9047 mrrL iL,NN.l=1 v I-ILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
BUILDING PROJECT IDENTI FICA- -4 PERMITNUMBER
I \ IWILDING: - - APPLICATION & PERMIT
ADD i a40 BUILDING ELECTRICAL PLUMBING MECHANICALDAIN4
NAME AME RMIT PLAN CHECK VALIDATION
v �- ,'1 ELECTRIC PE
PHONE L .. C ( ,.. - : i:>='�r`e+.;.1:I� )s FE'El'
GONTRACTOHS
r� !TAME I UTLETS-SWITCHES-RECEP 10.00/1.00
1 gbmr CC)CP UO NO. Q LIGHTING FIXTURES 10.00/1.00
CONTKACTGR'5
ADDRESS APPLIANCES-RESIDENTIAL 4.00
c - -1 > I^'�` PHONEL(Ci I PANELS 10.00
ARCHITECT DATE OF APPLICATION
" OR PANELS (OVER 200 AMP) 20.00 PLAN CHECK FEEP.C.NO.
ENGINEE ,t
'^ r' r .ND. •� SIGNS TRANS. 3.00
ARCH.ORENG.
ADDRESS--��� -- SPECIAL CIRCUIT 5.00 PERMIT VALIDATION
In EMP.METER OR POLE INS. 20.00 AUG 10 198
A NESSTS - MOTORS
,._ SEE FEE SCH.
�. SERVICE CHANGE 20.00 Chit of Cupe&no
• Dai
Fw„ 0 o LICENSED CONTRACTORS DECLARATION TEMP.POLE 30.00
a u W I hereby affirm that 1 am license)under provisions of Chapter 9
- a a& (commencing h Section 70001 of Division 3 of the Business and ISSUAN DATE -
H N i Professions Cod nd my license is in full force n fb I•� B G. ELEC . PL C .
z o= - License ass Lic.Number _ xX
z r w Date Contmclor_}�' '
reX OWNER-BUILDER DECLARATION "N;BUILDING ERMIYn;+ tJY{x
W ; LL N 1 hereby affirm that I am exempt from the Contractor's License MISC.- REFER TO ORD 'i nl••cd•` INFORMATION 't`.'8`i R3
r : 0 j Law for the following reason.(Sec.703 1.5,Businessand Professions PERMIT ISSUANCE VALUATION S/FT.
Fmy Code:Any city or county whichruquinsa pernsinoconstruct,alteq 10.00 •.
le C a O improve,demolish,or repair any Structure,prior to its issuance,also ELEC.CONTR. LIC.NO. FLEC.
0 a requires the applicant for such permit m file a signed statement that TOTAL
a.m y he is licensed pursuant to the provisions of lite Contractors License PERMIT TO
Hz >
Law(Chapter 9(commencing with Section 7000)ofDivision 3 ofthe - - l+'. .,A,t: ....
$a Business and Professions Code)or that he is exempt therefrom and DTV. " PLUMBING PERMIT) f `' t FEE
the basis fur the allege)exemption.Any vlolution ofSectian 703 L5 t" ' '� •' �,'.S+''? ':S
La 3 .• by any applicant for a permit subjects the epplicanl lou civil pend try h'f STOgI TYPE CONSTR.
of not more than five hundred Joilars(8500).1: ^ ALTER-DRAIN&VENT-WATER (EA.) 5.00 �( /
❑ I,as owner of the properly,or my employees with wages os BACK FLOW PROTECT. DEVICE 4.00
their sole compensation,will do the work,unit the structure is not OCC.G OUP ES.UNI 5
intended or offered for sale l5ec. 7044, Business unit Professions DRAINS-FLOOR,ROOF,AREA,COND. 5.00
Code:The Contractor's License Law does not apply loan owner of
property who builds or improves Thereon,and who docs such work Ar FIXTURES-PER TRAP 5.00
ve-
5O.FT.FLOOR AREA TOTAL ACREAGE
himself or through his own employees,provide)thin such impm
mentaerenolintendedorofl'ered for sale.If,however,the building GAS-EA.SYSTEM-I1NC.4OUTLETS 6.00
or improvement is sold within one year of completion, the owner-
builder will have the burden of proving that he Jid not build or im- `� GAS-EA.SYSTEM•OVER 4 (EA.) 2.00 BUILDING USE
prove for purpose of sal e)' INDUSTRIAL WASTE INT ER. 30.00 RES IND CON Pg oma
❑ 1,as owner of
licensed contractthe property,am exclusively contracting with - '--
ors to construct the project(Sec. 7044,Business LAWN SPRINKLERS- 1 INC 5 V.8. 6.00
and Professions Code:The Contractors License Law docs not apply ASSESSORS PARCEL NO.
to an owner of property who builds or improves thereon,and who LAWN SPRINKLERS-OVER 5(EA.) 1.00 p q
contracts for such projects wills a contractors)licensed pursuant hs 3 Ll U�
the Contractor's License Law, SEWER-SANITARY-STORM EA.200ft/10.00
❑ lam exempt under Sec. ,B.SvP.C.for Ibis TRACT O. PARCEL NO.
reason WATER HEATER W/VENT 6.00
Owner Date WATER SYSTEM 5.00
A .DATE ACC.FILE NO.
WORKF.RS'COMPENSATION DECLARATION �. WATER TREATING EQUIP. 5.00
1 hereby affirm that I have a ec,licate of consent to self-insure,
Of a certificate of Workers'Compensation Insurance,or a certilied ZONING ENG.SITE NO.
copy t No. (Sec. Co;n00 ab.C,), `7�
Policy N rt Company l
'O Ox,� Certified copy is hereby furnished.
Z Z v� Certdle copy is li eJ with file city inspection division. FIRE SPRINK ENERGY T-24
� O APPtlcan t - j� MISC.- REFER TO ORD. YE] N[] vC] NC3
N CERTIFICATE OF EXEMPTION FROM WORKERS' PERMIT ISSUANCE 10.00
LU COMPENSATION INSURANCE PLG.coNTR. FLOOD ZONE A.L.U.C.
a O LIC.NO. PLG.
Z (This section need not be completed if the permit is for one TOTAL }/ Y E] N� Y N[]
hundred dollars IS 100)or less.) _
V O 1 certify that in the performance of the work for which this per-
,it "-
LL F• is issued,I shall not employ any person in any manner w ato DTY' 1 MECHANICAL PERMIT 7��, FEE. .';.FEE'SUMMARY 'fieli
C1 become subject to the Workeri Compensation Laws of Calil.m u.
i Date Applicant
0. NOTICE TO APPLICANT: �• ALTER OR ADD TO MECH. 5.00 BUILDING
} If,al nr making This Cerlil icate of Fa
emption,you should become subject to the Workers' ns
rth .
Compeation - APPLIANCE 500 PLAN CHECK
provisions of the Labor Code, you must fo
with comply will, FEE
V such provisions or this permit shall be deemed revoked. AIR HANDLING UNIT(TO 10,000C.F.M.) 4.00
CONSTRUCTION LENDING AGENCY AIR HANDLING UNIT(OVER 10p00C.F.M.) 6.00 SEISMIC FEE O
1 hereby affirm Ilial there is a construction lending agency Ibr EXHAUST HOOD(WITH DUCT) 5.00
097
the performance of the work for whicl siS permit is issued(Sec.
30 I 97,Civ.C.). 1 } HEATING UNIT(TO 100,000 B.T.U.) 8.00 MICROFILM .�
Lender's Name�-,L ��If�
Lender's Address---- ��� HEATING UNIT(OVER 100,000 B.T.U.)9.60 ELECTRIC
format
I certify that 1 have read this application and slam that the above VENTILATION FAN (SINGLE) 4.00
inion is cornet.1 agree to comply with all city and countyPLUMBING V V
rJinances and state laws relating to building construction, and "' BOILER•COMP(3H.P.or100,000B.T.U.) 6,00
ercby authorim representatives of this city to enter upon the .E
abort-menli0ned property for inspection purposes. ^�' BOILER-COMP (Over 100,000 BTU)SEE FEE SCH. MECHANICAL ✓A
(Wt) agree to save, indemnify and keep harndess the City of MISC.- REFER TO ORD.
Cuperlulo against liabilities,judgment; costs unit expenses which CONST.TAX 4
may in any way accrue against Said City in consequence of the PERMIT ISSUANCE 10.00 _
grantin of this permit. ` MECH.CONT. LIC.NO. MECH.
is L J TOTAL
'S gnaluric ot'ApplicamiLmn,acto, We i
OFFICE COPY
POST THIS CARD NEAR FRONT OF BUILDING
PFRnvT NUMDEN
CIT . OF CUPERTINO n�ln
INSPECTION DIVISION
I r'G //•1 JOB INSPECTION RECORD
• JOB A DRESS 1IQT✓ l �O! L� PERMIT EXPIRATION
UNIT# LOT#
PERMIT EXPIRES IF WORK
OWNER i-ro r CONTRACTOR Q •7 r IS NOT STARTED WITHIN
INSPECTION DATE INSPECTOR INSPECTION RECORD 180 DAYS OF PERMIT ISSU-
ANCE OR 180 DAYS FROM
FOUNDATION ,7 LASTCALLED INSPECTION.
UFER
PREGUNITE PE �y�LD�ATION
Y
POUR NO CONCRETE UNTIL ABOVE HAS BEE SIGNED Quu-
UNDERGROUND /SLAB
PLUMBING City Of Cupertino
ELECTRICAL ISSUANCE DATE
MECHANICAL BLDG. ELECT vLc. MEcry.
DO NOT POUR FLOOR UNTIL ABOVE HAS BEEN SIGNED BUILDING PERMIT
INFORMATION
WOOD FLOOR VALUATION SIFT,
PLUMBING
MECHANICAL + '
• 'PERMIT TO
ELECTRICAL
FRAMING
• COMM
INSULA�'ION STORIE_
OCC.GROUP _.RES(UNIT9
PLACENO SUBFLOOR UNTIL ABOVE AS BVEW SIGNED
SO.FT.FLOOR AREA TOTAL ACREAGE
ROOF
• DIAPHRAGM fl-2p.
BUILDING USE
RES IND CON PS Oma
APPLY NO ROOFING UNTIL ABOVE HAS BEEN SIGNED 1:1 El 1:1
ROUGH S L , ASSESSORS PARCEL NO.
PLUMBING 3S — O �d co /
GAS TESTFj 2 e,,.-;l TRACT NO, PARCEL NO.
MECHANICAL I ',
'ACC.DATE' ACL FILE NO.
ELECTRICAL _/ I FINALS DATE INSP.
FRAMING !AN * / 'j"4 ZONING ENG.SITE NO,
INSULATION PLUMBING
GAS
FIRE SPRINK ENERGY TZd
MECHANICAL YE]. N� Y ❑ N[]
COVER NO WORK UNTIL ABOV AS BEEN SIGUO HEATING
FLOOD ZONE a.LLLL.
LATH-INTERIOR Aislol ELECTRICAL
LATH-EXTERIOR _ 2z.-R-7 DEPT. Y N Y ❑ NE:]
SHEETROCK ( 7 GRADE FEE SUMMARY
SHEAR INTERIOR BUILDING
SHEAR EXTERIOR 6-7.3Jg'♦, TEMPORARY APPROVAL BUILDING - —
FIREWALLS ELECTRIC PLAN CHECK
GAS W FEE
NO TAPE OR PLASTER UNTIL ABOVE HAS E I SEISMIC FEE
OCCUPANCY OF BUILDING IS NOT PERMITTED UNTIL BUILDING FINAL ISSIGNED BY BUILDING INSPECTOR. . MICROFILM
ARRANGE FOR INSPECTION BY PHONING 252-4505, ELECTRIC
o� ONE WORKING DAY BEFORE REQUIRED INSPECTION. PLUMBING
PLEASE GIVE JOB ADDRESS WHEN PHONING.
Z
- SEE PERMIT FOR EXPIRATION DATE - MECHANICAL
IMPORTANT! CONST.TAX
PLEASE READ REVERSE SIDE BEFORE TOTAL
CALLING FOR FINAL INSPECTION.
OFFICE COPY