9049 APPLICANT TO'FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
- PERMIT NUMBER
BUILDING PROJECT IDENTIFICAT'- a 9049
ssO �yJ
/�
9UILDING APPLICATION & PER,`, .
ADOa I�•�i BUILDING-ELECTRICAL-PLUMBING-MECHANICAL
P
(%
LAN CMELK VALIDATION
DINNER' `yJa :•'Lx�-1G.4.M:F P
AME QTY. ELECTRIC PERMIT-;Y;t!;tsT�t4�I?'>JFEES,
CONTRACTORS UTLETS-SWITCHES-RECEP 10.00/1.0
NAME
2p LIGHTING FIXTURES 10.00/1.06
rd I Gf uc.No.� .,.
r. NrRAarofls .tea PPLIANCES-RESIDENTIAL 4.00
Appq E� �•-I�PNONE��� ` PANELS 10.00 j GATE OF APPLICATION
``CCTTIlIf/6. k-,(i 2D.DD PLAN CHECK FEE P.C.NO. .
ARCHITECT r PANELS (OVER 200 AMP)
OR e3.00
. ENGINEE r-IC.NO., r SIGNS TRANS. VALIDATION
ARCH.oR ENc. SPECIAL CIRCUIT 5.00PAUS
ADDaE
ere zIPCL -' EMP.METER OR POLE INS. 20.00
APPLICANTS - MOTORS SEE FEE SCH. %U
A DRESS
�I i cI , rxpP}
SERVICE CHANGE 20.00
TEMP.POLE 30'00 CIIY•r•100 -
°�z DECLARATION CIiY V,
LP o o LICENSED CONTRACTORS
L IBSUANCE DATE
Is u u I hereby affirm that I am licensed under provisioM of Chuptcr 9 DG ELEC PL ME
y a m (commencing with Section 7000)of Division 3 of the Business and
r
A.
Professions Co • and my license is in full fors'a�' d effect
O n Licen _ Lic.Number. 1-a1-
° Date Contractor -+"' 'S•'BUI DING ERMIT w$
x r "lap's i,1
awu OWNER-BUILDER DECLARATION REFER TO ORD +-1 •!rJ�k"y,l FORM TION%i +';+xp•v
3 LL N I hereby affirm that I am exempt from the Contractor's License MISC.- vALU TION S/FT.
la0a Lew for the fogowing reason.(Sec.703 1,5,tlusinasand lsrofessions
PERMIT ISSUANCE 10.00 r
NMS Code:Anycity orcounty which requires a permit to construct,alter. LIC.NO.
Eno 0-
ca a G improve,demolish,or repair any structure.prior to its issuance,also ELEC CONTE. ELEC./��s
° LL require the applicant for such permit ID file a signed statement that TOT
Wm he is licensed pursuant to the provisions of Um Contractor's License .L. • '...j /
F z i
Law(Chapter 9(commencing with Section 7000)of Uivision3of the i,.`- LJ
i i o Business and Professions Code)or that he is exempt tlmrelrom and DTV. PLUMBING PERMIT a �� 1; FEE STORIES TYPE CONSTR.
MI- Ne basis fur the alleged exemption.Any violation of Section 7031.
a 5 A
sby any applicant for a permit subjects the applicant Ina civil penalty .-
gLTER-DRAIN&VENT-WATER (EA.) 5.0 'y
of not more than five hundred dollars(3500).1:
❑ 1,as owner of the property,or my employees with wages as BACK FLOW PROTECT. DEVICE 4.00 OCC.GROUPREs.PJNITS
their suit compensation,will do the work,and the structure is not 1
intended or offered for sale (Sec. 7044, Business and Professions DRAINS-FLOOR,ROOF,AREA,COND. 5.00
Cade:The Contractor's License Law does not apply to an owner of 5.00 SO.F Loofl A A TOTAL ACREAGE
property who builds or improves thereon,and who does such work 2 F IXTUR ES-PER TRAP
himself or through his own employees,provided that such improve- GAS.EA.SYSTEM-11 6.00
menta are not intended or offered for sale.If,however,lire building
or improvement is sold within one year of completion,elle owner- GAS-EA.SYSTEM-OVER 4(EA.) 2.00 BUILDING USE
builder will have the burden of proving that he did not build or im- ES IND eON l OOr
prove for purpose of sale.). INDUSTRIAL WASTE INTER. 30.00
❑ I,as owner of the property,am exclusively contracting with
lice mad contractors to construct the project(Sec.7044,Business �. LAWN SPRINKLERS- 1 INC 5 V.B. 6.00 ASSESSONS PARCEL NO.
and Professions Code:The Contractor's License Law docs not apply •?!7 - U �-
to an owner of property who builds or improves thereon,and who -- LAWN SPRINKLERS-OVER 5 IEA.1 1.00 JJ ��
contracts for such projects with a conlractoas)licensed pursuant In SEWER-SANITARY-STORM EA.200tt/10.00 TRACT NO. PARCEL NO.
the Contractor's License Law.
❑ Iain exempt under Sec. ,B.&P.Cb for this WATER HEATER W/VENT 6.00
reason 5.00 ACC.OATE ACC.FILE NO.
Owner Data WATER SYSTEM
WORK ERS'COMPENSATION DECLARATION WATER TREATING EQUIP. 5.00
1 hereby affirm That I have a certificate of coiucnt to sell-insure, ZONING ENG.SITE NO.
or a certificate of Workers'Compensationr insurance,or a certified
copy[hereof(Sec.3800,Lab.C.I s�rt C_
Policy No. Company FIRE SPRINK ENERGY T-24
Q ❑ Certified copy is hereby furnis ed.
Z Z Certifwd1vl)vppyt,i;-U¢Q�with the city inspection division. MISC.• REFER TO ORD. Y C] N Y C] N[]
A p cant l r .� 1
f•• 0PERMIT ISSUANCE 10.00 FLOOD ZONE A.L.U.C.
- CERTIFICATE OF EXEMPTION FROM WORKERS'
w > COMPENSATION INSURANCE PLG.CONTR. tIC.NO. PLG Y0 N0 YNO
TOT
D- O (This section need not be completed if the permit is 1'or one
7 Z hundred dollars IS 100)or It- r• i+4+-
(, O 1 certify that in the performance of[he work far which this per DTV. MECHANICAL PERMIT. 'FEE •' �' -
LL t mil is issued,I shall not employ any person in oily manner so as In I
UILDING
O W become subject to the Workers'Compensation Laws of California.
Dalt Applicant ALTER OR ADD TO MECH. 5.00
} N NOTICE TO APPLICANT: If,after making this Certificate of Ex- 5.00 PLAN CHECK
? eruption,you should become subject to the Workeri Compensation APPLIANCE FEE
provisions of the Labor Code, you must forthwith comply with AIR HANDLING UNIT(TO 10,000C.FAL) 4.00 -
(� such provisions or this permit shall be deemed revoked.
CONSTRUCTION LENDING AGENCY AIR HANDLING UNIT(OVER 10,000 C.F.M.I 5.00 SEISMIC FEE
I hereby uffinn the[ there is a construction lending agency for EXHAUST HOOD (WITH DUCT) 5'0 MICROFILM
the performance of the work for which this ppc lit is issued(Sec. HEATING UNIT(TO 100,000 B.T.U.) 8.00
3097,Civ.C.)' CU o f N f l I y)�
Lender's Name - HEATING UNIT(OVER 100,000 B.T.U.)9.50 ELECTRIC
Lender s AdJre- T CSSI I Esa
VENT
1.. ity that I have read this application and state that the above -^ VENTILATION FAN(SINGLE) 4.00
.0PLUMBING 'mss
�;• information is correct.I agree to comply with all city and county I BOILER-COMP(3 H.P.or 100,0009-T,U.) 6.00
ordinance and nate laws relating [o building construction, and
j hereby Wthorim representatives of this city tO .nler upon the BOILER-COMP low(600,000 BTU)SEE FEE SCR. MECHANICAL L/
"�.✓ awve-mentioned property for inspection purposes. REFER TO ORD. QQ
(We) agree to save, indemnify and keep harmless the City of MISC.• CONST.TAX
Cupertino against liabilities,judgments,cults and expenses which PERMIT ISSUANCE t0.D0
may in any way accrue a.L said City in consequence of the
nen{ )his permit. MECH.CONT. LIC.NO. MECH.
TDrPy� �� TOTAL,:, ",
ngnatur u APp lyunl(('omvcWr Dalt �
OFFICE COPY '
POST THIS CARD NEAR FRONT OF BUILDING
rFNMITINUAOIBER�
CIT', OF CUPERTINO
INSPECTION DIVISION
JOB INSPECTION RECORD
���� //�� ^ PERMIT EXPIRATION
• JOB ADDRESS - L L U�T# LOT#
PERMIT EXPIRES IF WORK
OWNER CONTRACTOR IS NOT STARTED WITHIN
INSPECTION DATE INSPECTOR I INSPECTION RECORD 180 DAYS OF PERMIT ISSU-
FOUNDATION ANCE OR 180 DAYS FROM
LIFER — fb LASTCALLED INSPECTION'.
PR EGUN I TE vyy-yAl.�Onnory
POUR NO CONCRETE UNTIL ABOVE HAS BEEN SIGNED Au"
UNDERGROUND /SLAB
PLUMBING City of Cupertino
ELECTRICAL ISSUANCE DATE
MECHANICAL BLDG. ELECT. PLG. MECH.
Of' 9, 1 4�
00 NOT POUR FLOOR UNTIL ABOVE HAS BEEN SIGNED euly M PERMIT
WOOD FLOOR INFORRMATION
VALUATION
PLUMBING
MECHANICAL 'E
ELECTRICAL r 'PERMITTO
FRAMINGCE
ATION STORIES., ! - TVPI ONSTR.
IN j
' OCC. , OUP 'RES.UNITS `
PLACE NO SUBFLOOR UNTIL ABOVE HAS B N SIGNED
ROOF _ 50.FT,FLOOR AREA TOTAL ACREAGE /
DIAPHRAGM ''B
, BUILDING USE
RES IND CON PB Orner
APPLY NO ROOFING UNTIL ABOVE HAS BEEN SIGNED0 ID
ASSESSORS PARCEL NO.
ROUGH TUC
PLUMBING
367-7— b f—Oof
TRACT NO. PARCEL NO.
GAS TEST g-Lt
MECHANICAL 'o, %'/•
ELECTRICAL -/y 6 FINALS DATE INSP. ACC.DATE ACG FILE NO.
FRAMING SAN # // ZONING ENG.SITE NO.
INSULATION I D E� PLUMBING
GAS
MECHANICAL
FIRESPRINK ENERGY T]<
Y [:] rv� v [3N�
COVER NO WORK UNTIL ABOVE HAS BEEN SIGNED HEATING
FLOOD ZONE A.L.U.C.
LATH-INTERIOR 7 ELECTRICAL 4 -519-
LATH-EXTERIOR FIRE DEPT. Y❑ N� v ❑ N❑
SHEETROCK z_ 7 GRADE FEE SUMMARY
SHEAR INTERIOR 1.2 BUILDING BUILDING
SHEAR EXTERIOR TEMPORARY APPROVAL ` '
FIREWALLS ELECTRIC PLAN CHECK ' --
' GAS FEE
NO TAPE OR PLASTER UNTIL ABOVE HAS BEEN SIGNED OCCUPANCY SEISMIC FEE
OCCUPANCY OF BUILDING ISNOTPERMITTED UNTIL BUILDING FINAL ISSIGNED BY BUILDING INSPECTOR. MICROFILM
LU ARRANGE FOR INSPECTION BY PHONING 252-4505, ELECTRIC
ONE WORKING DAY BEFORE REQUIRED INSPECTION. PLUMBING
0� PLEASE GIVE JOB ADDRESS WHEN PHONING.
Z MECHANICAL
— SEE PERMIT FOR EXPIRATION DATE —
CONST.TAX
IMPORTANT!
PLEASE READ REVERSE SIDE BEFORE TOTAL
CALLING FOR FINAL INSPECTION.
OFFICE COPY