16893 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
BUILDING PROJECT IDENTIFICATION -PERMIT NUMBER
BUILDING APPLICATION & PERMIT q O(�d
ADDRE 16 v
Gk� EJ BUILDING-ELECTRICAL-PLUMBING-MECHANICAL
OWNS 'S - V PLAN CHECK VALIDATION
NAMFQTY. ELECTRIC PERMIT FEE
u mo o PHDN S
CONTRACTOR S v
UTLETS-SWITCHES-RECEP 10.00/1.00/^�, nl/ LIC.NoQ a3 LIGHTING FIXTURES 10.00/7.00
CONTRACTORS PPLIANCES-RESIDENTIAL 4.00
s d , ONEQr //' PANELS 10.00
DATE OF APPLICATIONPH
ARCHITECT PLAN CHECK FEE ?.C.NO.
OR PANELS(OVER 200 AMP) 20.00 b
ENGINEER
LIC.No. SIGNS TRANS. 3.00
ARCH.OR ENG, PERMIT VALIDATION
ADDRESS SPECIAL CIRCUIT 5.00
ZIP TEMP.METER OR POLE INS. 20.00 .
APPLICANT'S MOTORS
ADDRESS SEE FEE SCH.
T n
SERVICE CHANGE O 20.00
o o LICENSED CONTRACTORS DECLARATION V
a I hereby affum[hm 1 am licensed under provisimu of Chapter 9 ISSUANCE DATE
w (commencing with Section 7000)of Division 3 of the Business and BLDG. ELECT. PLG. MECH.
wv, Professions Cod a the nse is in full f d IF�c ❑
x o m- License CWss_ Lin.Nwn be .a.l�
o! HDale Contructar Cit/ of Cupertino$ ce p rtIDO BUILDIPERMIT
¢ ¢ ¢ < OWNER-BUILDER DECLARATION INFORMATION
boar' MISC.- REFER TO ORD
X ;u.N I hereby affirm that I am exempt from the Contractor's License
uO¢ Law for the ity or county
oreason.(Sec. uiresa,ermit to Professions PERMIT ISSUANCE 10.88 VALUATION $/FT.
� - Code: e,dem y demolish,
conn pair any requiresa p prior
t o consua t.ce,alalter,
2 Q improve,demolish,or repair any structure,prior to its issuance,also ELEC.CONTR. LIC.N0. ELEC.
- O u requires the applicant for such permit to file a signed statement that TOTAL PERMIT TO
AX m he is licensed pursuant to the provisions of toe Contractor's License
wLaw(Chapter 9(tommencingwith Section 7000).fDivision 3 ofthe
F i o Business and Professions Code)or that he is exempt therefrom and OTV. PLUMBING PERMIT FEE
ic H $ the basis for the alleged exemption.Any violation of Section 7031.5 STORIES TYPE CONSTR.
o; � by any applicant for a permit subjects the applicant loo civil penalty ALTER-DRAIN -WATER IEA.) 5.00
of not more than five hundred dollars(5504):
❑ 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,COND. 5.00
Code:The Contractor's License Law does not apply to an owner of
property who builds or Improves thereon,and who does inch work FIXTURES-PER TRAP 5.00 S0.FT.FLODR AREA TOTAL ACREAGE
himself or through his own employees,provided that such improve-
ments are notintended or offered for sale.If,however,the building GAS-EA.SYSTEM-11NC.4OUTLETS 6.00
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 he did not build or im- . . .
RES IND CON PB Ocher
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 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 contractor(s)licensed pursuant to
the Contractor's License Law. SEWER-SANITARY-STORM EA.200ft/10.00 TRACT NO: PARCEL NO.
O lam exempt under Sec.-,BARC.for this WATER HEATER W/VENT 6 rdO
reason IF
Owner Date WATER SYSTEM - 5.00
ACC.-DATE ACC.FILE NO,
WORKERS'COMPENSATION DECLARATION WATER TREATING EQUIP. 5.00
I hereby affirm that I have a certificate of consent to self-insure' ZONING ENG.SITE N0.
or a certD"o of WLA��_pensa'on Insurance or a certified
COPY t .Polic Q ❑ e copyu nisheJ. - FIRE$PRINK ENERGY T-Z9
Z Z ,FJ Cer'fit c with the city inspection division. MISC.- REFER TO ORD.O mansY❑ N❑ Y ❑ N❑
CC rn PERMIT ISSUANCE .00 DO FLOOD ZONE A.L.0 C.
CE TI ICA TIE OIr IiXEMPTION PROM WORKERS'
aQCOMPENSATION INSURANCE PLO.CONTR. LIQ NO. PLG.' 1 acs V❑ N❑ V❑ NE)Section need not be completed if the permit is for one TOTAL
M'Z hundred dollars IS 100)-1 less.)
L) O 1 certify that in the performance of the work for which this per. DTV. MECHANICAL PERMIT FEE FEE SUMMARY
Ul U mil is issued,I shall not employ any person in any manner so as to
become subject to the Workers'Compensation Laws of California.
Q y Date Applicant ALTER OR ADD TO MECH. 5.00 VELECTRIC
to NOTICE TO APPLICANT: If,after making this Certificate of Ex-
F = emplion,you should become subject to the Workers'Compensation APPLIANCE 5.00
provisions of the Labor.Code, you must forthwith comply with - -
V such provisions or this permit shall be deemed revoked. AIR HANDLING UNIT(TO 10=C.F.M.) 4.00
CONSTRUCTION LENDING AGENCY AIRHANDLING UNIT(OVER 10MOC.RM.) 6.00
I hereby affirm that there is a construction lending agency for EXHAUST HOOD (WITH DUCT) 5:00
the perfonllance of the work for which this permit is issued(Sec. HEATING UNIT(TO 100,000 B.T.U.) 8.00
3097;Civ.C.).
Lender's Name HEATI NG UN IT(OV E R 100,000 B.T.U.)9.50 Leader's Addmss
1 certify that I 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 countyPLUMBING
ordinances and state laws relating to building construction, and BOILER-COMP(3 H.P.or 100,000 B.T.U.) 6.00
hereby authorize representatives of this city to enter upon the BOI LER-COMP(Over 100,000 STU)SEE FEE SCH. MECHANICAL
above-mention property for inspection purposes.
(We) agree t Save, indemnify and keep harmless the City of MISC,- REFER TO ORD.
§uperfino again liabilities,judgments, costs and expenses which CONST:TAX
in any way accrue against said City in consequence of the PERMIT ISSUANCE 10.00
of This pe it. MECH.CONT: LIC.NO. MECH.
CTg . TOTAL TOTAL �ydJ
Signa r o Applicant/Contractor Date
OFFICE COPY
1 R
POST THIS CARD NEAR FRONT OF BUILDING PERMIT NUMBER
CITY OF CUPERTINO, 16893
INSPECTION DIVISION
d/Co„y npp�B INSPECTION RECORD
X03
PERMIT EXPIRATION
J08 ADDRESS 1J UNIT# - _LOT#
O�, PERMIT EXPIRES IF WORK;
coNTRncroR
OWNER V ,Q1 IS NOT STARTED:WITHIN
INSPECTION DATE INSPECTOR INSPECTION RECORD 180 DAYS OF PERMIT ISSU-
FOUNDATION - ANCE OR 180 DAYS FROM
NOTE: LAST CALLED INSPECTION.
UFER ALL GRADING AND DRAINAGE SHALL BE INSTALLED
PREGUNITE TO COMPLY WITH THE APPROVED PLANS AND CIT/OF PERMIT VALIDATION
CUPERTINO STANDARDS. '1
GARAGE SLABS �'h► - �,
POUR NO CONCRETE UNTIL ABOVE HAS BEEN SIGNED
UNDERGROUND /SLAB .JAN 1 9 1989 -
PLUMBING -
ELECTRICAL - c;tIV of rmpprf;nA
ISSEIANCE DATE
MECHANICAL - BLDG ELECT I PLG. MF.CH.
DO NOT POUR FLOOR UNTIL ABOVE HAS BEEN SIGNED BUILDING PERMIT
INFORMATION
WOOD FLOOR - VALUATION SIFT.
PLUMBING
MECHANICAL -
PEHMIT TO
' - ELECTRICAL
FRAMING
INSULATION - - STORIES TYPE CONSTH.
GCC.GROUP RES.UNITS
PLACE NO SUBFLOOR UNTIL ABOVE HAS BEEN SIGNED -
SO FT-FLOOR AREA TOTAL ACREAGE
. ROOF NOTE:NO FINAL INSP,SHALL BE MADE BEFORE
DIAPHRAGM THE CONSTRUCTION TAX IS PAID
BU LDING USE
ROOF SHEATHING - � - � � � � HEs IND CON ve tim•, .
APPLY NO ROOFING UNTIL ABOVE HAS BEEN SIGNED FINALS DATE INSP. ❑ ❑ ❑ ❑
.ASSESSORS PARCEL NO
. .ROUGH SAN.#
PLUMBING ELECT.ENERGY TRACT NO. PARCEL NO
TUBS 8 SHOWER PAN - - PLUMBING ENERGY- -
MECHANICAL MECH..ENERGY
- ELECTRICAL BUILDING ENERGY . ACC.DATE ACC.FILE NO:
FRAMING ELECT.FINAI.TEST
INSULATIONPLUMBING ZONING - ENG.SITE NO,
GAS TEST GAS - '
FIRE SPRINK ENERGY LP<
MECHANICAL Y NQ Y ❑ No
COVER NO WORK UNTIL ABOVE HAS BEEN SIGNED HEATING
FLOOD ZONE ALuc.
EXTERIOR SHEAR ELECTRICAL RELEASE v(] . NO v ❑, N❑•
INTERIOR SHEAR - FIRE DEPT
SHEETROCK- - GRADE FEE SUMMARY
EXTERIOR LATH BUILDING
INTERIOR-LATH TEMPORARY APPROVALS BUILDING
SCRATCH COAT ELECTRIC PLAN CHECK
GAS FEE
NO TAPE OR PLASTER UNTIL ABOVE HAS BEEN SIGNED OCCUPANCY. SEISMIC FEE
OCCUPANCY OF BUILDING ISNOT PERMITTED UNTIL BUILDING FINAL ISSIGNED BY BUILDING INSPECTOR. MICROFILM
i
ARRANGE FOR INSPECTION BY PHONING 252-4505, ELECTRIC
F ONE WORKING DAY BEFORE, REQUIRED INSPECTION: . PLUMBING'v. o� PLEASE GIVE JOB ADDRESS WHEN PHONING.
Z E MECHANICAL
- SEE,PERMIT FOR EXPIRATION DAT -
IMPORTANT! CONST.rnx
PLEASE READ REVERSE`SIDE BEFORE TOTAL l lr•�
CALLING FOR-FINAL INSPECTION'.
OFFICE COPY