12341 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
BUI LDI NG PROJECT I DENTI FI ''.ION PERMIT NUMBER
X BUILDING APPLICATION & Pi-.MIT
ADo.Ess a/ �_',C,
370 eOn�n'+ Ll BUILDING-ELECTRICAL-PLUMBING-MECHANICAL 1234
OWNERS r "'.• " ... PLAN CHECK VALIDATION
N4M 7 TV: Yf^: -1t,.24 ELECTRICPERMiT. FEE
/ L' PHONE3�7
)LIIX, CONTR R'S UTLETS-SWITCHES-RECEP 10.0011.00 /(J-
NAME
NAME / C/
LIc.NO 3n,6 Uo LIGHTING FIXTURES 10.00/1,00
C2
TRACTIO'R'6 Q/p PPLIANCES-RESIDENTIAL 4.00
EZ�+J-� /I"P• PHONE, PANELS lO•DD DATE OFAPPLICATION
ARCHITECT PANELS (OVER 200 AMP) 20.00 PLAN CHECK FEE P.C.NO,
OF
A
ENGINEER owl e
r
,1 , LIc.No. SIGNS TRANS. 3.00 10
ARCHI OR ENG.
SPECIAL CIRCUIT 5.00 PERMIT VALIDATION
SS
ZIP TEMP.METER OR POLE INS. 20.00 M .
APPLICANrs
ADDRESS MOTORS SEE FEE SCH.
ADDRESS
SERVICE CHAN 20.00
w o o LICENSED CONTRACTORS DECLARATION
' .1 1 hereby affirm that I am licensed under provisions of Chapter 9 ISSUANCE DATE
Z y (commencing with Section 7000)of Division 3 of the Business and BLDG. ELECT. PLG.
H MEER.
A Professions Code my license is i I full fart f
8-Z M- ,License Class Lic.Numbe�� JQ� rA ❑ ❑ ❑ ❑
?m w Date Contractor
OWNER-BUILDER DECLARATION I -BUILDING PERMIT a
w u - _ INFORMATION'.
Ey.,
A. I herebyaffirm that 1 am exempt from the Contmctore License MISC.- REFER TO ORD
P VALUATION SIFT.
wok Code: nycit the following..we.which
requires
a perm
so essand
Professions PERMIT ISSUANCE 10.00 Q -�
= - Code:Any city or county which structure permit to construct alter, t-�
2 Q Improve,demolish,Or repair any structure,prior to its LaaYBace.also ELEC.CONTR, CIL.N0. ELEC. rlq / V
-D u requires the applicant for such permit to file a signed statement that TOTAL ./ PERMIT TO
u w eOi he is licensed pursuant to the provisions of the Contractor's License
ria Law(Chapter 9(commencing with Section 7000)ofDivision 3ofthe 'a'c PLUMBING'PERMIT.� T'1 :-FEE' eMJOer�' /NT,
3 o Business and Professions Code)or that he is exempt therefrom and UT,V• f
ecru the basis for the alleged exemption.Any violation of Section 7031.5 - 'i_'. ..b I 'I^"'r•°� ' STORIES TYPE CONSTR.
o; byany applicant forapermil subjects the applicant to a civil penalty ALTER-DRAIN -WATER (EA.) 5.00
of not mon,than five hundred dollars($500).):
❑ 1,as owner of the property,or my employees with wages as BACK FLOW PROTECT.DEVICE 4.00 OCC,GROUP RES.UNITS
their sole compmastion,will do the work,and the structure is not
intended or offered for IF (Sec. 7044, Business and Professions DRAINS-FLOOR,ROOF,AREA,COND. 5.00
Code:The Contractor's License Law does not apply to an owner of
property who builds or improves thereon,and who does such work FIXTURES-PER TRAP 5.00 50.FT,FLOOR AREA TOTAL ACREAGE
himself or through his own employees,provided that such improve- GAS-EA.SVSTEM-11NC.40UTLETS 6.00
ments arc not intended or offered for sale.If,however,the building
or improvement is sold within one year of completion,the owner- GAS-EA.SYSTEM-OVER 4 (EA.) 2.00 BUILDING USE
builder will have the burden of proving that he did not build or im- RES IND CON PR Omar
prove for purpose of Sale.). INDUSTRIAL WASTE INTER. 30.00
❑ 1,as owner of the property,am exclusively contracting with ❑ ❑ Cl ❑ ❑
licensed Contractors to construct the project(Sec.7044,Business LAWN SPRINKLERS•1 INC 5 V.B. 6.00 ASSESSORS PARCEL NO.
and Professions Code:The Contractor's License Law does not apply
to an owner of properly who builds or improves thereon.and who LAWN SPRINKLERS-OVER 5(EA.) 1.00
or
Contracts fsuch projects with a contractorls)licensed pursuant to
the Contractor's for License Law. SEWER-SANITARY-STORM EA.200ft/10.00 TRACT NO. PARCEL NO.
❑ I am exempt under Sec.-,B.&P.C.for this WATER HEATER W/VENT 6.00
reason
Owner Date WATER SYSTEM 5.00
ACC.DATE ACO.FILE N0.
WORKERS'COAIPENSATION DECLARATION WATER TREATING EQUIP. 5.00
I hereby affirm that I have a certificate of consent to selFlnsum. ZONING ENG.SITE NO.
or a certificate of Workeri sur Compensation Ince,or a certified
x
Policy
No.thereof(Sec.3800,Company -AF
Policy ere Company
Q ❑ Certified copy is hereby furnished(�VC&f.$/V7.JE1 FIRE SPRINK ENERGY T-24
Z Z ❑ Certified copy is filed with the city inspection division. REFER TO ORD..
0� Applicant V❑ N❑ V ❑ N❑
LU
Ccy CERTIFICATEPERMIT ISSUANCE 10.00 FLOOD ZONE A.L.U.C.
W >_ COk1PE EXEMPTION FROM WORKERS'NSATION INSURANCE PLG.CONTR. LIC.NO, PLG. Y❑ N❑ Y ❑ N❑
1 (This section need not be completed if the permit is for one TOTAL
Z hundred dollars($100)or less,)
U O I certify that in the Performance of the work fur which this per- MECHANICAL PERMIT FEE FEE SUMMARY . .
IL F mit is issued,I shall not employ any person in any manner so as to
U become subject to the Workers'Com ensation Laws of California.
Dl Date ) Applicant P BUILDING p
MI, ALTER OR ADD TO MECH. 5.00
} N NOTICE TO APPLICANT: IL after making this Certificate sa Ex-
F 2 emvision you should become subject m the Workers'Compensation APPLIANCE 5.00 PLAN CHECK (0 Provisions io the Labor Code, you must forthwith comply with FEE sA" Q
U such provisions or this permit shall be deemed revoked. AIR HANDLING UNIT(TO 10,000 C.F.M.) 4.00 A�
CONSTRUCTION LENDING AGENCY AIR HANDLING UNITIOVER 1O=C.F.M.) 6.00 SEISMIC FEE /
I hereby affirm that there is a construction lending agency for EXHAUST HOOD(WITH DUCT) 5.00
the 3097 performance MICROFILM
Civ.C.) of the work for which this permit is issued(Sec. HEATING UNIT(TO 100,000 B.T.U.) 8.00
Lender's Name HEATI NG UN IT(OV ER 100,000 B.T.U.)9.50 ELECTRIC 0
Lender's Address
I certify that I have read this application and state that the above VENTILATION FAN (SINGLE) _ 4.00
information is correct.I agree to comply with all city and county PLUMBING
ordinances and stale laws relating (o building construction, and BOILER-COMP(3 H.P.or 100,000 B.T.U.) 6.00
hereby authorize representatives of this city to enter upon the BOILER-COMP (Over IOO,DODSTU)SEE FEESCH. MECHANICAL
above-mentioned property for inspection purposes.
(We) agree to Save, indemnify and keep harmless the City of MISC.- REFER TO ORD.
Cupertino against liabilities,judgments, costs and expenses which PERMIT ISSUANCE 10.001CONST.TAX
may in oft way accrue,against said City c gyans��tbp /
gmnlln$Of this per d. f L[�M1 G(/ MECH.CONT. LIC.N0. MECH.
//7/BJ TOTAL TOTAL Y
wfn 6
Signature ofA icant/Contractor
OFFICE COPY
POST THIS CARD NEAR FRONT OF BUILDING
Pf Rnflt NVSIFlFR
CI , f OF CUPERTINO 12341
INSPECTION DIVISION
JOB�I INSPECTION ARE/CO'-RD
JOB ADDR LOT# PERMIT EXPIRATION
PERMIT EXPIRES IF WORK
OWNER CONTRACTOR
IS NOT STARTED WITHIN
L INSPECTION'f?:`'r: DATE' IINSPECTOR - INSPECTION RECORD '• 180 DAYS OF PERMIT ISSU-
FOUNDATION ANCE OR 180 DAYS FROM
LASTCALLED INSPECTION.
LIFER
PREGUNITE PERMIT VALIDATION
.,POUR NO CONCRETE UNTIL'ABOVE,HAS BEEN SIGNED
UNDERGROUND /SLAB
PLUMBING
ELECTRICAL IssunrvcE DATE
BLDG. ELECT. PLG. MECR.
MECHANICAL
El E] El ❑
DO NOT POUR FLOOR UNTIL ABOVE HAS BEEN SIGNED .a; . BUILDING PERMIT
WINFORMATION
WOOD FLOOR -
VALUATION SIFT.
PLUMBING
MECHANICAL
PERMIT TO
ELECTRICAL
FRAMING
INSULATION
STORIES TYPE CO.1
.1
OCG.GROUP RES,UNITS
PLACE NO SUBFLOOR UNTIL'ABOVE HAS BEEN SIGNED
' SO.FT.FLOOR AREA TOTAL ACREAGE
ROOF
DIAPHRAGM
BUILDING USE
NES IND CON PB Olner
:APPLY NO ROOFING UNTIL ABOVE HAS BEEN SIGNED ❑ ❑ ❑ ❑ ❑
ASSESSORS PARCEL NO.
ROUGH
PLUMBING
GAB TEST TRACT NO. PARCEL NO,
MECHANICAL
ACC.DATE ACC.FILE NO.
ELECTRICAL y FINALS DATE. - INSP.
FRAMING SAN 0 ZONING ENG SITE NO.
INSULATION PLUMBING
GAS
FIRE SPRINK ENERGY T 2
MECHANICAL Y El N� v [] N
l COVER NO WORK UNTIL ABOVE HAS BEEN SIGNEO.,v HEATING
LATH-INTERIOR ELECTRICAL FLOOD ZONE A.L.V.C.
LATH-EXTERIOR FIRE DEPT. Y❑ N(] Yo N❑
SHEETROCK GRADE FEESUMMARY
SHEAR INTERIOR BUILDING H ' S - BUILDING
SHEAR EXTERIOR TEMPORARY APPROVALS --
FIREWALLS ELECTRIC PLAN CHECK
F
GAS EE
NO TAPE OR PLASTER UNTIL ABOVE HAS BEEN SIGNED JOCCUPANCY SEISMIC FEE
OCCUPANCYOF 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.
OFGICE COPY