11417 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
a)IIABUI LDING PROJECT 1 DENTI FICATION PERMIT NUMBER
rJ
WILDING
APPLICATION & PERMIT
A°°R°aa 11417
905 Ge�27� mf>Dc.eA? ZAN6 BUILDING-ELECTRICAL-PLUMBING-MECHANICAL
OWNERS PLAN CHECK VALIDATION
• NAME /` � OTY. ELECTRIC PERMIT FEE
/�ON UTJc1C-o PHONEW S 2 ,
CONTRACTORS UTLETS-SWITCHES-RECEP 10.00/1.00
NAME
71CHAGZ :5LODA S' uc.ND, 34'7 03 LIGHTING FIXTURES 10.00/1.00
CONTRACTOR'SPPLIANCES-RESIDENTIAL 4.00
ADDRESS ,/
G000hIe6+�e2o� APHDNA95--14/'4 PANELS 10.00 DATE OF APPLICATION
ARCHITECTPANELS (OVER 200 AMP) 20.00 PLAN CHECK FEE P.C.NO.
OR
ENGINEER
uo No. SIGNS TRANS. 3.00
ARCH,OR END. SPECIAL CIRCUIT 5.00 PERMIT VALIDATION
ADDRESS
xIP EMP.METER OR POLE INS. 20.00
Ar'S
ADDRESS MOTORS SEE FEE SCH. /1�.,,�✓�'r�
SERVICE CHANGE 20.00
woo LICENSED CONTRACTORS DECLARATION
¢ u I hereby affirm that 1 am licensed under provisions of Chapter 9 ISSUANCE DATE
N<w (commencing with Section 7000)of Division 3 of the Business and BLDG. ELECT. PLG. MECH.
H o i Professions Code, d my license is in full for �Q gF{ecl.�ryn ❑ ❑ ❑ ❑
Z o=- icense CI Lic.Number�-r-/ D-/
o w H or DatcContractor
a y SE BUILDING PERMIT
¢ ¢w¢ OWNER-BUILDER DECLARATION
o A O MISC.- REFER TO ORD FORMATION
E
;u I- I hereby affirm that I am exempt from the Contractors Licensepro
FwLaw for the following reason. 7031.5,Business and Professions10.00ION ' SIFT.
Ng pERM1T ISSUANCE
Code:Any city or county which requires a permit to construct eller, (�
rt ¢ ¢G improve,demolish,or repair any structure,prior to its issuance,also ELEC.CONTR. LIC.NO. ELEC. 1
A7
-O u requires the applicant for such permit to file a signed statement that TOTAL D
X $ hews(Chapter
pursuanten in provisions of the )ofDivtors License
X Z Q Law(Chaped Pursuant to the with Section the Co f Division 3 of the S`WOW17� T
P i O Business and Professions Code)or that he is exempt therefrom and QTY. PLUMBING PERMIT FEE /t'
¢ H$ the basis for the alleged exemption.Any violation of Section 7031.5 V PE CONSTR. .
IS by any applicant for a permit subjects the applicant too civil penalty ALTER-DRAIN&VENT-WATER (EA.) 5.00
of not more than five hundred dollars($500).):
❑ 1,as owner of the property,or my employees Willi 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 to(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 such work FIXTURES-PER TRAP 5.00 SD.FT.FLOOR AREA TOTAL ACREAGE
himself or through his own employees,provided that such improve-
mentsarenotintendedorofferedforsale.If,however,the building GAS-EA.SYSTEM-I1NC.4OUTLETS 6.00
or improvement is sold within one year of completion,the owner- GAS-EA.SYSTEM-OVER 4 IEA.) 2.00 BUILDING USE
builder will have the burden of proving that he did not build or im- RES IND CON PB Omer
prove for purpose of sale.). INDUSTRIAL WASTE INTER. 30.00
El 1,as owner'of the property,am exclusively contracting with ❑ ❑ ❑ ❑ ❑
licensed contractors to construct the project(Sec. 7044,Business LAWN SPRINKLERS-1 INC S 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)licensed pursuant to SEWER-SANITARY-STORM EA.200ft/10,00
the Contractor's License Law. TRACT NO. PARCEL NO.
❑ lain exempt under Sec.-,B.&P.C.for this WATER HEATER W/VENT 6.00
reason
Owner Date 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 ofconsent to self-insure, ZONING ENG.SITE NO.
ora certificate of Workers'Compensation Insurance,ora certified
Poli LWWuany.
0 Certified copy lsh rebyf ri hed. FIRE SPRINK ENERGY T-24
❑ C 4iG o yi filed/w; yt in ection division. MISC- REFER TO ORD,
Z ZO APPlican Y ❑ N❑ Y ❑ N❑
OC W CERTIFICATEOF EXEMPTION FROM WORKERS' PERMIT ISSUANCE 10.00
F LOOD ZONE A.LLLC.
ED > COMPENSATION INSURANCE PLG.CONTR. LIC.NO. PLC.
CIE. O (This section need not be completed if the permit is for one TOTAL Y❑ N❑ Y❑ N❑
D Z hundred dollars($100)or less.)
U O 1 certify that in the performance of the Work for which this Per. QTY MECHANICAL PERMIT FEE, FEE SUMMARY
IL F mil is issued, I shall not employ any person in any manner so as to
U become subject to the Workers'Compensation Laws of California. _
W Dale Applicant BUILDING (/V
a ALTER OR ADD TO MECH. 5.00 a
} m NOTICE TO APPLICANT: If,after making this Certificate sa F:x-
?
Crop!Lon,you should became subject must Workers'Compensation APPLIANCE 5.00 PLAN CHECK
provisions io the Labor Cade, you must forthwith comply with FEE
U such provisions or this permit shall be deemed revoked. AIR HANDLING UNIT(TO 10,000 C.F.M.) 4.00
CONSTRUCTION LENDING AGENCY AIR HANDLING UNIT(OVER IQOOOC.EM.) 6.00 SEISMIC FEE j0
I hereby affirm that there is a construction lending agency for EXHAUST HOOD(WITH DUCT) 5.00
the performance of the work for which this permit is issued(Sec. MICROFILM
3097,Civ.CJ. HEATING UNIT(TO 100,000 B.T.U.) 6.00
Lenders Name HEATING UNIT(OVER 100,000 B.T.U.)9.50 ELECTRIC
Lender's Address
• I certify that l 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 properly for inspection purposes.
(We) agree to Savo, indemnify and keep harmless the City of MISC.- REFER TO ORD.
Cupertino against liabilities,judgments, costs and expenses which CONST.TAX
PERMIT ISSUANCE 10.00
may in any a gqace�� a mst s J City in consequence of the I
his r!ran,L MECH.CONT. LIC.NO. MECH.
W c-, atf " G TOTAL TOTAL oL,s
Signature of Applicant/Contractor Dat
OFFICE COPY
POST THIS CARD NEAR FRONT OF BUILDING
PERMIT NUMBER
CITY OF CUPERTINO �� 7
INSPECTION DIVISION
• JOB INSPECTION RECORD
/ 1n PERMIT EXPIRATION
JOB ADDRESS�► 905 CDY'l�. Madera L/1 UNIT# LOT# PERMIT EXPIRES IF WORK
OWNER CONTRACTOR 5 IS NOT STARTED WITHIN
INSPECTION DATE INSPECTOR INSPECTION RECORD 180 DAYS OF PERMIT ISSU-
FOUNDATION ANCE OR 180 DAYS FROM
UFER LASTCALLED INSPECTION.
PREGUNITE PERMIT VALIDATION
POUR NO CONCRETE UNTIL ABOVE HAS BEEN SIGNED
UNDERGROUND /SLAB �M
PLUMBING
ELECTRICAL ISSUANCE DATE
MECHANICAL BLDG. ELECT. PLG. MECH.
El El ❑ r ❑
DO NOT POUR FLOOR UNTIL ABOVE HAS BEEN SIGNED BUILDING vERMIT
INFORMATION
WOOD FLOOR - � vALuanoN S/Fr.
PLUMBING
MECHANICAL .
ELECTRICAL PFRN+Ir TO
R
FRAMING AP/y�W c—AoiR�
INSULATION STORIES TYPE CONSTR,
OCC.GROUP HES.UNITS
PLACE NO SUBFLOOR UNTIL ABOVE HAS BEEN SIGNED
• ROOF SO.FT.FLOOR AREA TOTAL ACREAGE
DIAPHRAGM
BUILDING USE
RES IND CON PB olhe'
APPLY NO ROOFING UNTIL ABOVE HAS BEEN SIGNED ❑ '0 ❑ 0 ❑
ASSESSORS PARCEL NO.
ROUGH
PLUMBING
iNACT NO. PARCEL N0.
GAS TEST
MECHANICAL
' ELECTRICAL FINALS DATE INSP. ACC.DATE ACF FILE NO.
FRAMING SAN *
INSULATION PLUMBING ZONING END SITE NO.
GAS
_ FIRE SEE INK ENERGY:T]A
MECHANI AL Y [:] NF] Y ❑ N❑
COVER NO WORK UNTIL ABOVE HAS BEEN SIGNED HEATIN
FLOOD ZONE A.L.U.C,
LATH-INTERIOR ELECTRI AL
LATH-EXTERIOR FIRE DEk, Yo N❑ Y 0. NQ
SHEETROCK GRADE FEE SUMMARY
SHEAR INTERIOR BUILDING -7-4
..J -•
SHEAR EXTERIOR TEMPORARY APPROVALS BUILDING
FIREWALLS ELECTRIC . PLAN CHECK
GAS FEE
NO TAPE OR PLASTER UNTIL ABOVE HAS BEEN SIGNED JOCCUPANCY SEISMIC FEE
OCCUPANCY OF BUILDING IS NOTPERMITTED UNTIL BUILDING FINAL ISSIGNED BY BUILDING INSPECTOR. MICROFILM
ELI ARRANGE FOR INSPECTION BY PHONING 252-4505, ELECTRIC
F ONE WORKING DAY BEFORE REQUIRED INSPECTION. FAN
z PLEASE GIVE JOB ADDRESS WHEN PHONING.
- SEE PERMIT FOR EXPIRATION DATE -IMPORTANT!PLEASE READ REVERSE SIDE BEFORE
CALLING FOR FINAL INSPECTION.
,OFFICE COPY