12528 _ APPLICANT TO FILL IN INFORMATIONAWHIN RED LINES - USE BALL POINT PEN ONLY
• BUILDING PROJECT I DENTIFICATIONMW PERMIT NUMBER
Alf
APPLICATION & PERMIT
A R
BUILDING-ELECTRICAL-PLUMBING-MECHANICAL 12528
DIANE 'S - PLAN CHECK VALIDATION
E DTV. ELECTRIC PERMIT FEE
�( NaMrancroR's /, Tf� OUTLETS-SWITCHES-RECEP 10.00/1.00
Xy / /YCm.No. Z Z LIGHTING FIXTURES 10.00/1.00
/ CONTRACTOR'S APPLIANCES-RESIDENTIAL 4.00
ADDRESS -
/J�, PANELS 10.00 DATE OF APPLICATION
ARCHITECT PANELS (OVER 200 A
ENGINEER MP) 20.00 PLAN CHECK FEE P.C.NO.
OR
LIC.No. SIGNS TRANS. 3.00
ARCH.
oo Ess ENG' SPECIAL CIRCUIT 5,0Q PERMIT VALIDATION
ZIP TEMP.METER OR POLE INS. 20.00
ADDRESsTs MOTORS SEE FEE SCH. ---ttt
SERVICE CHANGE 20.00 /r�7
woo I LICENSED CONTRACTORS DECLARATION }S / ll
¢ u I herebyaffirm that I am licensed under provisions of Chapter 9 ISSU N
y< i (commencing with Section 7000)of Division 3 of the Business and BLDG. E LG. MECH.
i Professions Code�I3pd Ty license is in full for Z
z o License CIT s.JAe Lic.Numbe ❑ ❑
g a DateContractor
a y s BUILDING PERMIT
¢ ¢ W OWNER-BUILDER DECLARATION INFORMATION
o MISC.- REFER TO ORD
E:
;a. y I hereby affirm that I am exempt from the Contractor's License
n.a. Law for the following reason.(Sec.7031.5,Business and Professions PERMIT ISSUANCE 10.00 VALUATION S/FT.
E - st Code:Any city or cuuntywhich requires.permit construct,alter, (/C �4 0
2 ¢¢0 improve,demolish,or repair any structure,prior to its issuance,also ELEC.CONTR. LIC,NO. ELEC.
n - D ¢ requires the applicant for such permit to file a signed statement that TOTAL PERMIT TO
whe is licensed pursuant to the provisions of the Contractor's License
Fz> Law(Chapter 9(commencing with Section 7000)ofDivision 3 ofthe
x ao Business and Professions Code)or that he is exempt therefrom and QTY. , PLUMBING PERMIT FEE
¢I-o the basis for the alleged exemption.Any violation of Section703L5 STORIES TYPE CONSTR.
a, by any applicant for a permit subjects the applicant to a civil Penalty ALTER-DRAIN -WATER IEA.) 5.00
of not more than five hundred dollars($500).):
❑ I,as owner of the property,or my employees with wages as BACK FLOW PROTECT.DEVICE 4.00 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,CONO. 5.00
Code:The Contractor's License Law does not apply to an owner of
property who builds or improves thereon,and who does such work FIXTURES,PER TRAP 5.00 SG.FT,FLOOR AREA TOTAL ACREAGE
himself or through his own employees,provided that such improve.
ments are not intended oroffered forsale.If,however,the building GAS-EA.SYSTEM-11NC.4OUTLETS 8.00
or improvement is sold within one year of completion,the owner- GAS-EASYSTEM•OVER 4(EA.) 200 BUILDING USE
builder will have the burden of proving that h . . .
e did not build or im' RES IND CON PB Omer
prove for purpose of sale.). INDUSTRIAL WASTE INTER. 30.00 - ❑ ❑ ❑ ❑ ❑
❑ I,as owner of the property,am exclusively contracting with
licensed contractors to construct the project(Sec. 7044,Business I 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 owner of property who builds or improves thereon,and who LAWN SPRINKLERS-OVER 5(EA.) 1.00
contracts for such projects with a contmctoAs)licensed pursuant to
the Contractor's License Law. SEWER-SANITARY-STORM EA.200ft/10.00 TRACT NO. PARCEL N0.
❑ lam exempt under Sec.-,BAP.C.for this WATER HEATER W/VENT 6.00
reason -
Owner Date WATER SYSTEM 5.00 -
- ACL.DATE ACC.FILE NO,
WORKERS'COMPENSATION DECLARATION WATER TREATING EQUIP. 5.00
I hereby affirm that I have a certificate of consent to sell'-insure, ZONING ENG.SITE NO.,
or a certificate of Workers'Compensation Insurance,or a certified
copy thereof(Sec.3800,Lab.CJ.
Policy No. Company
O ❑ o is ere yfamished. FIRE SPRINK ENERGY T-24
Z Z ertified P s with the city inspection division. MISC.- REFER TO ORD.
Q pplicanl Y ❑ N❑ Y ❑ No
� to RTIFICATEOF EXEMP ON FROM WORKERS' PERMIT ISSUANCE 10.00 FLOOD ZONE A.L.u.C.
11J _ COM PF-NSATI INSURANCE PLG.CONTR. LIC.NO. PLG.
IL o (This section need not be ompleted If the permit is for one TOTAL Y❑ N❑ Y ❑ N❑
D Z hundred dollars(S 100)or les
U O 1 certify that in the perfo once of the ork for which this per, DTV. MECHANICAL PERMIT FEE FEE SUMMARY
Iy H mit is Issu d, shall not employ y rso in any manner o as to
LLW beco j t the WorkersC a in.. BUILDING
sx,//ll Did Applicant ALTER OR ADD TO MECH. 5.00
} N w NO APPLICANT: If,a mu mg his •rtificate of Gx
F ?/ crop n, au should become subject to the Wor rs'Compensation APPLIANCE 5.00 PLAN CHECK
Pro
visions of the Labor Code, you must for with comply with FEE
C..1 such provisions or this permit shall be deemed •vaked. AIR HANDLING UNIT(TO 1Q000CF.M.) 4.00
CONSTRUCTION LENDINGA 'NCY AIR HANDLING UNIT(OVER IQOODC.EM.) 6.00 SEISMIC FEE
1 hereby affirm that there is a Construction learns asency for EXHAUST HOOD(WITH DUCT) 5.00
the performance of the work for which this permit is issued(Sec. MICROFILM
3097,Civ.C.). t HEATING UNIT(TO 100,000 B.T.U-) 8.00
4eader's Name HEATING UN IT(OVER 100,000 B.T.U.)9,501 ELECTRIC
Lender's Address
1 certify that I have read this application and stale 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-COMPI3 H.P.or 100,000 B.T.U.) 6.00
hereby authorize representatives of this city to enter upon the BOILER-COMP(Over 100,000 BTU)SEE FEE SCH. MECHANICAL
above-mentioned property for inspection purposes. -
(We) agree to save, indemnify and keep harmless the City of MISC.- 'REFER TO ORD.
Cupertino ag 'car liabilities,judgments, costs and expenses which CONST.TAX
y in y ay accrue against said City in consequence of the PERMIT ISSUANCE 10.00
a 'n MECITCONT. LIC.NO. MECH.
TOTAL TOTAL LC/
Signature of Applican ontractor Date
OFFICE COPY
POST THIS CARD NE6SERTINO
ONTOFBUILDING
'
ER
CITY OF PEFMI
12�NO5
28
INSPECTION DIVISION
JOB INSPECTION RECORD,
PERMIT EXPIRATION
'JOB ADDRESS A/�/1- / ESQ`// �Z UNIT# LOT# PERMIT EXPIRES IF WORK
OWNER CONTRACTOR IS NOT STARTED'WITHIN
10 INSPECTION DATE INSPECTOR INISPEtTION RECORD 180DAYS OFPERMIT ISSU-
ANCE OR 180 DAYS F OM
FOUNDATION' p, '-Yf, LASTCALLED INSPECTION.
UFER
PREGUNITE PERMITVALIDATION
J
POUR NO CONCRETE UNTIL ABOVE HAS BEEN SIGNED 1
UNDERGROUND /SLAB 2
. 1 T
PLUMBING ��
ELECTRICAL ISSUANCE DATE
MECHANICAL - BLDG. ELECT. PLG. MECH.
DO NOT POUR FLOOR UNTIL ABOVE HAS BEEN SIGNED BUILDING PERMIT
INFORMATION
WOOD FLOOR A anoN $IFT.
PLUMBING '
MECHANICAL
PERMIT TO
ELECTRICAL
FRAMING.
STORIES TYPE CONSTR.
INSULATION '
` OCC GROUP RES.UNITS
PLACE NO SUBFLOOR UNTIL ABOVE HAS BEEN SIGNED,
ROOF ' - SO"FT.FLOORAFEA TOTALACREAGE
DIAPHRAGM BUILDING use
RES IND CON PB Other
ffAPP..LY NO ROOFING UNTIL ABOVE HAS BEEN SIGNED : ASSESSORS❑PARCEL NO.
ROUGH
PLUMBING
TRACT NO. PARCEL NO.
GAS TEST
MECHANICAL
ELECTRICAL' FINALS DATE INSP. Acc.DATE Acc.FILE No.
FRAMING SAN #
ZONING ENG.SITE NO.
INSULATION - PLUMBING
GAS
FIRE SPRINK ENERGY T.24
. MECHANICAL Y ❑ N[] Y ❑ N❑
COVER NO WORK UNTIL ABOVE HAS BEEWSIGNE%,', HEATING
LATH—INTERIOR ELECTRICAL FLOOD ZONE A.L.0 C.
LATH—EXTERIOR FIRE DEPT. - _ v�. " Y I] NE]
SHEETROCK ' GRADE FEE SUMMARY
SHEAR INTERIOR BUILDING ''iZ BUILDING
SHEAR EXTERIOR TEMPORARY APPROVALS
FIREWALLS ELECTRIC - PLAN CHECK
GAS FEE
ANO TAPE OR PLASTER UNTIL ABOVE HAS BEEN SIGNED OCCUPANCY SEISMIC FEE
OCCUPANCYOF BUILDING IS NOTPERMITTED UNTIL BUILDING FINAL ISSIGNED BY BUILDING INSPECTOR. MICROFILM
1
H} ARRANGE FOR INSPECTION BY PHONING 252-4505, ELECTRIC
ONE WORKING DAY BEFORE REQUIRED INSPECTION. PLUMBING
PLEASE GIVE JOB ADDRESS WHEN PHONING.
Z^^. MECHANICAL
— SEE PERMIT FOR EXPIRATION DATE —
IMPORTANT! coNST.4Ax
I PLEASE READ REVERSE SIDE BEFORE
TOTAL
CALLING FOR FINAL INSPECTION.
OFFICE COPY