9046 APPLICANT TO FILL IN INFORMA ION WITHIN RED LINES — USE BALL POINT PEN ONLY
PERMIT NUMBER
" BUILDING PROJECT I DENTI FICA'�h �N � APPLICATION Sf PEI sT 9046
'
RUaoINc
ADORE f Jn y, /}O� _ BUILDING—ELECTRICAL—PLUMBING—MECHANICAL
• O,A,NERL f _.c .. PLAN CHECK VALIDATION
EOTY., s'» ELECTRIC PERMIT
.y. PHaNern.,.... ,I TEFF.;
CONTRACTORS (p UTLETS-SWITCHES-RECEP 10.00/1.00
NAME
Y LIC.NO.� I 0 LIGHTING FIXTURES 10.00/1.00
NTRACTG
CGWs APPLIANCES-RESIDENTIAL 4.00
WlnF(�/
as
. CI PHONE y '�-{I� PANELS 10,00 DATE OF APPLICATION
ARCHITECTPLAN CHECK FEE P.C.NO.
PANELS (OVER 200 AMP) 20.00
OR
ENGINEER 5LC„ /'I Op ,� SIGNS TRANS. 3.00
1 l- L L.NO.
5,00 - LIDATION
ARCH.OR ENQ � SPECIAL CIRCUIT '
ADDR
.f C, EMP.METER OR POLE INS. 20.00 — 'AUG 1
�g n �neC
APPLICANTS - MOTORS SEE FEE SCH. J JOO
ADDRESS �11 ”
aI Cu Y, — SERVICE CHANGE 20.00 City of CUp@►tIR6
W o o LICENSED CONTRACTORS DECLARATION TEMP.POLE 30.00
a u spa I hereby afnrm that I am licensed under provisions of Chapter 9ISSUANCE DATE
a o (commencing with Section 7000)of Division 3 or the Business and BLDG. E E . PLG. C
F D i Professions CoJ nd my license is in full for sd-eH�GL�
z o L— Licen I ss Lic,Number 1..521-
0 r w Date 'Contractor�.--
,;�';rjfBU DING' ER IT
OF w < OWNER-BUILDER DECLARATION ,'a:;Y!d"i.. FORM TION"
MISC.— REFER TO OR
E ;e H I hereby of irm that I am exempt from the Contractor's License VALUATION SIFT.
u' w0� Law for the following reason (Sec.703 I.S.Business and Professions PERMIT ISSUANCE 10.00 I
I- y Code:> Any city or county which requiresa permit to construct,alter.p y ELEC.CONTR, LIC,NO. ELEC.
a ¢ 4.0 improve,demolish,or repair an structure,prior to its issuance,also
¢ requires the applicant for such permit to file a signed statement that TOTAL PERM TO
wm" he is licensed pursuant to the provisions of the Contractor's License
aa z i Law(Chapter 9(commencing with Section 7000)ofDivlsion 3 of thee
4 o Business and Professions Code)or that he is exempt therefrom and QTY: „PLUMBINGPERMIT I e, c s FEE;r, BTORI S PE CONSTR.
¢ the basis for the alleged exemption.Any violation ofSeclion 7031.5 -
i; � by any applicant for a permit subjects the applicant too civil penally ALTER-DRAIN&VENT-WATER (EA.) 5.00 lkrzs
of not more than five hundred dollars 15500).):
Cl I,as owner of the property,or my employees with wages as BACK FLOW PROTECT.DEVICE 4.00 OCC.GFpUP R S,UNI S
their sole compensation,will do the work,and the structure is not ,.F�
intended or offered for sale (Sec. 7044, Business and Professions r. 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 docs such work ( FIXTURES-PER TRAP
ASVSTEM-11NC40UTLETS 6.00
S.00 SO.FT,FLOOR AREA TorA ACREAGE
himself or through his own employees,provided that such improve- 1' 7
menu are not intended or offered for sale.If,however.the building GAS-E . . (,
or improvement is sold within one year of com plclion,the owner- GAS-EA.SYSTEM-OVER 4 (EA.) 2.00 B LDING USE
builder will have the burden of proving that he did not build or im- REB IND CON PB D\NFA
prove for purpose of sale.). I 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 1 ASSESSORS PARCEL NO.
and Professions Cade:The Contractor's License Law does not applyOVER 5 IEA.) 1.00 (f 1 3 _ C —CIU
to an owner of properly who builds or improves thereon.and who LAWN SPRINKLERS- �J
contracts for such Projects with a contractoAs)licensed pursuant to SEWER-SANITARY-STORM EA,200ft/10.00 TRACT NO. 21ILEN
.the Contractor's License Law,
❑ I am exempt under Sec. ,BAP.C.for this WATER HEATER W/VENT 60062reason
Owner' Date WATER SYSTEM 5.00 A C. A .WORKERS'COMPENSATION DECLARATION --. WATER TREATING EQUIP.I hereby afnrm that I have a certificate of consent to self-insure, ZONING .or a certificate of Workeri Compensation Insurance,or a certified
copyIhereof(Sec.3800 Lab.C.). 'FC_PolicyNoCamPanyO Certified copy la hereby furnished. FIRE SPRINK Z Z @P Certifie�cppyC i�nled with the city inspection division. MISC.- REFER TO ORD. Y❑ N❑ ❑Ap l ant_F— y PERMIT ISSUANCE 10.00 FLOOD ZONECC — CERTIFICATE OF EXEMPTION FROM WORKERS'
LU > COMPENSATION INSURANCE PLG.CONTR. LIC.NO. TOTAL y❑ N❑ ❑
1 O (This section need not be completed if the permit is for one r�
2 hundred dollars(5100)or Iess.) "' '' " - It.'j; I rs *sy> ' l d<+¢'FEE SUMMARY4 'x�,L`Vuf,
U O 1 certify that in the Performance of the work for which this per- DTV . /'. MECHANICAL PERMIT. <A '� .FEEy
mit is issued,1 shall not employ any person in any manner so as to t _
O W become subject to the Workers'Compensat ion Laws of California. - BUILDING
Date ApPI1Ca01 ALTER OR ADD TO MECH. 5.00 w
} y NOTICE TO APPLICANT: If,after making This Certificate of Lx- 5.00 PLAN CHECK _
? emption,you should become subject to the Workers'Compensation �„ APPLIANCE '
provisions of the Labor Code, you must forthwith comply will, F 00 FEE
Such provisions or this permit shall be deemed revoked. AIR HANDLING UNIT(TO 10,0000 .M 1 4
0
CONSTRUCTION LENDING AGENCY AIR HANDLING UNIT(OVER 10MC.F.M.) 6,00 SEISMIC FEE
I hereby affirm that there is a construction lending agency for EXHAUST HOOD(WITH DUCT) 5.00 MICROFILM /
the performance of the work Lfor which this permit is issued(Sec. I HEATING UNIT(TO 100,000 B.T.U.) 8.00 -
3097,Civ.C.). CU f- Is yb kI I-�_
Lender's Name HEATING UNIT(OVER 100,000 B.T.U.)9.50 ELECTRIC
Lender's Address PJLI
1 certify that I have read this application and state that the above VENTILATION FAN (SINGLE) 4.00 PLUMBING
P MB
I with all Cil end count '
LU
I;
orate[,I agree to comply Y y
information is correct. R P .�� BOILER-OOMPI3 H.P.or 100,000 B.T.U.) 6.00
r ! ordinances and slate laws relating to building conslruclion, and
hereby authorize representatives of this city to enter upon the BOILER-COMP IOver 100,000 BTU)SEE FEESCH. MECHANICAL
above-mentioned properly for inspection purposes.
(WA) agree to Save, indemnify and keep harmless the City of MISC.- REFER TO OR d%_ .�
Cupertino against liabilities,judgments, casts and expenses which CONST:TAX
may in any way acerae against Said City in consequence of the PERMIT ISSUANCE 10.00 -
wti gpI thi pC it. MECH.CONT. LIC.NO. MECH. r+ }
N; ¢ 5
C r t TOTAL / I
Tractor Date ./
signature of licant/Co n
OFFICE COPY '
POST THIS CARD NEAR FRONT OF BUILDING
CIT-, OF CUPERTINO PFHMIT NUNIBEH
INSPECTION DIVISION 904 6
,�]C JOB INSPECTION RECORD 2
• JOB DDRESS
-`1qo O ( NIT# LOT# ✓ PERMIT EXPIRATION
PERMIT EXPIRES IF WORK
OWNER CONTRACTORbe bon Y, IS NOT STARTED WITHIN
INSPECTION DATE INSPECTOR INSPECTION RECORD 180 DAYS OF PERMIT ISSu-
FOUNDATION -73ir Qz, V ANCE OR 180 DAYS FROM
LIFER -2-Fe J LASTCALLED INSPECTION.
PREGUNITE 'ALIDATION
POUR NO CONCRETE UNTIL ABOVE HAS BEEN SIGNED .AUG
UNDERGROUND /SLAB
PLUMBING
ELECTRICAL City of Cupertino
ISSUANCE DATE
MECHANICAL BLDG. ELECT. PLG.
00 NOT POUR FLOOR UNTIL ABOVE HAS BEEN SIGNED Bu DINGPERMIT
WOOD FLOOR INFORMATION
PLUMBING VALUATION SIFT.
MECHANICAL
ELECTRICAL - PERMIT TO1
FRAMING ,
INSULATION STORIES' PECONSTR.
yV �� OCC.GROUP -RES.UNITS
PLACE NO SUBFLOOR UNTIL ABOVE HAS BEEN SIGNED
ROOF SO.FT.FLOOR AREA TOTAL ACREAGE
DIAPHRAGM
HES NO BUILDING
CON USEPS Omer
APPLY NO ROOFING UNTIL ABOVE HAS BEEN SIGNED ❑ ❑ ❑
ROUGH u I ASSESSOPWARCEL NO.
PLUMBING 3 j- � _C,---
GAS
j
GAS TEST sem('-O� ,S TRACT NO. PAgCEL NO.
MECHANICAL �2 G eV�d 2"-$°t nuc! O' lee9-
ELECTRICAL J. G FINALS DATE INSP. •Acc.onTE Acc.FILE No.
FRAMING �'7 SAN a
INSULATION -$'� PLUMBING zONING
ENG.SITE N0.
GAS
MECHANI AL FIRE SPRINK ENERGY T 24
COVER NO WORK UNTIL
OVER BEEN SIG ED HEATING YC:] N❑ ` ❑ N❑
LATH-INTERIOR ,Z 13 Bel ELECTRICAL FLOOD ZONE A.L.U.C.
LATH-EXTERIOR y'
']rY7 FIRE DEPT. `'❑ No v ❑ N❑
SHEETROCK E GRADE
SHEAR INTERIOR FEE SUMMARY
BUILDING
SHEAR EXTERIOR _ TEMPORARY APPROVALS BUILDING
FIREWALLS -8•� ELECTRIC PLAN CHECK
GAS FEE
NO TAPE OR PLASTER UNTIL ABOVE HAS BEEN SIGNED occuPANcv SEISMIC FEE
OCCUPANCY OF BUILDING IS NOT PERMITTED UNTIL BUILDING FINAL ISSIGNED BY BUILDING INSPECTOR.
MICROFILM �
ARRANGE FOR INSPECTION BY PHONING 252.4505, ELECTRIC
�� ONE WORKING DAY BEFORE REQUIRED INSPECTION. /
Z PLEASE GIVE JOB ADDRESS WHEN PHONING. PLUMBING
— SEE PERMIT FOR EXPIRATION DATE — MECHANICAL
IMPORTANT! CONST.TAX
PLEASE READ REVERSE SIDE BEFORE TOTAL
CALLING FOR FINAL INSPECTION.
OFFICE COPY