13260 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
.,�BUI LOING PROJECT IDENTIFICATION - PERMIT NUMBER
BUILDING APPLICATION & PERMIT
ADDR�sa1 311 co i I b US � BUILDING-ELECTRICAL-PLUMBING-MECHJNA 13260
OWNER'S PLAN CHECK VALIDATION
/� Q
NAME
IC-k Poi' hlV -O� DQd"` 1S$D CITU. ELECTRIC PERMIT /1
CONTRACTORS �NAME -. OUTLETS-SWITCHES-RECEP 10.00!1:00S�L r LIC,ND, LIGHTING FIXTURES 10.00/1.00
CONTH ACTOR's PPLIANCES-RESIDENTIAL 4.00' PAID
ADDRESS
PHONE PANELS 10.00 DATE OF APPLICATION
ARCHITECT PLAN C ECK FEE P.C.NO.
OR PANELS (OVER 200 AMP) 20.00 JLC j 1c
ENGINEER
uc,No. SIGNS TRANS. 3.00
ARCH,DR ENG.
,� R N
ADDRESS / SPECIAL CIRCUIT 5.00 (I- y - 10 �1
ZIP TEMP.METER OR POLE INS. 0.00
APPLICAN MOTORS SEE FEE SCH.
SERVICE CHANGE I�{1 ei Oi00 II .L Le..
woo LICENSED CONTRACTORS DECLARATION /s
<v I hereby affirm that I am licensed under provisions of Chapter 9 cit of Cupar In -ISSUANCE-DATE v-,
c w (commencing with Section 7000)of Division 3 of the Business and LV ,e(f1'�Q1 -E(T-9I='I1 POGs^''MECH.'
r D i Professions Code,and my license is in full force and effect (0. UU E(�T]Id1 ❑
Z o n License Claw Lic.Number I
o z Dame Contractor
P y s BUILDING PERMIT
¢ ¢ W ¢ OWNER-BUILDER DECLARATION INFORMATION
o " MISC.- REFER TO ORD
X
;°' H 1 hereby affirm that I am exempt from the Contractor's License VALUATION SIFT.
Loa Law for the fallowing reason.(Sec.703 1.5,Businessand Professions PERMIT ISSUANCE 10.00
H - Code:Any city or county which requires permit to construct,alter, J �
Q al Q 0 improve,demolish,or repair any structure,prior to im issuance,also ELEC.CONTR. LIC.NO. ELEC. //-(/(, /
O u requires the applicant for such permit to file a signed statement that TOTAL 3 U PERMIT TO
E $w he is licensed pursuant to the provisions of the Contractor's License �-A� T<Oh/ /
iii Law(Chapter 9(commencing with Section 7000)ofDivision 3 of the (._
3 m o Business and Professions Code)or that he is exempt therefrom and CITY. PLUMBING PERMIT FEE
¢r $ the basis for the alleged exemption.Any violation of Section 7031.5 STORIES TYPE CONSTR.
A. by any applicant for a permit subjects the applicant ma civil penally ALTER-DRAIN -WATER IEA.) 5.00 Q �-
of not more than five hundred dollars(4500).): 2
❑ 1,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 (See. 7044, Business and Professions At� DRAINS-FLOOR,ROOF,AREA,COND. 5.00
Code:The Contractors License Law does not apply to an owner of ..._
property who builds or improves thereon,and who does such work FIXTURES-PER TRAP _ 5.0 SQ FT.FLOOR AREA TOTAL ACREAGE
himself,or through his own employees,provided that such improve GAS-EA.SVSTEM-1 TIS 6.00
menta are not intended or offered for sale.If,however,the building ,�`u
or improvement is sold within one year of completion,the owner- GAS,EA.SVSTEM-OVER IEA.) 2.00 BUILDING USE
builder will have the burden of proving that Ise did not build or im RES IND CON PB Other
prove for purpose of sale.). I NOUSTR IAL WASTE I TER. I ' '�C30,00
❑ I as owner of the property,am exclusively contracting with ❑ ❑ C3 1:1licensed contractors to construct the project(Sec. 7044,Business LAWN SPRINKLERS-hIN05 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-O sE+ 516At� jjQQ
contracts for jeers wilhaconlractorts)licensed pursuant to SEWER-SANITARYMEA.200ft/10.00 TRACT NO. PARCEL NO.
the C , LicerNe Law,
❑ In axe ptu er Sec. ,B.&P.C.for this WATER HEATER W/VENT 6.00
real
" own Data WATER SYSTEM 5.00
ACC.DATE ACC.FILE NO.
WORKERS'COMPENSATION DECLARATION WATER TREATING EQUIP. 5.00
1 hereby affirm that I have a certificate of consent to self-mame, ZONING ' ENG.SITE N0.
or a certificate of Workers'Compensation Insurance,or a certified
copy(hereof(Sec.3800,Lab.C.L -
Policy No. Company
O ❑ Certified Copy is hereby furnished. FIRE SPRINK ENERGY T 24
Z Z ❑ Certified copy is filed with the city inspection division. REFER TO ORD
SC.- .
O Applicant MIY ❑ N❑ Y ❑ N❑
vCERTIFICATE OF EXEMPTION FROM WORKERS' PERMIT ISSUANCE 10.00 FLOOD ZONE A.L.u.c.
LEI > COMPENSATION INSURANCE PLG.CONTR. LIC.NO. PLG. dL
CL O (This section need not be completed if the permit is for one TOTAL V❑ N❑ Y❑ No
D Z hundred dollars IS 100)or less.)
U O 1 certify that in the performance of the work for which this per- QTY. MECHANICAL PERMIT FEE FEE SUMMARY
LL P mit is issued,1 shall not employ any person in any manner so as to
U become subject to the Workers Compensation Laws of California. -�
ED
Date Applicant ALTER OR ADD TO MECH. 5.00 FSEI�MICFEE
S
} N NOTICE TO APPLICANT: If,after making this Certificate of Ex-
F z emption,you should become subject to the Workers'Compensation APPLIANCE 5.00
provlslons of the Labor Code, you must forthwith comply with .
U such provisions or this permit shall be deemed revoked. AIR HANDLING 11NITs1T 10,000C.F.M.) 4.00
CONSTRUCTION LENDING AGENCY AIR HANDLING UNIT(OVER 10=C.F.M.) 6.00 421 hereby affirm that there is a construction lending agency for EXHAUST HOOD (WITHDUCT) 5.00
the performance of the work for which this permit is issued(Sec.3097,Civ.C.). ' HEATING L)NIT(TO 100,000,BTU.) 8.00
Lender's Name HEATING UNIT'109ER110 ,000 B.T.U.19.50 ��(�.
Lender's Address
I cetlify that I have read this application and state Ilett the above I 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-eON1P 13 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 STUI 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 liabLlitmix,judgments, costs and expenses which PERMIT ISSUANCE 10.00 CONST.TAX
may in Any way c ue a ainat said City in consequence of the
granlin fthis per L . MECH.CONT. LIQ NO. MECH.
TOTAL TOTAL'
Signature pplicanl/Conlmetor Dater -
OFFICE COPY -
POST THIS CARD NEAR FRONT OF BUILDING
PERMIT NUMBER
CITY OF CUPERTINO 0
INSPECTION DIVISION
JOB INSPECTION RECORD*
PERMIT EXPIRATION
JOB ADDRESS 21311 COLUMBUS AVENUE uNIT# Lor#
RICHARD ANDERSON SELFPERMIT EXPIRES IF WORK
,
• OWNER CONTRACTOR � IS NOT. STARTED WITHIN
INSPECTION DATE INSPECTOR INSPECTION RECORD tau DAYS OF PERMIT ISSU-
FOUNDATION _ ANCE OR 180 DAYS•FRpOM
LIFER %� ! I Ll3 � T INi
PREGUNITE•
POUR NO CONCRETE UNTIL ABOVE HAS BEEN SIGNED 1"-1 G�Qe �Q 1 Jul•\ 9- 13„1 +
PLUMBING UNDERGROUND /SLAB y,.a 6� IJ L1,I.. INSPECT]
ELECTRICAL S
BLDG. E ECT. PLG. MECH.
MECHANICAL
DO NOT POUR FLOOR UNTIL ABOVE HAS BEEN SIGNED BUILDING PERMIT
WOOD FLOOR L INFORMATION
� VALUATION 3/FT.
PLUMBING
- � v
MECHANICAL
AA PENMIT To
ELECTRICAL _ /] xnl. X,f_A/' m n
FRAMING !/ BZW/ L
STORIES TYPE CONSTR.
INSULATION
OCC,GROUP RES.UNITS
IRLACE NO SUBFLOOR UNTIL ABOVE HAS BEEN SIGNED
SO.FL,FLOOR AREA . TOTAL ACREAGE
ROOF
DIAPHRAGM .
BUILDING USE,
1RES IND CON PB Othxr
APPLY NO ROOFING UNTIL ABOVE HAS BEEN SIGNED El I] El 0 ❑
ASSESSORS PARCEL NO.
ROUGH
PLUMBING - j7.
TRACT NO. PARCEL N0.
GAS TEST
MECHANICAL.
ELECTRICAL ACC.DATE, ACGFILE NO.
I :r'; FINALS DATE INSP.
FRAMING SAN #
ZONING ENG.SITE NO.
INSULATION - PLUMBING
GAS
FIRESPRINK ENERGYT,2<
MECHANICAL Y 0N❑- v [DN[3
COVER NO WORK UNTIL ABOVE HAS BEEN SIGNED HEATING
LATH-INTERIOR ELECTRICAL FLOOD ZONE A.L.u.C,
LATH-EXTERIOR ..� - FIRE DEPT. 1 Y No Yo N[]
SHEETROCK GRADE FEE SUMMARY
SHEAR INTERIOR - BUILDING 2
SHEAR EXTERIOR TEMPORARY APPROVAL BUILDING
FIREWALLS . ELECTRIC PLAN CHECK „y `
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
w 1. ARRANGE FOR INSPECTION BY PHONING 252-4505, ELECTRIC
ONE WORKING DAY BEFORE REQUIRED INSPECTION. PLUMBING
PLEASE GIVE JOB ADDRESS WHEN PHONING. ti IZ MECHANICAL
- SEE PERMIT FOR EXPIRATION DATE -
- CONST.TAX
IMPORTANT!
PLEASE READ REVERSE SIDE.BEFORE - . TOTAL
CALLING FOR FINAL INSPECTION.
OFFICECOPY .I