11351 APPLICANT TO FILL IN INFO__ TION WITHIN RED LINES - USE BAIL POINT PEN ONLY \
•
BUI LD1 NG PROJECT 1 DENTI FICA PERMIT NUMBER
BUILDING APPLICATION & PEFW
y ANNREss
Q31 EftrES �- BUILDING-ELECTRICAL-PLUMBING -MECHANICAL 11351
OWNERS G-/�i PLAN CHECK VALIDATION
NnNE _/ 25��"O�yq CITY. ELECTRIC PERMIT FEE
NE 7,L�
PHO
NON,ERAcroRs � � " ' OUTLETS-SWITCHES-RECEP 10.00/1.00
,xvu�sta DLE/ uc.No. LIGHTING FIXTURES 10.00/1.00
ADDRRACrNR's APPLIANCES-RESIDENTIAL 4.00 3 `7
CONTRACTORS
�/ / r Zµ3-3 7
1 ch �/vWt_ A/C a 11.1. PANELS , 1Q.QQ DATE OF APPLICATION
ARCHITECT 1ZtW OSF PANELS (OVER 200 AMP) 20.00 PLAN CHECK FEE P.C.NO,
OR W/
ENGINEER
LIC.No. SIGNS TRANS. 3.00
ADDRESS ENc. SPECIAL CIRCUIT 5.00 PERMIT VALIDATION
APPLICANT
ZIP TEMP.METER OR POLE INS. 20.00 ANNRE55 MOTORS SEE FEE SCH.
'7` _
�L /�/ A✓�Sr SERVICECHANGE ,� 20.00 0
Woo LICENSED CONTRACTORS DECLARATION
a i w I hereby affirm that I am licensed under provisions of Chapter 9 ISSUANCE DATE
vve a m (commencing with Section 7000)of Division 3 of the Business and BLDG. ELECT. PLG. MECH.
H w z Professions Cole,ap{my license is in full fort 99 fe
z o w- License Class_[3_Lie.Number_ T
9 r o Date p/ Contractor
a x BUILDING PERMIT
It ¢ ¢ OWNER-BUILDER DECLARATION ,
o d INFORMATION
E.
; r I hereby affirm that I am exempt from the Contractor's License MISC.- REFER TO ORD
vt VALUATION $/FT.
H .. o¢ Law for the following reason.(Sec.7031.5,Business and Professions PERMIT ISSUANCE 10.00
Code:Any city or county which requiresa permit to construct,alter, 9� �
2 ¢¢ improve,demolish,or repair any structure,prior to its imuamce,also ELEC.CONTE. LIC NO. ELEC. ^� e_ 4C
wo ac requires the applicant for such permit to file a signed statement that TOTAL J PERMIT TO
he is licensed pursuant to the provisions of the Contractors License /1 /
FZQ Law(Chapter 9(commencing with Section 7000)of Division 3 ofthe /t�17��(02X/
i o Business and Professions Code)or that he is exempt therefrom and QTY. PLUMBING PERMIT FEE
RH$ the basis for the alleged exemption.Any violation of Section 7031.5 STORIES TYPE CONSTR.
o ; _ by any applicant for a permit subjects the applicant loa civil penalty ALTER-DRAIN -WATER (EA.) 5.00
of not more than five hundred dollars(5500).):
❑ 1,as owner of the property,or my employees with wages as BACK FLOW PROTECT. DEVICE 4.00 OCC.GROUP RES.UNITS
their sole conspensation,will do the work,and the structure is not
intended or offered I., sale (Sec. 7044, Business and Professions DRAINS-FLOOR,ROOF,AREA,GOND- 5.00
Code:The Contractor's License Law docs not apply to an owner of
property who builds or improves thereon,and who does such work FIXTURES-PER TRAP 5.00 SO.Fr.FLOOR AREA TOTAL ACREAGE
m,iislare through his own eared for sale.
I I,ho Dever,at th improve'
GAS-EA.SYSTEM-11 NC.4 OUTLETS 6.00
mems are not t is sold
or offered for sale.If,however,the balding
or improvement is sold within one year of completion,the owner- GAS EASYSTEM OVER 4(EA) 200
builder will have the burden of proving that he did not buil)or im - . - . .
BUILDING USE
prove 11,as owner
of the). INDUSTRIAL WASTE INTER. 30.00 RES IND CON PB Omer
❑ 1,as owner of the property,be exclusively contracting with � El El ED
licensed contractors to construct the project ISec. 7044,Business LAWN SPRINKLERS-1 INC 6 V.B. 6.00 ASSE550R5 PARCEL NO.
and Professions Code:The Contractor's License Law docs not apply
to an owner of property who builds or improves thereon.and who LAWN SPRINKLERS-OVER 5(EA.) 1.00
contracts for such project,with a contrectons)licensed pursuant to
the Contractor's License Law. SEWER-SANITARY-STORM EA.200ft/10.00 TRACT NO. PARCEL NO.
❑ lam exempt under Sec. ,B.&P.C.for this
anon WATER HEATER W/VENT 6.00
Owner Date WATER SYSTEM 5.00 ACC DATE ACG FILE NO.
WORK ERS'COMPENSATION DECLARATION WATER TREATING EQUIP. 5.00
I hereby affirm that I have a certificate of consent to self-insure,
or a certificate of Workers'Compensation Insurance,or a certified ZONING ENG.SITE NO.
copy thereof(Sec.3800,Lab.C).
Policy No. m
Copany
-❑�/Certified copy is hereby furnished. FIRE$PRINK ENERGY Toa
z Z 7[��CcNICse py issfile with ilyx in. ection Division.
Hp Appllcanf_ C _ / MISC.- REFER TO ORD. v NEIv NC3
M w CERTIFICATE OF EXEMPTION FROM WORKERSPERMIT ISSUANCE 10.00/0 FLOODZONE A.L.U.C.
LU > COhIPENSATION INSURANCE PLG.CONTR. LIC.NO.
CL ❑ PLG.
z:) Z d
(Thissectionneed not be complete) if the permit is for one TOTAL' YE)
❑ N Y N
hundred dollars IS 100)or less.)
U O 1 aeNify that in the performance of the work(or which this per- CITY. MECHANICAL PERMIT FEE SUMMARY
LL U mit is issued,I shall not employ any person in any manner so as to FEE
become subject to the Workers'Compensation Laws of California.
LU
Date-Applicant ALTER OR ADD TO MECH. 5.00 BUILDING �Sa
>_ W NOTICE TO APPLICAN'C If,after making this Certificate of Ex
F. 2 emption,you should become subject to the Workers'Compensation APPLIANCE 5.00 PLAN CHECK
U
provisions of the Labor Code, you must forthwith comply with - FEE 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=11F.M.) 6.00 SEISMIC FEE
1 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(Sec. MICROFILM
3097,Civ.C.). HEATING UNIT(TO 100,000 B.T.U.) 8.00
Lender's Name
Lender's Address HEATING UN IT(OVER 100,000 B.T.U.)9.50 ELECTRIC
I�• 1 certify that 1 have real this application and state that the above VENTILATION FAN (SINGLE) 4.00
information iscorrect.
state l I agree tcomply with all city and county PLUMBING
ordinances and lues relating to building construction, and BOILER-COMP(3 H.P.or 100,000 B.T.U.) 6.00
above-ereby authorize representatives for ins of this city es enter upon the BOI LER-COMP (Over 100,000 BTU)SEE FEE SCH. MECHANICAL /S-
above-mentioned property for inspection purposes.
(We) agree m save, indemnify and keep harmless the City o1' MISC.- REFER TO ORD.
Cupertino against liabilities,juDgmcnfs, costs and eexpenses which PERMIT ISSUANCE 10.00 0 - CONST.TAX
may in any way accrue against said City in cum squence of the
gomti2obfthis per L MECH.CONT. LIC NO. MECH.
- TOTAL /�w TOTAL
afure of Applicant/Contractor
Date
OFFICE COPY
` 3 POST THISNEAR FRONT OF BU DING "
CIT�F CUPERTINO PFRMITNUMBER
INSPECTION DIVISION 11351
JOB INSPECTION RECORD
I
/0313 F. FQfes 1� • UNIT# LOT# PERMIT EXPIRATION
JOB ADDRESS
b' , IQ as PERMIT EXPIRES IF WORK
OWNER' 1"1 CONTRACTOR Lo .B el' r, er IS NOT STARTED WITHIN
INSPE ION DATE IN ECTOR INSPECTION RECORD 180 DAYS OF PERMIT ISSU-
FOUNDATION 0V7 .fir ANCE OR 180 DAYS FROM
UFER / _ LAST CALLED INSPECTION.
PREGUNITE PERMIT VALIDATION
POUR NO CONCRETE UNTIL ABOVE HAS BEEN SIGNED 1` ;
UNDERGROUND /SLAB /
PLUMBING 1
ELECTRICAL
ISSUANCE DATE
MECHANICAL BLDG. ELECT. PLG. MECH.
❑ ❑ T❑•
DO NOT POUR FLOOR UNTIL ABVBEEN SIGNED BUILDING PERMIT
WOOD FLOOR - INFORMATION
PLUMBING _ /7 VALUATION S/FT.
MECHANICAL 231 DO
ELECTRICAL PERMIT TO
FRAMING 14Q /-1761 I
INSULATION C���6 siORIEs TYPE CONSTR.
OCC.GROUP RES.UNITS
PLACE NO SUBFLOOR UNTIL ABOVE HAS BEEN SIGNED
ROOF SO.FT.FLOOR AREA TOTAL ACREAGE
DIAPHRAGM
BUILDING USE
- RES IND CON PB Olnr•r
APPLY NO ROOFING UNTIL ABOVE HAS BEEN SIGNED ❑ ❑ ❑ ❑ ❑
PLUMBING
ASSESSORS PARCEL NO.
ROUGH �� VL
GAS TEST TRACT NO, PARCEL NO.
MECHANICAL
ELECTRICALFINALS DATE INSP. ACC.DATE ACC.FILE NO.
FRAMING SAN #
INSULATION _ U PLUMBING 3 Wl Zo"I"c ENG.SITE No.
GAS 7 /
MECHANICAL FIRE SPRINK ENERGY L]<
COVER NO WORK UNTIL ABOVE HAS BEEN SIGNED HEATING V ❑ N❑ Y ❑ N❑
LATH-INTERIOR _ FLOOD ZONE A.L.U.C.
ELECTRICAL 77
LATH-EXTERIOR -�� FIRE DEPT. Y ❑ N❑ Y ❑ N❑
SHEETROCK GRADE FEE SUMMARY
SHEAR INTERIOR BUILDING
BUILDING
SHEAR EXTERIOR
TEMPORARY APPROVALS
FIREWALLS ELECTRIC PLAN CHECK
GAS FEE
NO TAPE OR PLASTER UNTIL ABOVE HAS BEEN SIGNED loCCUPANCY SEISMIC FEE
OCCUPANCYOF BUILDING IS NOT PERMITTED UNTIL BUILDING FINAL IS SIGNED BY BUILDING INSPECTOR. MICROFILM
w ARRANGE FOR INSPECTION BY PHONING 252-4505, „ ELECTRIC
~O� ONE WORKING DAY BEFORE REQUIRED INSPECTION. ?: PLUMBING
Z
•PLEASE GIVE JOB ADDRESS WHEN PHONING.
SEE PERMIT FOR EXPIRATION DATE - MECHANICAL i
' CONST.TAX
IMPORTANT!
PLEASE READ REVERSE SIDE BEFORE TOTAL
CALLING FOR FINAL INSPECTION.
OFFICE COPY
CITY OF CUPERTINO
INSPECTION DIVISION
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