12729 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
BU LDI NG PROJECT I DENTI FICATI ON PERMIT NUMBER
y aun ING APPLICATION & PERMIT
/
ADDRESS
in BUILDING - ELECTRICAL-PLUMBING-MECHANICAL 12729
OWNER'S /J DTV. ELECTRIC PERMIT FEE PLAN CHECK VALIDATION
NAME / / 7 ^ O
CONTRACTOR'S
�j NAME - 3 UTLETS-SWITCHES-RECEP 10.00/1.00
LIGHTING FIXTURES 10.00/1.00
CONTRACTORS PPLIANCES-RESIDENTIAL 4.00
ADDRESS
NEa93�s PANELS 10.00 DATE OFAPPLICATION
RCHITECi PLAN CHECK FEE P.C.NO.
OR PANELS (OVER 200 AMP) 20.00
ENGI NEE R� /J�I�
/- LIC.No. SIGNS TRANS. 3.00
ARLH.
ORE
R ENO. IT VALIDATION
ADD
SPECIAL CIRCUIT 5.00
IP EMP.METER OR POLE INS. 20.00
PTS
ADDRESS MOTORS SEEFEESCH.
SERVICE CHANGE 20.00
w o o �s�{s� �y LICENSED CONTRACTORS DECLARATION �1 �,"p 17
a U b I hereby affirm that I am licensed under provisions of Chapter 9 e �JrvwftrISSUANCE DATE
at G N (commencing with Section 7000)of Division 3 of the Business and BLDG. ELECT. PLG. MECH.
Hoa Prof scions Code J m I' nsc is in full for
a O o{'-- License 1 Lic.Numbs
o y F o Dale Contractor e e
P T s BUILDING PERMIT
E E ,EE ac OWNER-BUILDER DECLARA
TION INFORMATION
X
A y I hereby affirm that I um exempt from the Contractor'sLicense MISC.-
VALUATION SIFT.
H .. oa Uw for the following mason.(Sec.7031.5,Business and Professions PERMIT ISSUANCE 10.00
Code:Any city or county'which requires a permit to construct.alter, / 13 S-n
QQ Q improves demolish,or repair any structure,prior to its issuance,aha ELEC.CONTR. LIC.NO. ELEC. a./ /
- O u requires the applicant fur Such permit t0 file a Signed statement that TOTAL / PERMIT TO
whe is licensed pursuant to the provisions of the Contractor's License n
Hai Law.(Chapter 9(Commencing with Section 7000)of Division 3 ofthe pW/,e-r A4,,,,C �[r
- a Business and professions Code)or that he is exempt therefrom and CITY. PLUMBING PERMIT FEE
the basis for the alleged exemption.Any violation of Section 703 t.5 STORIES TYPE CONSTR.
i by any applicant for a permit subjects the applicant toa Civil penally ALTER-DRAIN&VENT-WATER (EA.) 5,00 676IA1l:7_�-
of not mom than five hundred dollars($500).)
❑ I,as owner Of the property,or my employees with wags ss 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
properly who builds or improves Illercon,and who docs,UCL work FIXTURES-PER TRAP 5.00 SO.FT.FLOOR AREA TOTALACREAGE
himself or through his own employees,provided that such improve-
�,�' mems are not intended or offered for Sale,If.however,the building GAS-EA.SV STEM-11NC.4 OUTLETS 6.00
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-
REB Irvo CON PB ower
prove for purpose afsale.). INDUSTRIAL WASTE INTER. 30.00
❑ I,as owner of the property,um exclusively contracting with ❑ ❑ ❑ ❑ ❑
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 Conlracmr's License Law does nut apply
to an owner Of property who builds Or improves thereon,and who LAWN SPRINKLERS-OVER 5(EA.) 1.00
cantraCls for such projects with a contractoms)licensed pursuant to
the COntracmr's Liccnu Law. SEW EH-SAN A.200f1/10.00 TRACT NO. PARCEL NO.
❑ I am exempt under Sec.-,B.&P.C.for this WATER HEATER W/VENT 6.00
reason
Owner Date WATER SYSTE 5.00 ACC.DATE ACC.FILE NO.
WORKERS'COMPENSA'I'ION DECLARATION WATER TREA GEQUIP. 5.00
1 hereby Minn that 1 have a Certificate of-consent to self-insum, ZONING ENG.SITE NO.
or a certificate of Workers'Compensation I sumnce,or a Certified
y � e -
O ❑ C"14Yit co yis he nby(u is led. FIRE SPRINK ENERGY T-24
Z Z ❑ Certified c y is filed with t Ity ins Ion visi n.
0-) Apphcant MISC.- REFER TO ORD. Y ❑ No v ❑ No
M res CERTI F1CATE 01'EXEMPTION FROM WORKERS' PERMIT ISSUANCE 10.00 ,r FLOOD ZONE A.L.0 C.
LL COMPENSATION INSURANCIi PLG.CONTR. LIC.NO. PLG. r v❑ N( Y[3 N❑
CL Z 1'fhis scaion treed nut be completed if the permit is for arc TOTAL
hundred dollars IS 100)or less.)
U O 1 certify that in the performance of the work for which this per- CITU. MECHANICAL PERMIT FEE FEE SUMMARY
LL F mit is issued,1 shall not employ any Peron in any manner so as to
U become subject to the Workers'Compensation Laws of California.
O Sri BUILDING
IS. Uate Applicant ALTER OR AD CH. 5.00 l�
} res NOTICE TO APPLICANT: If,after making this Certificate of Ex-
F ? emption,you should become Subject to the Workers'Compensation APPLIANCE 5.00 PLAN CHECK
ITT of the LaM1nr Code, you must forthwith comply with FEE
U such provisions or this permit shall be deemed revoked. AIR HANDL I ( PMC.F.M.) 4.00
CONSTRUCTION LENDING AGENCY AIR HANDLING UN fT DCT) 5,00 F.M.) 6.00 SEISMIC FEE M
I hereby affirm that there H a construction lending agency for EXHAUST H I U
the performance Of the work for which this permit is issued(Sec. MICROFILM
3097,Civ.C.), HEATING UNIT(TO 100,000 B.T.U.) 8.00
lender's Name HEATING UNIT(OVER 100,000 B.T.U.)9.50 3
Lender's Address ELECTRIC I C
1 certify that I have read this application and state that the above VENTILATION FAN (SINGLE) 4.00
.formation is correct. I agree m comply with all city and county PLUMBING ted ,-�
ordinances and state laws relating to building construction, and BOILER 13 H.P.or 100,000 B.T.U.1 6.00
di
hareby authorize representatives of this city to enter upon the
above-mentioned property for inspection purposes. BOILER-COMP (Our 11X1,000 BTU)SEE FEE SCH. MECHANICAL
(Wc) agree to save, indemnify and keep harmless the City of MISC.- REFER TO ORD.
Cupertino against liabilities,judgments casts and expenses which CONST.TAX
may in y way seems,against said in -ousequence of the PERMIT ISSUANCE 10.00 -Q-h,_
joint g the,permit MECH.CONT. LIC.NO. MECH.
TDTAL ntlCnn[racmr Uat ��TOTAL y4`Fe
Signature of APPlea
OFFICE COPY
POST THIS CARD NEAR FRONT OF BUILDING
PFRAIR NUMBER
" CITY OF CUPERTINO
INSPECTION DIVISION 12729
JOB IN- EC ION RECORD
3 PERMIT EXPIRATION
JOB ADDRESS � INI L # PERMIT EXPIRES IF WORK
OWNER L_lACONTRACTOR IS NOT STARTED WITHIN
INSPECTION DATE INSPECTOR INSPECTION REC 180 DAYS OF PERMIT ISSU.
�-(D-$Z ANCE OR 180 DAYS FROM
FOUNDATION { ,IVa LASTCALLED INSPECTION.
UFER
PREGUNITE - PERMIT VALIDATION
POUR NO CONCRETE UNTIL ABOVE HAS BEEN SIGNED
UNDERGROUND /SLAB
PLUMBING
ELECTRICAL �2� ISSeANCE DAT
MECHANICAL eLoc. LECT. c. c .
DO NOT POUR FLOOR UNTIL ABOVE HAS BEEN SIGNED BUILDING PERMIT
INFORMATION
WOOD FLOOR VALUATION $IFT.
PLUMBING
MECHANICAL
ER I TO
ELECTRICAL
FRAMING J
ST ES TYPE CONSTR.
INSULATION
I
OCC.GHOUP RES.UNITS
PLACE NO SUBFLOOR UNTIL ABOVE HAS BEEN SIGNED
ROOF SO,FT FLOOR AREA TOTAL ACREAGE
DIAPHRAGM
BUILDING USE
N IND CON PB Other
APPLY NO ROOFING UNTIL ABOVE HAS BEEN SIGNED El 0 11 0
ASSESSORS PARCEL NO.
PLUMBING ROUGH
GAS TEST TRACT NO PARCEL NO.
MECHANICAL
ACC,DATE ACC.FILE N0.
ELECTRICAL FINALS DATE INSP. v
FRAMING SAN #
INSULATION - PLUMBING ZONING ENG.SITE NO.
GAS
MECHANICAL FIRE SPR INK ENERGY T.za
COVER NO WORK UNTIL ABOVE HAS BEEN SIGNED HEATING Y N[] Y N�
LATH—INTERIOR ELECTRICAL ROOD ZONE ALU C.
LATH—EXTERIOR i FIRE DEPT. Y❑ "❑ Y ❑ No
SHEETROCK GRADE - FEE SUMMARY
SHEAR INTERIOR BUILDING O O-,
SHEAR EXTERIOR TEMPORARY APPROVALS BUILDING ,-
FIREWALLS I ELECTRIC PLAN CHECK
GAS FEE
NO TAPE OR PLASTER UNTIL ABOVE HAS BEEN SIGNED OCCUPANCY SEISMIC FEE '
OCCUPANCYOF BUILDING ISNOTPERMITTED UNTIL BUILDING FINALISSIGNED BY BUILDING INSPECTOR. MICROFILM
I
INSPECTION BY PHONING 252-4505, ELECTRIC
IrmaDAY BEFORE�REQUIRED INSPECTION. PLUMBINGOB ADDRESS WHEN PHONING. MECHANICALRMIT FOR EXPIRATION DATE -
IMPORTANT! CONST.TAX
E READ REVERSE SIDE BEFORE TOTALLING FOR FINAL INSPECTION.
OFFICE COPY