C 8165 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
BU LDI NG PROJECT I DENTI FICATI ON IT NUMBER
ADILDING APPLICATION & PERMIT 16 5
%�I BNe
BUILDING-ELECTRICAL-PLUMBING-MECHANICAL
9 ER 3 N CHECK VALIDATION
GAME
DTV. ELECTRIC PERMIT FEE
G PHONE
NTRACTOR'S
N . OUTLETS-SWITCHES-RECEP 10.00/1.00 e(
r LIc.No LIGHTING FIXTURES 10.00/1.00
SONTRACTOR'S
ADDRESS ? PPLIANCES-RESIDENTIAL 4.00
I HONE PANELS 10.00 DATE OF APPLICATION
AYfYMISf
OR PANELS (OVER 200 AMP) 20.00 PLAN CHECK FEE P.C.NO.
ENGINES
uC.No, QZ SIGNS TRANS. 3.00
AflCH.OR ENG.
ADDRESS SPECIALCI RCUIT 5.00 PERMIT VALIDATION
APPLICANTS ZIP EMP.METER OR POLE 20.00 PAI
ADDRESS MOTORS SEE CH.
0" Lail SERVICE CHANGE 20.00 CT - �-
oai
'. 02. LICENSED CONTRACTORS DECLARA ON TEMP.POLEGityCupPr .00
X<i w 1 hereby affirm that I am licensed under provisions of Chapter 9 Ify Of CBgW�IN
< (commencing with Section 7000)of Division 3 of the Business and I S A DATE
e. Professions Co nd ylicense is in full lO 1 BLDG. ELECT, PLG. MECH.
2 O Licenqse C�la�ss � Lic.Number. T� f (� f
y r iu Date .7 0--��-Conlructo �I LJ- L';51_
E ¢ w s, OWNF:R-BUILDER DF. RATIO BUILDING PERMIT
X ;LL H I hereby affirm tlmt I am exempt from the Contractor's License MISC.- REFER TO ORD INFORMATION
F u O j Law tot the following reason.(Sec.7031.5,Business and Professions O VgLUATION S/FT.
Code:Any city or county whichrequiresa permit toconstrucgalteq PERMIT ISSUANCE 10.00 / GYifl
¢ ¢ ¢ FO improve,demolish,or repair any structure,prior to its issuance,also ELEC.CONTR. LIC.NO. - ELEC. '•'T OUv
aS O u requires the applicant for such permit to file a signed stntemenf Ihet
TOTAL ERMIT TO
w he is licensed pursuant t0 the provisions of[he Contractor%License
Law(Chapter 9(commencing with Section7000)ofDwision30R le r�•d�/ 7a e) ^,)
4 a Business and Professions Code)or that he is exempt therefrom and OTV. PLUMBING PERMIT FEE
¢ I- the basis for the alleged exemption.Any violation of Section 7031.5 STORIES TYPE CONSTR.
aR by any applicant for a Permit subjects the applicant toa civil penaltyMALTER-DRAINAIN&VENT-WATER IEA.) 5.00
ofnot more than five hundred dollars(5500).):❑ I,as owner of the property or my employees with wages as. W PROTECT. DEVICE 4.00heir sole Compenstion,will do the work,and the structure is notOCC.GROUP RES.UNITS
imended or offered for sale(Sec. 7044, Business and ProfessionsOOR,ROOF,AREA,CON D. 5.00Code:The Contractor's License Law does not apply to an owner ofproperty who builds or improves thereon,and who does such work -PER TRAP B.Oo 0 SO.FT.FLOOR AREA TOTAL ACREAGE
himself or through his own employees provided that such improve-
mentsarenotinghhis or offered for .however,thatsuhe buildingVSTEM-1 INC.40UTLETS 6.00
or improvement is sold within one year of completion,the owner- VSTEM-OVER 4 IFA 2.00
builder will have the burden of proving that he did not build or am. BUILDING USE
prove 1.aso neeose of sale.). INDUSTRIAL WASTE INTER. 30.00 RES IND CON PS Omer
❑ L as owner of the property,he exclusively. 7044,contracting with ❑ 0 ❑ ❑ 0
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 owner of properly who builds or improves thereon,and who LAWN SPRINKLERS-OVER !EA 1,00
contracts for such projects with a contractorts)licensed pursuant to
the Contractors License Law. SEWER-SANITARY-S .200ft/10.00 TRACT NO. PARCEL NO.
❑ [am exempt under Sec. ,B.&P.C.for this
reason WATER HEATER W/VENT 6.00
Owner Date WATER SYSTE _ 1985 5.00
ACC.GATE ACC.FILE NO. .
WORK ERS'COMPENSATION DECLARATION WATER TREATING EQUIMy Of P. 5.00
I hereby affirm that 1 have a certificate of consent to self-insure,
co a certificate of Workers'Compensation Iny ra ce, a certified ZONING ENG.SITE NO.
avelfino
copy thereof(See.3 800, pmylxp�
Policy No. Company 7 �
Cl ❑ Certified CO mreby furnishc FIRE SPRINK ENERGYT]4
Z Z ;4etlifie is filed with aty inspection division.
P: O Applicant MISC.- REFER TO ORD. Y [] N E] Y C] N�
� - CE 'KATE OF EXEMPTION FROM WORKERS' PERMIT ISSUANCE 10.00 FLOOD ZONE a.L.u.c.
Wa 0 COMPENSATION INSURANCE. PLG.CONTR. ❑C.NO. PLG, 0_(This section need not be completed if the permit is for one TOTAL Q Y N V C] N
=) Z hundred dollars IS 100)or less.
U O I certify that in the performance of the work for which this per- OTV MECHANICAL'PERMIT FEE FEE SUMMARY
LL F- mit is issued,I shall not.employ any person in any manner so as to
O Do become subject Wthe Workers'Compensation Laws of California.
IS. Date ApplicantALTER OR ADD TO MECH. 5.00 BUILDING /l0
} Z NOTICE TO APPLICANT: If,after making this Certificate of fix
- emption,you should become subject to the Workers'Compensation APPLIANCE 5.00 PLAN CHECK
provisions of the Labor Cade, you must forthwith comply with
U such provisions or this permit shall be deemed revoked. AIR HANDLING UNIT ITO 10=12-F.M.) 4.00 FEE
CONSTRUCTION LENDING AGENCY AIR HANDLING UNIT(OVER 6.00 SEISMIC FEE O S
1 hereby affirm that there is a construction is
agency r EXHAUST HOOD(WITH DUCT) 5.00
the performance of the work for which this permitmit is issued fgacec. MICROFILM
Nam097,ci HEATING UNIT(TO 0 .LU 17 C9'iPO
Lender's Name
Lender's Address H EATI N G UNIT(OV ER100,0 OB.T.U.)9.50 ELECTRIC L�7p
I certify that 1 have read this application and state that the above VENTILATION FAN ( ) (fjp(PO
J information n correct. I agree to comply with all city and county PLUMBING p�
ordinances and slate'laws relating to building construction, and BOILER-COMPI3 H.P.or 100,000 B.T.U.1 6.00
hereby authorize representatives of this city ID enter upon the
above-mentioned property for inspection purposes. BOILER-COMP (Over 100,000 BTU)SEE FEE SCH. MECHANICAL
(We) agree to save, indemnify and keep harmless the City of MISC.- REFER TO ORD.
Cupertino against liabilities,judgments, costs and expenses which CONST.TAX
may ay accrue gas said City in consequence of the PERMIT ISSUANCE 10.00 a 1
g this permit MECH.CONT. LIC.NO. MECH.
Si eof Applicant/Co tractor Dale TDTAL / / TOTAL
OFFICE COPY �J
POST THIS CARD NEAR FRONT OF BUILDING
I • �: t
I PERMIT NUMBER'
CITY OF CUPERTINO'
z = " INSPECTION DIVISION
JOB INSPECTION RECORD,. '
• i' . I1'/J //1� /j��V! PERMIT EXPIRATION'
JOBADDRESS ''I ll (�I VIa I ofoh410U T# _LOT# 1. 1.
PERMIT EXPIRES I
OWNER CONTRACTOR . 2 IS NOT STARTED WITHIN
INSPECTION DATE INSPECTOR INSPECTION RECORD 180 DAYS OF PERMIT ISSU
FOUNDATION (Z - I ANCE OR 180 DAYS FROM
LASTCALLED INSPECTION.
LIFER
PREGUNITE • - �' PERMIT VALIDATION
.. it •�.
POUR NO CONCRETE UNTIL ABOVE HAS BEEN SIGNED
UNDERGROUND /SLAB 3l,/�sPLUMBING - ., `
ELECTRICAL E - ISSUANCE DATE
MECHANICAL - e Ecec ••PLc MECH. '
DO NOT POUR FLOOR UNTIL ABOVE HAS BEEN SIGNEDBUILDING PER MIT
INFORMATION
WOOD FLOOR VALUATION S/FT.
PLUMBING
MECHANICAL - ' ' `/ E c '�• `
ELECTRICAL ' PERMIT. l O TO /�
FRAMING ^ - -. 1 77V' /
INSULATION _ - STORIES TYPE CONSTR.
OCC.GROUP RES.UNITS
;PLACE NO SUBFLOOR UNTIL ABOVE HAS BEEN SIGNED
ROOF - SO,FT,FLOOR AREA TOTAL ACREAGE
- DIAPHRAGM - RUILDINGUSE .
IND CON PB OInP1
APPLY NO ROOFING UNTIL ABOVE HAS BEEN SIGNED I 1:1 El ❑ ❑
ROUGH
ASSESSO RS PARCEL NO.
� - � � � " -
PLUMBING -
GAS TEST, - TRACT NO. PARCEL NO.
MECHANICAL -
ELECTRICAL FINALS DATE INSP. ACC..DATE ACG FILE NO.. •
' FRAMING ,i SAN # ZONING ENG.SITE NO,
INSULATION PLUMBING
' GAS
MECHANICAL FIRE SPRINK - ENERGY T@E ,
COVER NO WORK UNTIL ABOVE HAS BEEN SIGNED HEATING; Y❑ N❑ Y ❑ N❑
LATH-INTERIOR ELECTRICAL FLOODZONE IA L.U,C. -
LATH-EXTERIOR IF FIRE DEPT. YE]' IN C] - 'Y ❑ N❑'
SHEETROCK — GRADEFEE SUMMARY
SHEAR INTERIOR BUILDING
SHEAR EXTERIOR - - - TEMPORARY APPROVALS
FIREWALLS - ELECTRIC - PLAN CHECK
GAS. FEE ..
NO TAPE OR PLASTER UNTIL ABOVE HAS BEEN SIGNED OCCUPANCY SEISMIC FEE ;
UCCUPANCY OF BUILDING IS NOT PERMITTED UNTIL BUILDING FINAL IS SIGNED BY BUILDING INSPECTOR. MICROFILM
w ARRANGE,FOR INSPECTION BY..PHONING 252-4505, , ELECTRIC
F ONE WORKING DAY BEFORE' REQUIRED INSPECTION. PLUMBING
0 PLEASE GIVE JOB ADDRESS WHEN J PHONING. r z MECHANICAL
- SEE PERMIT FOR EXPIRATION DATE -
IMPORTANT! .
ATE -IMPORTANT! . CONST:TAX
PLEASE READ REVERSE SIDE BEFORE TOTAL <
CALLING FOR FINAL INSPECTION.
- , OFFICE`COPY - - -