11605 4 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
BUILDING PROJECT IDENTIFICATION PERMIT NUMBER
BUILDING APPLICATION & PERMIT
11605
ADDRESS
� BUILDING-ELECTRICAL-PLUMBING-MECHANICAL
OWNERS PLAN CHECK VALIDATION
NAME - DTV. ELECTRIC PERMIT FEE
- LI..NE
oN RACTOR's
UT
-SWITCHES-S
10.00/1.00
ME
LID.N . 2- LIGHTING FIXTURES 10.00/1.00
40NTFACTORS ` Qif iT1 PPLIANCES-RESIDENTIAL 4.00
Ess ' r` 1�11RxJ PANELS 10.00 DATE OF APPLICATION
ITECTPANELS (OVER 200 AMP) 20.00 PLAN CHECK FEE P.C.NO.
OR
ENGINEER
uc.Na. SIGNS TRANS. 3.00
ARCH OR ENG, SPECIALCIRCUIT 5.00 PERMIT VALIDATION
ADDRESS
ZIP EMP.METER OR POLE INS. 20.00 r
ADDRESrvrs MOTORS SEE FEE SCH.aoDREss
SERVICE CHANGE 20.00w0a LICENSED CONTRACTORS DECLARATION
v1 hereby affirm (hat I am licensed under provisions of Chapter 9 Is E DATE
y a m (commencing with Section 7000)of Division 3 of the Business and I -SEL PLG. MECH.
H y i Professions Coe(i nd y license is in full fore and ffe ❑ ❑
z
0. LEI)- License Classj_ Lic.Number C�- -
2 m t a Uaw Contractor
¢ m¢ a OWNER-BUILDER UECLARAT ION BUILDING PERMIT
_ ¢w INFORMATION
o>" MISC.- REFER TO ORD
w; 0
Is, I hereby affirm that 1 am exempt from the Contractors License VALUATION $/FT.
L0 ¢ Law farlhe following mercury
Business PERMIT ISSUANCE 10.00
L- N m � Code: e,d mulish coin pair any structure,
a tune, riort o its issuan e,alsoL�E
a-Q �-d"-Q
5 2 Q 0 improve,demolish,or repair strUC Wre,prior[a its issuance,also ELEC.CONTR. LIC.NO. ELEC. /
aa m 0, requires the applicant for such permit to file a signed statement that TOTAL PER MIT TO
°' $ be is licensed pursuant to the provisions of the Contractor's License, /
F Z Qw Law(Chapter 9(coin me acing with Section 7000)of Division 3 ofthe /•1/T Jiw-yV0
4 0 Business and Professions Code)or that he is exempt therefrom and OTV. PLUMBING PERMIT FEE
M H$ the basis for the alleged exemption.Any violation of Section 7031.5 STORIES TYPE CONSTR.
by any applicant for a permit subjects the applicant to a civil penalty ALTER-DRAIN& VENT-WATER (EA.) 5.00
of not more than flvcbundred doliars($5000:
❑ 1,as owner of the property,or my employees with wages as BACK FLOW PROTECT.DEVICE 4.00 OCC.GROUP RES.UNITS
their sole compensation,will do the work,and the structure Is not
intended or offered for sale(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 docs such work FIXTURES-PER TRAP 5.00 SQ FT.FLOOR AREA TOTAL ACREAGE
himself or through his own employees,provided that such improve- GAS-EA.SVSTEM-i INC.40UTLETS 6.00
mems are not intended or offered for sale.If,however,the building
I or improvement is sold within one year of completion,the owner-
! builder will have the burden of roving that he did not build or int- GAS-EA.SYSTEM-OVER 4(EA.) 2.00 BUILDING USE
.5� p RES IND CON PB Other
prove for purpose of sale.). INDUSTR IAL WASTE INTER. 30,00
❑licensed as nwner of ore property,he exclusively .7044,Bu with ❑ ❑ ❑ ❑ ❑
adPro contractors to construct the project(Sec.7044,Business LAWN SPRINKLERS-1 INC 5 V.B. 6.00 g55ESS0R5 PARCEL NO.
and Professions property Contractor's License s thereon,
does not apply
to an owner of properly who builds or improves thereon,and who LAWN SPRINKLERS-OVER 5(EA.) 1,00
contracts for such projects with a contractors)licensed pursuant to
the Contractor's License Law. SEWER-SANITARY-STORM EA.200ft/10.00 TRACT NO. PARCEL No.
❑ I am exempt under Sec. ,B.&KC.for this WATER HEATER W/VENT 6.00
reason
Owner Date - WATER SYSTEM 5.00 ACC.DATE ACO.FILE NO,
WORKERS'COMPEN SATION DECLARATION WATER TREATING EQUIP. 5.00
I hereby affirm that I have a certificate ofconsent to self-insure. ZONING ENG.SITE NO.
or a certificate of Workers'Compensation Insurance,or a certified
copy thereof(See.3800,Lab.
Policy No. Comps 19A' MI5
O ❑ Certified CUpy is hereby urrished. FIRESPRINK ENERGY T-2e
Z Z ❑ Cert ied co Is file w'h the city inspection Division. MISC.- flEFER TO ORD.
O Applicant _ Y❑ N❑ Y ❑ No
CC �' CERTIFICATIi OPL 'b I n WOR HRS' PERMIT ISSUANCE 10.00 FLOOD ZONE A.L.U.C.
LTJ > COMPENSATION INSURANCE PLG.CONTR. LIC.NO. PLG. Y❑ N❑ Y ❑ N❑
CL O (This section need not he completed if the permit is for one TOTAL
0 Z hundred dollars(5100)or less.)
U O I certify Ihul in the performance of the work for which this per- DTV. MECHANICAL PERMIT FEE FEE SUMMARY
U. 1 mit is issued, ) shall not employ any person in any manner so as to
O become subject to the Workers'Compensation Laws of Cahlormla' BUILDING 7�
y DmtJ
c Applicvnt ALTER OR ADD TO MECH. 5.00
} Ut NOTICE TO APPLICANT: If,after making this Certificate of Ex-
F Z emplion,you should become subject to the Workers'Compensmiom APPLIANCE 5.00 PLAN CHECK p/
provisions of the Labor Cade, you must forthwith comply with FEE
O
U 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 10=C.FM.) 6.00 SEISMIC FEE
I hereby affirm that (here is a construction lending agency for EXHAUST HOOD (WITH DUCT) 5.00
the performance of the work for which this permit is issued(Sec. MICROFILM
3097,Civ.CJ. HEATING UNIT(TO 100,000 B.T.U.) 8.00
Lender's Name ' HEATING UNIT(0
Lender's Addre e � 100,000 B.T.U.)9.50 ELECTRIC
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 to building construction, and BOILER-COMP(3 H.P.or 100,000 B.T.U.) 6.00
hereby autto a representatives of this city to enter upon the BOILER-COMP(Over 100,00D BTU)SEE FEE SCH. MECHANICAL
above, a property for inspection purposes.
(We) agree o save, indemnify and keep harmless the City of MISC.- REFER TO ORD.
Cupertino egai t liabilities,judgments, costs and expenses which CONST.TAX
ma y wa acerae t said City in consequence of the PERMIT ISSUANCE 10.00
1
if,
is P I h. MECH.CONT. LIC.NO. MECH.
TOTAL TOTAL 7� _
Sig Lure of Applle Conuucmr Date
OFFICE COPY
w
�e • - - POST THIS CARD NEAR FRONT OF BUILDING
'PERMIT NUMBER
CITY OF CUPERTINO 11605
INSPECTION DIVISION
JOB INSPECTION RECORD
PERMIT EXPIRATION T
JOB ADDRESSEll UNIT# LOT# E
lq PERMIT EXPIRES IF WORK
OWNER CONTRACTOR IS NOT STARTED WITHIN
Le INSPECTION IF DATE INSPECTOR INSPECTION RECORD 180 DAYSOF PERMIT ISSU-
FOUNDATION ANCE OR 180 DAYS FROM
LIFER @n
LABESTCALLED INSCTION.
PREGUNITE PERMIT VALIDATION
POUR NO CONCRETE UNTIL ABOVE HAS BEEN SIGNED �.
UNDERGROUND /SLAB
PLUMBING
ELECTRICAL ISSUANCE DATE
MECHANICAL BLDG, ELECT. I PLG. MECH.
DO NOT POUR FLOOR UNTIL ABOVE HAS BEEN SIGNED BUILDING PERMIT
INFORMATION 'S
WOOD FLOOR *VALUATION SIFT.
PLUMBINGMECHANICAL
ELECTRICAL - TT
:FRAMING.INSULATIONv colvsTR.
OCC.GROUP RES,UNITS
'PLACE NO SUBFLOOR UNTIL ABOVE HAS BEEN SIGNED
imlo�
'ROOF SO.FT.FLOOR AREA TOTAL ACREAGE
DIAPHRAGM
BUILDING USE
RES IND CON PB Olney
LTAPPLY NO ROOFING UNTIL ABOVE HAS BEEN SIGNED ❑ ❑ ❑ ❑ ❑
ASSESSORS PARCEL NO.
ROUGH
PLUMBING
GAS TEST TRACT NO. NO.
PARCEL
MECHANICAL
ACC.DATE ACC.FILE NO.
`-- ' ELECTRICAL M
ALS IDATEINSP.FRAMING ZONING ENG:SITE NO,
INSULATION •. � '
FIRE SPRINK' ENERGY T-24
- AL
COVER NO WORK UNTIL ABOVE HAS BEEN SIGNED v OO NE Y ❑ N�
FLOOD ZONE A.L.u.c.
LATH—INTERIOR, L N❑LATH—EXTERIOR -SHEETRC - FEE SUMMARY
SHEAR INTERIOR BUILDING
SHEAR EXTERIOR. TEMPORARY APPROVALS BUILDING
FIREWALLS ELECTRICPLAN CHECK A,
GAS FEE
LNO TAPE OR PLASTER UNTIL ABOVE MAS BEEN SIGNED OCCUPANCY SEISMIC FEE U_
UCCUPANCY OF BUILDING IS NOT PERMITTED UNTIL BUILDING FINAL IS SIGNED BY BUILDING INSPECTOR. MICROFILM
` ARRANGE FOR INSPECTION BY PHONING 252-4505, ELECTRIC
W I o ONE WORKING DAY BEFORE REQUIRED INSPECTION. PLUMBING
PLEASE GIVE JOB ADDRESS WHEN PHONING.
Z
` 'ha - SEE PERMIT FOR EXPIRATION DATE - MECHANICAL
IMPORTANT!
CONST.TAX
PLEASE READ REVERSE SIDE BEFORE TOTAL
CALLING FOR FINAL INSPECTION.
OFFICECOPY