10178 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
t,8UILD1NGPROJECT 1 D NTIFICATION PERMIT NUMBER
LTOING o APPLICATION & PERMIT 1017 8
aDOREaS/Q S/LO Jr icvl.
(R.. 3 BUILDING-ELECTRICAL-PLUMBING-MECHANICAL
OWNE
NAME 4d'cvgw 4C.4,X� Asf,�Or PLAN CHECK VALIDATION
T� 3�O DTV. ELECTRIC PERMIT FEE 2 n ln/ / .
CONTRACTORS ,PIHO u.
NAME G�nOs���yyg M�pwE'C.S r UTLETS-SWITCHES-RECEP 10.00/1.00 Q - v -
G I' LIc.Epta��y M0 LIGHTING FIXTURES 10.00/1.00 eo
CONTRACTORS
1f d,✓/ PPLIANCES-RESIDENTIAL 4.00
1;142M1;142M fapW PHO 7
7-Z4( /` sitPANELS 10.00 Q DATE OF APPLICATION
ARCHITECT pkgry CHECK FEE P.C.NO.
DR
ENGINEER ..�` PANELS (OVER 200 AMP) 20.00
LIC.No. ISIGNS TRANS. 3.00
ARCH.OR ADDRESS ENG �r SPECIALCIRCUIT 5,00 PERMIT VALIDATION
ZIP TEMP.METER OR POLE INS. 20.00
As MOTORS - SEE FEE SCH.
ADDRESS
pDREss
C-1- SERVICE CHANGE PAID 20.00
H o O LICENSED CONTRACTORS DECLA ATION TEMP.POLE 3
<v w I hereby affirm that I am licensed under provisions of Chapter 9 ISSUANCE DATE
w c (commencing with Section 7000)of Division 3 of the Business and ^�^ BLpG ELECT. PLG. MECH.
H y z Professions Code,anopypIy license is in full force nd etftU I n II_ ❑
Z O m - License Class Lic.Numbe Y M Y
N w Date_�.j_:�� i'-_Comractor
f City of Cupertino gUI LDING PERMIT
o v U OWNER-BUILDER DECLARATI N INFORMATION
X ; LL y 1 hereby affirm that I am exempt from the Contractor's License MISC.- REFER TO ORD
w VALUATION $/FT.
H u O J Law for the following reason.(See.7031.5,Busines,SAnd Professions PERMIT ISSUANCE 10.00 a
Code:Any city or county which requires a permit to construct alter,
Q cr¢a improve,demolish,or repair any structure,prior to its issuance,also ELEC.CONTR. LIC.NO.
ELEC. ` /L
O LL requiresisic the applicant for such permit to file a signed statement that TOTAL (J PERMIT TO
E
hn w he is licensed 9pursuant(commencing the provisions of the Commvision License -
Hza Law(Cband Prosions )with Section is 00)Exempt therefrom
the
and /t�/'r�RyU e_./U/O
f 4 o Rosiness and he alleged Code)or that he is exempt therefrom and OTY- PLUMBING PERMIT FEE A, C) L
R f$ the basany
the alleged ermit subjects
tsthAnyea plica ttoa ewil malty03 1.5 STORIES TYPE CONSTR.
T ; _ by any applicant fora permit subjects the applicant to a civil penalty
of not more than five hundred dollars 11500)J: ALTER-DRAIN III VENT-WATER (EA.) 5.00
❑ I,as owner of the property,or my employees with wages as BACK FLOW PROTECT. DEVICE 4.00
their sole compensation,will do the work,and the structure is not OCC.GROUP RES.UNITS
intended or offered for sale (Sec. 7044, Business and Professions DRAINS-FLOOR,ROOF,AREA,GOND. 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 $0.FT.FLOOR AREA TOTAL ACREAGE
himself mis re through his own employees.provided what such intprove-
mmself. not intended or employeesa e.provided
thathowevsuch
building GAS-EA.SYSTEM-11NC.4OUTLETS 6.00
or improvement is sold within one year of completion,the owner-
builder will have the burden of proving that hC did not build or im GAS-EA.SYSTEM-OVER 4(EA.) 2.00 BUILDING USE
prove for purpose of sale.). RES IND CON PB Other
❑ I,as owner of the property,am exclusively contracting with INDUSTRIAL WASTE INTER. 30.00 El
licensed contractors to construct the project(Sec.7044,Business LAWN SPRINKLERS-I INC 5 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 comractor(s)licensed pursuant to
the Contractor's License Law. SEWER-SANITARY-STORM EA.200ft/10.00 TRACT NO. PARCEL NO.
❑ lam exempt under See..,BARC.for this WATER HEATER W/VENT 6.00
reason
Owner Date WATER SYSTEM 5.00 ACC.DATE ACC.FILE NO.-
WORKERS'COMPF-NSATION DECLARATION WATER TREATING EQUIP. 5.00
1 hereby affirm that I have a certificate ofconsent to setfinsure,
or a certificate of Workers'Compensation Insurance,or a certified ZONING ENG.SITE NO.
W
Se C.)
4 Y
0 ❑ Certified copy ishereby furnished. FIRESPRINK ENERGY T 24
Z Z tytCertif' opy is filed ith the city in,,ec'on division.
I"' O Applicant.11"21111, MISC.- REFER TO ORD. YE] N� Y ❑ NO
rn PERMIT ISSUANCE 10.00 FLOODZONE A.L.u.c.
!r CER PI TEPE EXEMPTION FROM WORKERS'
CL COMPENSATION INSURANCE: PLG.coryrR, LIC.No. PLG. ❑ ❑ ❑ ❑
1 (This dollars
need or be completed if the permit is for one TOTAL Y N Y N
0 Z hundred dollars(5100)or less.)
U O I certify shat in the performance of the work for which this per. CITY. MECHANICAL PERMIT FEE FEE SUMMARY
U. F mit is issued,I shall not employ any person in any manner so as to
.O W become subject to the Workers'Compensation Laws of California.
Dale Applicant BUILDING
>_ y NOTICE TO APPLICANT: If,after making this Certificate of Ex- ALTER OR ADD'TO MECH. 5.00
Fz emption,you should became subject to the.Workers'Campenmlion APPLIANCE 5.00 PLAN CHECK
provisions of the Labor Code, you must forthwith comply with FEE
C.1 such provisions or this permit shall be deemed revoked. AIR HANDLING UNIT(TO 10=C.F.M.) 4.00
CONSTRUCTION LENDING AGENCY AIR HANDLING UNIT(OVER 1000C.F.M.) 6.00 SEISMIC FEE d�
AI hereby affirm that there is a construction lending agency for EXHAUST HOOD(WITH DUCT).. 5.00
c performance of the work for which this permit is issued(Sec. MICROFILM
3097,Cre.CJ. HEATING UNIT(TO 100,000 B.T.U.) 8.00
a;Lender's Name
- - - :Genders Address HEATI NO UN IT(OV ER 100,000 B.T.U.)9.50 ELECTRIC �✓
of1 certily that I have read this application and state that the above VENTILATION FAN (SINGLE) 4.00
information is cornet. I agree ti comply with alt city and coomy PLUMBING
Informmolinam.ado and state laws relating to 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 100,000 BTUI SEE FEE SCH.above-mentioned property for inspection purposes. MECHANICAL
(We) agree,to save, indemnify and keep harmless the City of MISC.- REFER TO ORD.
Cupertino against liabilities,judgments, costs and expenses which CONST.TAX
may in any way accrue against said City in consequence of the PERMIT ISSUANCE 10.00
gloat This permit ��/ MECH.CONT. LIC.NO. MECH. TOTAL V v
TOTAL /�f
' oat o Applicant on[raaor Da[
- OFFICE COPY
JPOST THIS CARD NEAR FRONT'OF BUILDING
PERFVT NUM6ER
CITY OF CUPERTINO
INSPECTION DIVISION' T o1 ?8
JOB.INSPEC�T7ION RECORD ?• Ic
I D�O e' UNIT# �' LOT# PERMIT EXPIRATION
JOB ADDRESS ,4L
' .PERMIT EXPIRES IF WORK,
OWNER CONTRACTOR IS NOT STARTED' WITHIN
INSPECTION DATE INSPECTOR I PECTION RE O D :.•180 DAYS OF PERMIT ISSUI
FOUNDATION - ANCE OR 180 DAYS FROM
LIFER ;
^,I 8C 'K '.,LAST CALLED INSPECTION.`
PREGUNITE >•- 'O—" fi� PER
VALIDATION 1I
• -;A " •
POUR NO CONCRETE UNTIL ABOVE HAS BEEN SIGNED
UNDERGROUND /SLAB 0 p
PLUMBING
ELECTRICAL . . .. " �,.
- ISSUANCE DATE
MECHANICAL BLDG. .ELECT,. - PLG. MECH. '
DO NOT POUR FLOOR UNTIL ABOVE HAS BEEN SIGNED BUILDING PERMIT
WOOD FLOOR _ -INFORMATION
VALUATION - SIFT.
•PLUMBING - � - ' a � .. '
MECHANICAL '• -
ELECTRICAL " T
FRAMING -
INSULATION - .STORIES rPE Co SIR. . ,
OCC.GROUP RES.UNITS
PLACE NO SUBFLOOR UNTIL ABOVE HAS BEEN SIGNED
ROOF SO.FT,FLOOR AREA TOTAL ACREAGE
DIAPHRAGM !l '
BUILDING USE,
RES IND PB Olner
APPLY NO ROOFING UNTIL ABOVE HAS BEEN SIGNED ❑ ❑ ❑ ❑
ROUGH ASSESS71 P RCEL.ND
PLUMBING .•: '
GAS TEST % TRACT NO. PARCEL NO.
MECHANICAL -
Acc.OnrE- Acc.FILE No.
ELECTRICAL .
- 5-86 FINALS DATE INSP: .. + ..
FRAMING 1-3o-k6 IsAN # -
INSULATIONPLUMBING �Q �� NG :ENG.SITE No.
.. GAS
MECHANICAL FIRE RINK ENERGY T 2
/ N❑ ,1 V N❑ .
COVER NO WORK UNTIL ABOVE HAS BEEN SIGNED HEATING
LATH-INTERIOR I `
. . , ELECTRICAL FLOOD ZONE A.L.UC.
LATH-EXTERIOR• - - FIRE DEPT. °❑ .N❑ Y❑ N❑
SHEETROCK- /- �j - GRADE, t FEESUMMARY
'SHEAR INTERIOR • BUILDING pl
rREA
RIOR. TEM RARV APPROVALS'' -BUILDING
ELECTRIC PLAN CHECK,
GAS- FEE
PLASTER UNTIL ABOVE HAS BEEN SIGNED OCCUPANCY SEISMIC FEE
OF SUILDING'IS NOT PERMITTED UNTIL BUILDING FINAL IS SIGNED BY BUILDING INSPECTOR. MICROFILM
ARRANGE FOR INSPECTION BY PHONING 252-4505, • ELECTRIC
1 ONE WORKING DAY BEFORE,REQUIRED INSPECTION: PLUMB ING
z . PLEASE GIVE 706 ADDRESS WHEN PHONING.
- SEE PERMIT FOR EXPIRATION DATE - MECHANICAL
IMPORTANT! CONST.TAX
PLEASE READ REVERSE SIDE BEFORE TOTAL
CALLING FOR FINAL INSPECTION. - -
OFFICE COPY
ADDITIONAL PERMIT FEES
BUILDING PROJECT 1 DENTI FICATION VALUATION
0°ILDING
aGDREO
NAME
SeFEE SUMMARY
PMDM;�'HG -SSO
cR"` ns d1 ( YS(J BUILDING
G PLAN CHECK
ADDRR dons FEE
°NL3 I SEISMIC FEE
2TY. ELECTRIC PERMIT FEE
UTLETS-SWITCHES-RECEP ELECTRIC
LIGHTING FIXTURES PLUMBING
PPLIANCES-RESIDENTIAL
PANELS MECHANICAL
SIGNS
SIGNS TRANS. TOTAL
SPECIAL CIRCUIT
EMP.METER OR POLE INS. vEBmrr vnuDATION
MOTORS SEE FEE SCH, n
Q SERVICE CHANGE y
z2 N
F °
�5 TOTAL
ISSUANCE DATE
W GTV. PLUMBING PERMIT CL FEE BLDG ELECT. PLG. NEC..
=) Z ALTER-DRAIN&VENT-WATER(EA.) ❑ ❑
V O BACKFLOW PROTECT.DEVICE
LL I
W DRAINS-FLOOR,ROOF,AREA.COND.
} u FIXTURES-PER TRAP
N
F— ? GAS-EA.SYSTEM-I INC.0 OUTLETS
(„) GAS-EA.SYSTEM-OVER 9IEA.)
INDUSTRIAL WASTE INTER.
LAWN SPRINKLERS-1 INC 5 V.B.
LAWN SPRINKLERS-OVER 51EA.)
SEWER-SANITARY-STORM EA.200ft/
WATER HEATER WNENT
WATER SYSTEM
WATER TREATING EQUIP.
TOTAI
CITY. MECHANICAL PERMIT FEE
ALTER OR ADD TO MECH.
APPLIANCE
AIR HANDLING UNITF.NL)
AIR HANDLING UNIT OVER IQ0WC.EM)
EXHAUST HOOD(WITH U 1 V
HEATING UNIT 1 _ 1 ,0 8 T.U.) .
nn
HEATI NGUNIT(O ERIDO.
VENTILATION FAN ) /
BOILER-DOIVP(3 H.P.or 100,000 B.T.U.) /
BOILER-COMP loW.100,000 aiu)SEE EEE SC..
TOTAL
— — s