17007 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
`r BU LD1 NG PROJECT I DENTI FICATI ON - PERMIT NUMBER
BUILDING APPLICATION & PERMIT 700
ADDRESS.75_�4
.Q/N WAY
BUILDING-ELECTRICAL-PLUMBING-MECHANICAL �;i
OWNER'S
N411E PLAN CHECK VALIDATION
gEA1 /✓A VJJ p / OTY. ELECTRIC PERMIT FEE
vHDrvE Z.�s��7p�O
CONTRACTORS
NAME OUTLETS-SWITCHES-RECEP 10.00/1.00 .,
d w/1/EsQ LIC.NO. LIGHTING FIXTURES 10.00/1.00
ADDRESS PPLIANCES-RESIDENTIAL 4.00
CONTRA
PHONE PANELS 10.00 DATE OF APPLICATION
ORHCHrtECT PANELS (OVER 200 AMPI 20,00 PLAN CHECK FEE P.C.N0.
NGINEER
LIC,NO, SIGNS TRANS. 3.00
ADDRESS Enc' SPECIALCIRCUIT 5.00 PERMIT VALIDATION
ZIP FrEMP.METER OR POLE INS. 20.00 ZI2Zl8O
APPLICANT rvs MOTORS SEE FEE SCH.
ADDRESS
SERVICE CHANGE 20.00
a ¢ z
Foo LICENSED CONTRACTORS DECLARATION -
au 2 1 hereby affirm that I am licensed under provisions of Chapter 9
2 w ISSUANCE DATE
P,¢ (commencing with Section 7000)of Division 3 of the Business and
'w BLDG. ELECT. PLG. MECH.
F y w Professions Code.and my license is in full force and effect. DEC 1:1a
z O w- License Class Lic.Number
P
w 2 w Date Contractor City of Cupertino BUILDING PERMIT
e, a OWNER-BUILDER DECLARATION
s o A " INFORMATION
X ; u 1 hereby affirm that I am exempt from the Contractor's License MISC.- REFER TO ORD
FCO¢ Law for the following reason, 7031.5.Bisinessand Prufessions PERMIT ISSUANCE �.OB30.00 �ZO YVALUATION� $/FT.
Code:Any city or county which requiresa permit to construct,alter,
2 a Q improve,demolish.or repair any structure,prior to its issuance,also ELEC.CONTR. LIC.NO. .ELEC. o T
O ¢ requires tiro applicant for such permit to tile a signed statement that TOTAL
n w m u he is licensed pursuant to the provisions of the Contractors License i ��jMODPERMIT TO
F z r
Law(Chapter!)(commencing with Section 700000f Division 3 of the EL /l/TCNBn/
4 o Business and Professions Code)or that he is exempt therefrom and QTY. PLUMBING PERMIT FEE
¢ r- o Bre basis for the alleged exemption.Any violation of Section 703 L5 STORIES TYPE CONSTR,
i;m by any applicant for a permit subjects the applicant to u civil penalty gLTER-DRAIN -WATER (EA.) 5.00
of not more than five hundred dollar,(S500).):
`4 I,as owner of the property,or my employees with wages as BACK FLOW PROTECTDEVICE 4.00
their sole compensation,will do the work,and the str¢mre is not . OCC.GROUP RES.UNITS
intended or offered for sale (Sec. 7044, Business and Professions DRAINS-FLOOR,ROOF,AR EA,COND. 5.00
Code: Contractor's License Law docs not apply to an owner of
property
r through
builds or Improves employees,
pr,and whin docs such work FIXTURES-PER TRAP S;QO 2, SQ FT.FLOOR AREA TOTAL ACREAGE
himself re through his own employees,provided that such improve-building
meats ore not intended or nflcmA for sale.If,however,the building GAS-EA.SYSTEM-11NC.40UTLETS 6.00
or improvement is sold within one year of completion,the owner- GAS-EA.SYSTEM-OVER 4(EA.) 2.00
builder will have the burden of proving that he did not build or im- BUILDING USE
prove for purpose of sale.). RES IND CON PB Other
❑ 1,as owner of the property,am exclusively contracting with INDUSTRIAL WASTE INTER. 30.00 ❑ ❑ ❑
licensed contractors od to construct the project La 7044,Business LAWN SPRINKLERS-1 INC 5 V.B. 6.00 ASSESSORSPARCEL NO.
toProfessions Codes ty Contractor's License Law Jac not apply
to frowner of property who huildstr improves ,sed oandwho LAWN SPA IN KLERS-OV OVER 5 (EA.) 1.00
contracts for such projects with a contractarls)licensed pursuant to
the Contractor's License Law. SEWER-SAN ITAR V-STORM EA.200ft/10.00 TRACT NO. PARCEL NO.
❑ lam exempt under Ser..,B,&P,C.for this WATER HEATER W/VENT 6.00
ensu,
Owner_ �. Date/j-Jj_ WATER SYSTEM 5.00
ACC.DATE ACC FILE NO.
Wb KERS'COMPENSATION DECLARATION WATER TREATING EQUIP. 5.00
1 hereby affirm that I have o..filicale of consent to sell'-insure,
or a certificate of Workers'Compensation Insurance,or a certified ZONING ENG.SITE NO.
copy Omoof(Sec.3800,Lab.C.L
Policy No. Company
O ❑ Certified copy is hereby furnished.
RE SPRINK ENERGY T-
Z Z ❑ Certified copy is fled with the city inspection division. 24
Applicant MISC.- REFER TO ORD. y. ❑ N v � Ni]
~ O PERMIT ISSUANCE
LU - CIiRTIPICCOMONSATI N INSURONI WORKERS' 12.00"12-0aFLDOD ZONE A.L.u.C.
LU
0 COMPENSATION INSURANCE PLG.CONTR.. LIC.No. PLG
K Z (This section need not be completed if the permit is for one TOTAL I ry v w YE] N D Y E] N�
U O h dndred dol l ars IS 100)nr Itss.)
I certify that In the performance of the work for which this per- QTY. MECHANICAL PERMIT FEE FEE SUMMARY
LL H mit is issued.1 shall not employ any person in any manner so as to
U become Subject)q tie Workers'f�amppnsat ion l ws o�j,C,alifornia.
Date-?�. Applicant - "/ -� ALTER OR ADD TO MECH. 5.00 BUILDING qo,�
} rn N'O CI: TO APR( CAN'T': If of making this C'tificate of 1!x-
F ? emption,you should become subject to the Workers'Conpensalion APPLIANCE 5.00 PLAN CHECK (I�'/,/I C
provisions of the Labor Code, you must forthwith comply with FEE
U such provisions or this permit shall be deemed revoked. AIR HANDLING UNIT(TO IO=C.F.M.) 4.00
CONSTRUCTION LENDING AGENCY AIR HANDLING UNIT(OVER 10=C.EM.) 6.00 SEISMIC FEE ) Q
I hereby affirm that there is a construction lending agency for EXHAUST HOOD (WITH DUCT) 5.00
the performance of the work for which this permit is issued(Sea MICROFILM
3097,CIv.C.). HEATING UNIT(TO 100,000B.T.U.) 8.00
Lender's Name
Lender's Address HEATING UN IT(OVER 100,000 B.T.U.)9.50 ELECTRIC
I certify that I have mad this application and state that the above VENTILATION FAN (SINGLE) 4.00
information is correct. 1 agree to comply with all city and county BOILER H.P.or 100PLUMBING yrQo
ordinances and state laws relating to building construction, and ,000 B.T.U.) 6.00
hereby authorize representatives of this city to enter upon the BOILER-COMP love.100,000 BTU)SEE FEE SCH.
above-mentioned property for inspection purposes. MECHANICAL
(We) ,gra to save, indenmify and keep harmless the City of MISC.- REFER TO ORD,
rpertino 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
ranting of Uris permit. �1 f I MECH.CONT, LIC.NO. MECH.
-,L na 1A.1.yI� 1,? 1; 4A TOTAL TOTAL ( 5�.
Sig -of Applicant/Contracto Uato
OFFICE COPY -41
w-'
POST THIS CARD NEAR FRONT OF BUILDING PERMIT NUMBER
CITY OF CUPERTINO 17007
INSPECTION DIVISION
JOB INSPECTION RECORD
1 PERMIT EXPIRATION
JOB ADO 75�y ..Erle �QG UNIT# _LOT# PERMIT EXPIRES IF WORK
OWNER S CONTRACTOR elm to Ic IS NOT STARTED WITHIN
INSPECTION DATE INSPECTOR INSPECTION RECORD 180 DAYS OF PERMIT ISSU-
FOUNDATION ANCE OR 180 DAYS FROM
NOTE: LASTCALLED INSPECTION.
UFER ALL GRADING AND DRAINAGE SHALL BE INSTALLED
PREGUNITE TO COMPLY WITH THE APPROVED PLANS AND CITY OF PERMIT VALIDATION
CUPERTINO STANDARDS. E �^
GARAGE SLABS
POUR NO CONCRETE UNTIL ABOVE HAS BEEN SIGNED
UNDERGROUND /SLAB
PLUMBING
ELECTRICAL ISSUANCE DATE
MECHANICAL RLOc ELECT PLO. I MECH
DO NOT POUR FLOOR UNTIL ABOVE HAS BEEN SIGNED BUILDING PERMIT
WOOD FLOOR DEC 2VV
88 INFORMATION
PLUMBING VALUATION SIFT.
/ _
MECHANICAL City of CD eftin0
ELECTRICAL PERMIT TO
FRAMING
INSULATION STORIES TYPE CONGER
OCC GROUP RES UNITS,
PLACE NO SUBFLOOR UNTIL ABOVE HAS BEEN SIGNED
ROOF NOTE:NO FINAL INSP,SHALL BE MADE BEFORE SO IT.FLOOR PREP TOTAL ACREAGE
DIAPHRAGM THE CONSTRUCTION TAX IS PAID
ROOF SHEATHING RES IND LOi NON USEpaO,...i
APPLY NO ROOFING UNTIL ABOVE HAS BEEN SIGNED FINALS DATE INSP. ❑ ❑ 1:1 ❑ ❑
ROUGH SAN.N nssessoas PngceL rvo -
PLUMBING ELECT.ENERGY
TUBS 8 SHOWER PAN PLUMBING ENERGY TRACT NO. PARCEL T NO
MECHANICAL MECH.ENERGY
ELECTRICALBUILDING ENERGY
Acc DATE ACC.FILE NO
FRAMING S ELECT.FINAL TEST
INSULATIONPLUMBING ONING END SITE NO.
GAS TEST GAS
l
MECHANICAL FIRE SPRINrc ENERGY T.za
COVER NO WORK UNTIL ABOVE HAS BEEN SIGNED HEATING Y ❑ N❑ ` ❑ N❑
EXTERIOR SHEARELECTRICAL RELEASE FLOOD ZONE AL.uc
INTERIOR SHEAR @GAS .
-'— Y ❑ N❑ v ❑ , N❑
SHEETROCK J
FEESUMMARY
EXTERIOR LATH /+�
INTERIOR LATH PORAR ROVALS BUILDING Z r�l.� cro
SCRATCH COAT PLAN CHECK ! l/v CfJ/
FEE Yui .I
NO TAPE OR PLASTER UNTIL ABOVE HAS BEEN SIGNED SEISMIC FEE a ✓V
OCCUPANCY OF BUILDINGIS NOT PERMITTED UNTIL BUILDING FINAL IS SIGNED BY BUILDING INSPECTOR. MICROFILM
ELECTRIC 1' „ `
ARRANGE FOR INSPECTION BY PHONING 252-4505, ( ,(J
Eli ONE WORKING DAY BEFORE REQUIRED INSPECTION. PLUMBING
z PLEASE GIVE JOB ADDRESS WHEN PHONING.
— SEE PERMIT FOR EXPIRATION DATE — MECHANICAL
IMPORTANT! CONST.TAX
L PLEASE READ REVERSE SIDE BEFORE
CALLING FOR FINAL INSPECTION. TOTAL
OFFICE COPY