17092 A PLIC�ANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
BUILDING PROJECT IDENTIFICATION PERMIT NUMBERAPPLICATION(& PEFIMIT T
BVIL'DING
"
ADDHEu n
r V J7fe( d GI BUILDING - ELECTRICAL-PLUMBING -MECHANICAL . 17092
OWNER'S PLAN CHECK VALIDATION
?�
NAME
ar�< CITY. ELECTRIC PERMIT FEE
� PHDNE � 0�
CONTRACTOR'S
NAMEUTLETS-SWITCHES-RECEP 10.00/1.00
uc.H LIGHTING FIXTURES 10.00/1.00 /J
GON1VA .J r
ADDRESS croRs Aos- APPLIANCES-RESIDENTIAL 4.00 f
PHONE ��
PANELS 10.00 DATE OF APPLICATION
ARCHITECT1 PLAN CHECK FEE 1 . P.C.NO.
OR PANELS (OVER 200 AMP) '20.00
ENGINEER/fAL/M� p
IV f I uc.No. � /�6 SIGNS TRANS. 3.00
ARCH.OR ENG. PERMIT VALIDATION
ADDRESS L110
p. �p SPECIAL CIRCUIT 5.00
zIP 6102 EMP.METER OR POLE INS. 20.00
ADDRESS rs MOTORS SEE FEE SCH.
ADDRESS
As.,
I C '
I�IN aUr SERVICE CHANGE .00 ` 1 I
w o o LICENSED CONTRA RS DECLARATION • O Z s L V dl" '•� �
u w ISSUANCE GATE
I hereby affirm that 1 am licensed under provisions of Chapter 9
H a N (Commencing with Section 7000)of Division 3 of the Business and - APR 12
d-
BLDG. ELECT. PLG. MECH.
H a Professions C.ds,and my license is in full force and c.rr L
z O y - Licenx Cl Lie.Number--S-3 5
o a r Date=.B
Contractor
w _/_7� ciq 11usa
< m s Of go
I BUILDING PERMIT
Ite a OWNER-BUILDER UEChARA'I'IOIs' - INFORMATION
sa
wu. H I hereby affirm that 1 am exempt from the Contractor's License MISC.- REFER TO ORD
r .. o j law for the following reason.(Sec.7031.5,Rusin<ss and Professions PERMIT ISSUANCE - 10.00 ` NO(� d/FT.
Code Any city n6counly which requires a permit to construct,alter, 470
0 improve,demolish,or repuir any structure,prior to its issuance,also ELEC.CONTRA LIC.N0. - ELEGY
o u requires the applicant for such permit to tile a signed statement that TOTAL 7y 2
w$ he is licensed pursuant to the provisions of the Contractor's License PERMIT TO
rzi
Law(Chapter 9(commencing with Section 7000)of Division 3 ofthe � ��
4 o Business and Professions Code)or that be is exempt therefrom and .
I the basis for the alleged exemption.Any violation of Section 7031,5 DTV. PLUMBING PERMIT. FEE STORIES TYPE CONSTR.
n 3 by any applicant for a permit subject,the applicant toacivil penally
of not more than five hundred dollars(S500),): ALTER-DRAIN&VENT-WATER (EA.) 5.00
❑ 1,as owner of the property,or any employees with wages as BACK F LOW PROTECT. DEVICE 4.00 OCG GROUP RES.UNITS
sole comper.fiun,will do the work,and the structure is not
intended or offered for sole (Sec. 7044. Business and Professions DRAINS-FLOOR,ROOF,AR EA,COND. 5.00
Cade: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 sa ET PLCOR AREA uLACREAGE
himself re through his own cmred for,provided thus such improve- l e/ -0
himself <not throuh hiss on offered for sale.provided
however,the building GAS-EA.SYSTEM-1INC.4OUTLETS 8.00 P/ 7 S-0
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 be did not build or im- RES IND CON PB roar,
prove for purpose of sale.). ' INDUSTRIAL WASTE INTER3000
❑ 1,as owner of the property,am Cx Cl Usivciy contracting with . . E] 11 E] ElEl
licensed contractors to construe[ the project(Sec. 7044,Boniness LAWN SPRINKLERS-1 INC 5 V.B. 6.00 ASSESSORS PARCEL NO.
and Professions Code: On,Contractor's License Law does not apply Q
10 an owner of pruperty who builds or improves thereon,and who LAWN SPRINKLERS-OVER 5 (EA.) 1.00 18 ��
cunt racis for such projects with o contrdctorts)licensed pursuant to 599
the Contractor's License Law. SEWER-SANITARY-STORM EA.200ft/10.00 TRACT NO. PARCEL NO.
❑ I amexempi under Sec. .B.&P.C.for this WATER HEATER W/VENT 6.00
reason
Owner Dale WATER SYSTEM 5.00 ACC.DATE ACG FILE NO.
WORK ERS'COMPENSAI ION DECLARATION WATER TREATING EQUIP. 5.00
I hereby affirm that 1 have a certificate of consent to xlhinwm' r L ZONING ENG.SITE NO.
or a certificate of Workers'Compensation Insurance,or a certified
copy thereof(Sec.3800,Lb,CCrnupinn --J--��CCaa�� 1
O Policy Certilied copy a hereby 2L-5f a rU
FIRE SPRINK ENERGY RN
Z Z ❑ Certified t)�}WprY fiep it the city inspection division. MISC.- REFER TOORD. ❑ ❑ F
F O nnnheanl- _qs1'-1(_NP,r the
V N V N
aN CER'1'IFICA'1'1?017EXILMPTION FROM WORKERS' PERMIT ISSUANCE � 10.00 ZO FLOOD ZOrvE A.L.UC.
d 0 (This Lection COk1%ot be completed
if the Perlmlit is for one DLG.CONTRA LIC.NO. T TAL �.Z Y�, N❑ Y ❑ N❑
Z hundred dollars(S 100)or less
U O 1 certity that in the performance of the work for which this Per- QTY. MECHANICAL PERMIT FEE FEE SUMMARY
LL H mit is issued,1 shell not employ any person in any manner so as to
U W becomie subject to the WorkerCompensation Lws of California.
Date Applicant BUILDING
} QO NOTIC17 TO APPLICANT: If,after making this Certificate of Ex- ALTER OR ADD TO MECH. 5.00
♦- ? emptier,you should become subject to the Workeri Compensation APPLIANCE 5.00 PLAN CHECK _
provisions of the Labor Cade, you must forthwith comply with FEE
U such provisions or this Permit shall be deemed revoked. AIR HANDLING UNIT(TO 10=C.F.M.) 4.00 ' �]
CONS'I'RUCTION LIiNDING AGENCY AIR HANDLING UNIT(OVER 10=13C.ENL) 6.00 SEISMIC FEE I III'9
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 Na
d HEATING UNIT(OVER 100,000 B.T.U-)9.50 3 cZ.
Lenders Address ELECTRIC
I certify that l have read this application and stale Olaf the above VENTILATION FAN (SINGLE) 4.00 _
information is correct. I agree to comply with all city and county BOILER-COMP(3 H.P.or 100,000 B.T.U.) 6.00 PLUMBING 73,-.2 t
ordinances and stale laws relating to building construction, and my
herebhereby enthoriac «perry for ins of the city to enter upon theaboveBOILER-COMP poser 11X1,000 BTU)SEE FEE SCH. MECHANICAL
y
authorize
property for inspection puity to
(We) agree to save, indemnity and keep harmless the City of MISC.- REFER TO ORD.
upertlno against liabilities,judgments, costs and expenses whichCONST.TAX
ay in any way ace agai t said City in consequence of the PERMIT ISSUANCE 10.00 LUD 3 r 19.2-
Timing
9Ztoting o(this P p, MECH.CONT. LIG
at 0 NO. TOTAL /
7�,� TOTAL
Signa o P pommctor Date
OFFICE COPY,
POST THIS CARD,NEAR FRONT, OF BUILDING PERMIT NUMBER
CITY OF CUPERTINO709
INSPECTION DIVISION
JOB INSPECTION RECORD
PERMIT EXPIRATION
JOB ADDRESS /o rY7 !�1 UNIT# LOT#
L� 'PB�MI1I�EXPIRES IF WORK .1
OWNER '� l T'ed - CONTRACTOR - IS NOT STARTED WITHIN ;
INSPECTION DATE' IN PECTOR INSPECTION RECORD 180 DAYS OF PERMIT ISSU
I% ANCE OR 180 DAYS FROM
FOUNDATION NOTE: - '
LAST CALLED INSPECTION.
UFER ']., ��j ALL GRADING AND DRAINAGE SHALL BE INSTALLED
PREGUNITE TO COMPLY WITH THE APPROVED PLANS AND CITY OF PERMIT VALIDATION
CUPERTINO STANDARDS. _
GARAGE SLABS - "' •� '
POUR NO CONCRETE UNTIL ABOVE HAS BEEN SIGNED p
UNDERGROUND /SLAB .APR -1 Z t)U," "
PLUMBING r/ rJ /�}
ELECTRICAL CiN � ` V �^ `- ,P"t.RAT
VCG.
1�1Yi. ISSUANCE.NAI L
MECHANICAL ELECT: PLG. mecR...
C�l 1�R L�v V Ft4 QJ.
DO NOT POUR FLOOR UNTIL ABOVE HAS BEEN SIGNED - T BUILDING PE MIT
WOOD FLOOR INFORMATION
VALUATION SIFT,
PLUMBING 5' - •I _ 7
MECHANICAL
ELECTRICAL PE II TO
y I I
FRAMING,
INSULATION STORIES. TVPE CONSTR.
• i
CS7 /s y DCC.GH0UP RES.UNI TS
PLACE NO SUBFLOOR UNTIL ABOVE HAS BEEN SIGNED
SU IT GLDOR ARLA IOTAI,ACREAGE.
ROOF - NOTE:NO FINAL INSP,SHALL BE MADE BEFORE
DIAPHRAGM THE CONSTRUCTION TAX IS.PAID GI
BUILDING USE
ROOF SHEATHING i . . RES IND CON PB OmL-
APPLY NO ROOFING UNTIL ABOVE HAS BEER SIGNED FINALS DATE ~INSP. ❑ 0 F-1 ❑ E
ASSE5SOR5 PARC E L NO
'ROUGH SAN.H.. �7 QQ
PLUMBING 2' ELECT.ENERGY J�5 1 �_
IHACT NO. PARCEL'NO
TUBS 8 SHOWER PAN PLUMBING ENERGY—
MECHANICAL -?D MECH.ENERGY' ('
ELECTRICAL BUILDING ENERGY ACC.DATE ACC.FILE NO
FRAMING ELECT.FINAL TEST
ZONING ENG.SITE NO.
INSULATION PLUMBING I
GAS TEST - GAS -
s ' f MECHANICAL U FIRE SPRINK ENERGY T.]a
COVER NO WORK UNTIL ABOVE HAS BEEN SIGNED HEATINGY 1:1NE E "0 clMeq .1
FLOOD ZONE A.L UC. .�
EXTERIOR SHEAR ELECTRICAL RELEASE AE
INTERIOR SHEAR - FIRE DEPT.
- Y[:jN�. ❑ Na ,
SHEETROCK CUDIZ, GRADE - FEE SUMMARY
EXTERIOR LATH BUILDING
INTERIOR LATH - TEMPORARY APPROVALS
' . BUILDING
SCRATCH COAT ELECTRIC PLAN CHECK v
GAS' , FEE I
NO TAPE OR PLASTER UNTIL ABOVE HAS BEEN SIGNED OCCUPANCY SEISMIC FEE ','(,
OCCUPANCY OF BUILDING IS NOT PERMITTED UNTIL BUILDING FINAL ISSIGNED BY BUILDING INSPECTOR.
MICROFILMS
ARRANGE FOR INSPECTION BY PHONING 252-4505, ELECTRIC 3
H� ONE WORKING DAY BEFORE REQUIRED INSPECTION. PLUMBING-'� 0 PLEASE GIVE JOB ADDRESS WHEN PHONING.
- SEE PERMIT FOR EXPIRATION DATE - MECHANICAL
IMPORTANT! CONST.TAX
PLEASE READ REVERSE SIDE BEFORE TOTAL
CALLING FOR FINAL INSPECTION.
OFFICE COPY �r%{�