
❑ I, as owner of the properly, or my employees with wages as
their sole compensation, will do the work, and the structure is not
BACK FLOW PROTECT. DEVICE 4.00
OCC. GROUP
RES. urvcTs
DRAINS -FLOOR, ROOF, AR EA, COND. 5.00
intended of offered for sato (Sec. 7044, Business .,,it Professions
Code: The Contractor's License Law does not apply to an owner of
property who builds or improves thereon, and who does such work
Ihimsclf or through his own employees, provided that such improve-
mcntsarc not intended orcloned for sale. If, however, the building
FIXTURES - PER TRAP 5.00
GAS - EA. SYSTEM -1 INC.4 OUTLETS 6.00
SO. FT. FLOOR AREA
TOTAL ACREAGE
or improvement is sold within one year of completion, the owner-
builder will have file burden of proving that he did not build or ire
Prove forPurposeof sale.).
❑ as owner of the property, Bat contracting with
GAS - EA. SYSTEM -OVER 4 IEA.) 2.00
aua0we USE
RES IND CON PB Other
❑ 0 ❑ ❑
INDUSTRIAL WASTE INTER. 30.00
d project
licensed contractors to construct the project La 7044, of apply
's License Law Jaen not apply
and Professions Code: The who
to owner of property who builds improves (hereon, and who
LAWN SPRINKLERS - 1 INC 5 V.B. 6.00
LAWN SPRINKLERS -OVER 5 (EA.) 1.00
ASSESSORS PARCEL NO.
tr
contracts far such projects with a contramorts) licensed pursuant to
tr
the Contractor's License Law.
SEWER -SANITARY -STORM EA. 200ft/10.00
TRACT NO.
PARCEL NO.
❑ lam exempt under Sec. ,BAP.C. for this
WATER HEATER W/VENT 6.00
reason
Owner Date
WATER SYSTEM 5.00
ACC. DATE
ACC. FILE NO.
. WORK ERS'COMPENSATION DECLARATION
WATER TREATING EQUIP. 5.00
I hereby affirm that I have a certificate of consent to self -insure,
or a certificate of Workers'Compensatim, Insura ,ora ertil'ied
copy thereof(Sec. 3800, LaDC.I I a s�,
Policy No.-Company-%SL4�/
ZONING
ENG. SITE NO.
Raified copy's hereby fumisl it
rfi c p is filed %It 'if tin iv' nn.
Applinnt
FIRESPRINK
y C] rvC]
ENERGY T 24
Y 0 N�
MISC. - REFER TO ORD.
CERTIFICATE OF EXEMPT ION FROM WORKERS'
PERMIT ISSUANCE 10.00
FLOOD ZONE
A.L.u.c.
PLG. CONTR. LIC No,
PLG.
TOTAL
COMPENSATION INSURANCE
('Phis section need not be completed if the permit is for one
v� N�
Y� rv❑
11 )o „I'
-QTY li;, r1 (s• �, °s
. �y I MECHANICAL;PERMIT" 'e":8 (-, ,` FEE C
""" - "" -
.">FEE SUMMARY,', "
hundred dollars IS 100) or less.)s,
m
I certify that in the performance of clic work for which this per,
mit is issued, I shall not employ any person in any mannerso as bo
become subject W the Workers'Compensation Laws of California.
Date Applicant
BUILDING
ALTER OR ADD TO MECH. 5.00
NOTICE TO TO APPLICANT: If, after making this Certificate of Ex-
emption, you should become subject to file Workers' Compensation
provisions of the Labor Code, you must forthwith Comply with
such provisions or this Permit shall be deemed revoked
APPLIANCE 5.00
PLAN CHECK^S�
FEE
y
rat
AIR HANDLING UNIT (TO 10,10100C.F.M.) 4.00
AIRHANDLING UNIT(OVER 10000C.F.M.) 6.00
SEISMIC FEE
.. CONS TRUCTIONLENDING AGENCY
1 hereby affirm (hat there is a construction lending agency for
EXHAUST HOOD (WITH DUCT) 5.00
The performance of the work for which this Penni( is issued (Sec.
3097,
MICROFILM
HEATING UNIT (TO 100,000 B.T.U.) 8.00
HEATING UNIT (OVER 100,000 B.T.U.)
ELECTRIC
Lender's Name
coder's Address
I certify that I have read this application and state that the above
,if onnat ion is correct. I agree to comply with all City and county
ordinances and state laws relating to building construction, and
VENTILATION FAN (SINGLE) 4.00
PLUMBING
BOILER-COMP(3 H.P. or 100,000 B.T.U.) 6.00
BOILER -COMP (Over 100,000 BTU) SEE FEE SCH.
MECHANICAL
hereby authorize representatives of (his city to enter upon the
above-mentioned properly for inspection purposes.
MISC. - REFER TO ORD.
CONST. TAX
(We) agree to save, indemnify and keep harnrlc the Cily of
Cupertin against liabilities, judgments rosts an rentcs which
n any way Becrue against tai 'ily inqueue of the
gra g coil'
y
PERMIT ISSUANCE 10.00
ECM. CONT. LIC. NO, MECH.
TOTAL
TOTAL
�o'f O �
i ore o Applicant/Conlr ctor to
OFFIr-r- rr rcy
POST THIS CA NEA FRONS OF BUILDING r—
��
.CIT:YMF CUPERTINO (
.INSPECTION DIVISION
BINSPECT N RECORD
JOB ADDRESS I # LOQ'
PFRN11T NUMBER
11079 `
PERMIYEXPIRATION
PERMI PIRES-IFWORK'
OT STARTED WITHIN.
180 DAYS OF PERMITISSU-'
ANCE OR 180 DAYS FROM
LA ST CALLED INSPECTION.:
OWNER CONTRA,T
INSPECTION- A E INSPECTOR
INSPECTION REC RD
RE?
FOUNDATION.,
- }
�.
LIFER ... ,, ,.
PREGUNITE
- - ., _ �
" PERMIT VALIDATION,-
e 7 y rr, ,..•.
onrE
POUR NO CONCRETE UNTIL ABOVE HAS BEEN SIGNED
UNDERGROUND /.SLAB,
PLUMBING _
,. '.r
ELECTRICAL'IssuANCE
MECHANICAL
eL c.
ELECT.
PLC. ME
DO NOT POUR FLOOR UNTIL ABOVE HAS BEEN SIGNED
i 1 ,1
BUILDING PERMIT,
INFORMATION
WOOD FLOOR
PLUMBING
VALUATION
$/FT I
MECHANICAL,-,
ELECTRICAL
^ •:
STORIES TYPE comsTR.
FRAMING i " -'
INSULATION
+
•
OCC. GROUP
RES, UNITSi
41
.PLACE NO SUBFLOOR UNTIL ABOVE HAS BEEN SIGNED
•ROOF 1
n
♦
SO, FT. FLOOR AREA
.0 4.
TOTAL ACREAGE
DIAPHRAGM-
-
'
••
8
BUILDING USE '
RES,' IND' CON PB 'Ow.,
❑ ❑ ❑ ❑ ' '❑
APPLY"NO ROOFING UNTIL ABOVE HAS BEEN SIGNED
. ROUGH-
( - ;.
•p
._ ASSESSOR S PARCEL NO„•'
PLUMBING
GAS TEST -
'
,
f - -jDA
TRACT NO.
-
PARCE UN01'
.'e
-
MECHANICAL
INSP:
- FINALS,FRAMING
” ncconrE
A.cc.FaE NorELECTRICAL
SAN atINSULATION
PLUMBINGroNlNc
:
ENC, SITE No.
-
IN
GAS•-
. `MEC)HANICAL,
FIRESPRINK
+Y,❑ " NF]
ENERGY T14
` ° ❑`; N❑
COVER NO WORK UNTIL ABOVE HAS BEEN SIGNED
HEATING
LATH=INTERIORELECTRICAL
-�,
,FLOOD ZONE'
Y ❑ - N;O
.A.L: UO
° ❑ `9 N❑:
LATH- EXTERIOR.. '
FI REDEPT. ,! n.
SHEETROCK; -
GRADE? "'_
FEE SUMMARY
SHEAR INTERIOR ' '' +"�
BUILDING
BUILDING
SHEAR EXTERIOR'." -
•TEMPORARY1APPROVAL -
FIREWALLS
ELECTRIC.PLAN
CHECK
.FEE
GAS :,
NO TAPE OR PLASTER UNTIL ABOVE HAS BEEN SIGNED
OCgUPANCY'
'SEISMIC FEE.
OCCUPANCY OF BUILDING ISNOTPERMITTED UNTIL,BUILDING FINALISSIGNED BY BUILDING INSPECTOR.
"MICROFILM'
ARRANGE FOR INSPECTION BYPHONING.252-4505;.
~'� ONE WORKING DAY BEFORE'. REQUIRED`INSPECTION..
o PLEASE GIVE JOB ADDRESS WHEN PHONING.
Z
' '-SEE PERMIT FOR EXPIRATION DATE = -,''
ELECTRIC
-
PLUMBING
•
MECHANICAL
'
CONST.TAx"
IMPORTANT!
PLEASE READ REVERSE SIDE BEFORE ry,
,CALLING FOR FINAL INSPECTION.
TOTAL ,
OFFICECOPY -
;`APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - IISF RAI I Pnit%IT PFNI Grit V
BUILDING PROJECT I DENTI FICATI
IV ILDING
aDADDREss
22.2 7-CwN
APPLICATION &PER
BUILDING -ELECTRICAL- PLUMBING -MECHANICAL
PERMIT NUMBER
11079
ER's NA
11 O ME O'J
S PHONE •�rJ
TY, ELECTRIC PERMIT FEE
PLAN CHECK VALIDATION
DATE OF APPLICATION
PLAN CHECK FEE D.C. NO.
CONTR CTO
/ "AME 10
OUTLETS - SWITCHES -RECEP 10.00/1.00
LIGHTING FIXTURES 10.00/1.00
APPLIANCES- RESIDENTIAL 4.00
- NTR ACTOR'S
ADOREss
PHON d
ARCHITECT
OR
ENGINEER
PANELS 10.00
PANELS 200 AMP) 20.00
SIGNS TRANS. 3.00 -
' uc. ND.
ARCH OR ENO. .
ADDRESS
SPECIALCIRCUIT 5,00.
PER MIT VALIDATION
ZIP
TEMP. METER OR POLE INS. 20.00
-
e
ARDRESrvrs
AS
MOTORS SEE FEE SCH.
-
SERVICE CHANGE 20,00
r/
e{� Q J
J �r
^' ` 2 (i lJ
I SUANCE DATE '
1
-�'-• .LICENSED CONTRACTORS DECLARATION
I hereby affirm that 1 am licensed under provisions of Chami
ter 9
(commencing with Section 7000) of Divi3 of the Business and
Professions Code d m license ,is in fulldC
License Cl s Lie. Num h�/
ale Contractor
-
B- LD(s', ELLGrECC{T.
I {` LII
PLG. MECH.
El El
NER-BUILUER DECLTION
BUILDING PERMIT
1 hereby affirm that I am exempt froContractors icense
Law for the following reason. (Sec. 7031.siness and Professions
Code', Any city or county which requiresamit to construct,
improve, demolish, or repair any structureor to its issuance, also
requires the applicant for such permit to fsigned statement that
Ile is licensed pursuant to the provisions OContractor's s License
Law (Chapter 9 (commencing with Sectio0) of Division 3 of the
Business and Professions Code) or that hxempt therefrom and
the basis for the alleged exemption. Any vion of Section 7031.5
by any applicant fore permit subjects the applicant $500)licatoo civil penalty
of not more than five hundred subjects
is ):
0 1, as owner of the property, or my employees with wages as
their sole compensation, will do the work, and the structure is not
intended or offered for sale (Sec. 7044, Business and Professions
Code: The Contractor's License Low does not apply to an owner of
Property who builds or improves (hereon, and who docs such work
himself or through his own employees, provided that such improve-
mentsarenotintendedorofferedforsale. If however, the building
or improvement is sold within one year oICompletion, the owner -
builder will have the burden of proving that he did not build or im-
prove for purpose of sale.),
❑ I, as owner of the property, am exclusively contracting with
licensed contractors to construct the project (Sec. 7044, Business
and Professions Cade: The Contractors License Law does mat applyASSESSORS
to an owner of property who builds or improves tliereon, and whoERS
contracts for such projects with a contractors) licensed pursuant to
tile
the Contractor's License Law.
❑ l am exempt under Sec. BAP.C. for thisR
MISC. - REFER TO ORD
PERMIT ISSUANCE 10.00
INFORMATION
VALU
VALUATION
�/ V V v
g/FT.
ELEC. CONTR. LIC. NQ
ELEC.
TOTAL
PERMIT TO
�!�
�'v7. 2t,BM U ria -/--
QTY. PLUMBING PERMIT FEE
ALTER -DRAIN VENT -WATER (EA.) 5.00
STORIES
TYPE CONSTR.
BACK FLOW PROTECT. DEVICE 4.00
OCC. GROUP
RES. UNITS
DRAINS -FLOOR, ROOF, AREA, COND. 5.00
FIXTURES -PER TRAP 5.00
GAS - EA. SYSTEM -11 INC. 4 OUTLETS 6.00
GAS - EA. SYSTEM - OVER 4 (EA.) 2.00
SO. FT. FLOOR AREA
TOTAL ACREAGE
BUILDING USE
RES IND CON PB Omer
INDUSTRIAL WASTE INTER. 30.00
B. 6.00
LAWN SPRINKLERS- 1 INC 5 VMI-
PARCEL NO.
'
- OVER 5 (EA.) 1.00
RY-STORM EA. 200ft/10.00
W/VENT 6.00reasonOwner
TRACT NO.
PARCEL NO.
Date
5.00ACC.
ec1 WORKERS'COMPENSATION DECLARATION
herby affirm that I have a certificateofconvent to ri-insure,
DATE
ACC. FILE NO.
ING EQUIP. 5.001
or a certificate of WorkeriCompensation Insurn ora ertifiedZONING
copy thereof(Sec. 3800, LabC.).Policy No. Comny
ENG. SITE N0.
❑� C��Iiad copy is hereby furmsl dFIRE
SPRINK
Y D N ❑
'ENERGY T� 24
.v (] NQ
VC rt c is filed soh cit " . ti n iv on.
Applicant
Cr RTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(This section need not be completed if the permit is for one
hundred dollars (E 100) or less.)
MISC. - REFER TO ORD.
PERMIT ISSUANCE 10.00
FLOOD ZONE
V ❑ N
A. L. U.C.
V N[]
PLG.00NTR. LIC. NO.
PLG.
TOTAL
�A
QTY MECHANICAL PERMIT FEE
FEE SUMMARY
Lcertify that in the performance of the work for which this per-
mit is issued, I shall not employ any person in any manner so as to
become subject to the,Workers• Compensation Laws of California.
Date
BUILDING
��.i-e
Applicant
NOTICE TO APPLICANT: If, after making this Certificate of Ex-
ALTER OR ADD TO MECH. 5.00
cmption,you should became subject to the Workers' Compensation
provisions of the Labor Code, you must forthwith comply with
such provisions or this permit shall be deemed revoked:
APPLIANCE 5.00
PLAN CHECK
FEE
^^ 1
AIR HANDLING UNIT (TO 1QODOCF.NL) 4.00
CONSTRUCTION LENDING AGENCY
AIR HANDLING UNIT (OVER 10=C. F.M.) 6.00
SEISMIC FEE
s"'b
EXHAUST HOOD (WITH DUCT) 5.00
1 hereby affirm that there is a construction lending agency for
the performance of the work for which this permit is issued (Sec.
3097, Civ.C.).
Lender's Name
Lender's Address
r
MICROFILM
HEATING UNIT (TO 100,000 B.T.U.) . 8.00
I HEATING UNIT (OVER 100,000 B.T.U.)9.50
ELECTRIC
1 certify that 1 have read this application and stale that the above
information is correct. I agree to comply with all city and county
ordinances end state laws relating to building construction, and
hereby authorize representatives of this city W enter upon the
above-mentioned property for inspection purposes.
VENTILATION FAN (SINGLE) 400
..
BOILER- COMP(3 H.P. or 100,000 B.T.U.) 6.00
PLUMBING
'
.BOILER -COMP (Over 100,000 BTU) SEE FEE SCH.
MECHANICAL
(We) agree to save, indemnify and keep hannle the City of
Cupertis against liabilities, judgments St. an enses which'
any way accrue, against sai ity in Mac of the
gra gm g tri {emdt'
y
i aro o Applicant/Conlr clot I to
MISC. - flEFER TO ORD.
'PERMIT ISSUANCE 10.00
CONST. TAX
ECH. CONT LIC. NO. MECH.
CONT. LIC. NO. MECH.
- TOTAL
TOTAL
6� 0