C 8490 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
BUILDING PROJECT IDENTIFICATION PERMIT NUMBER
' n000e"ssv APPLICATION & PERMIT ���O
•_=7 zS / BUILDING — ELECTRICAL—PLUMBING—MECHANICAL
f' OWNER'S
PLAN CHECK VALIDATION
NAME QTY. ELECTRIC PERMIT FEE
ti PHONE(,»-�
j CONTRACTOR'S
NAmE ( UTLETS-SWITCHES-RECEP. 10.00/1.00
z(/S_J6 uC.No. LIGHTING FIXTURES 10.00/1.00
CONTRACTOR'S
ADDRESS PPLIANCES-RESIDENTIAL 4,00
77 L PHONE 6 PANELS 10.08 GATE OF APPLICATION
ARCHITECT PANELS (OVER 200 AMP) 20,00 PLAN CHECK FEE P.C.NO.
NE R
uC.ND. SIGNS TRANS. 3.00
ADDRESS ENG' SPECIALCIRCUIT 5,00 PERMIT VALIDATION
2I /1 EMP.METER OR POLE INS. 20.00
APDL CANT'S
ADDRESS MOTORS SEE FEE SCH. P
'
SERVICE CHANGE 20.00 ✓
wo o LICENSED CONTRACTORS DECLARATION TEMP,POLE 30.00 -
< i I hereby affirm that 1 am licensed under provisions of Chapter 9 ISSUANCE DATE
y ¢w (commencing with Section 7000)of Division 3 Of the Business and s ELECT. PLG.
F H z Professions Codggnd 7y license is in full force' d efjg f ❑
z o w— License Class_p �_Lic.N full f CupertinoN�/21
g w t w (Date 4'�9_���p�_Contracmr�
a City ofMA MIDOING PERMIT
a wsal OWNER-BUILDER DECLARATION INFORMATION
I hereby affirm that I am exempt from the Contractor's License MISC.— REFER TO ORD
w o¢ Law for the following reason.(Sec.7031.5,Business and Professions IIDN $/FT.
PERMIT ISSUANCE 10.00 �f IIU
Code:Any city or county which requirese permit to construct,alter, -
W EQ p j improve,demolish,or repair any structure,prior to its issuance,also ELEC.CONTR. LIC,NO. ELEC. (� / / D
E
m 01I1f requires
the applicant for such permit to file a signed statement that TOTAL PERMIT TO
he Is licensed pursuant IO the provisions Of the Contractor's License �I
y/ r2>
Law(Chapter 9(commeneingwilh Section 7000)ofDivision3 ofthe Il'Ddi7a6V VC �r,�
4 ao ! Business and Professions Code)or that he is exempt therefrom and QTY. PLUMBING PERMIT FEE
M I- the basis for the alleged exemption.Any violation of5ection 7031.5 - STORIES TYPE CONSTR.
nby any applicant for a permit subjects the applicant too civil penalty ALTER-DRAIN -WATER (EA.) 5.00
.fuel more than five hundred dollars($500)J:
❑ I,as owner of the property,or my employees with wages as BACK FLOW PROTECT.DEVICE 4.00 '
their sole compensation,will do the work,and the structure is not OCC.GROUP RES.urvlTs
intended or offered for Sale (Sec. 7044, Business and ProfessionsDRAINS-FLOOR,ROOF,AREA,COND. 5.00
Code:The Contractor's License Law does not apply to an owner of
properly who builds or improves thereon,and who does such work F IXTUR ES-PER TRAP 5.00 So.FT.FLOOR AREA TOTAL ACREAGE
himself through his own employees.Provided that such improve-
ments are
mnot intended or offered for sale.If,however,such
building GAS.EA.SYSTEM-1 INCA OUTLETS 6.00
or improvement is sold within one year of completion,the owner
builder will have the burden.of proving that he did not build or im- GAS-EA.SYSTEM-OVER 4(EA.) 2.00 BUILDING USE
prove for purpose of sale.). INDUSTRIAL WASTE INTER3000 E IND CON PB Other
. .
❑ 1,as owner of the property,am exclusively contracting with ❑ El ❑
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 Contractor's License Law does not apply '
to an owner of property 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.
❑ l am exempt under Sec. ,B.&P.C.for this WATER HEATER W/VENT 6.00 ,
reason
Owner Dare WATER SYSTEM 5.00 ACC.GATE ACO.FILE N0.
i WORKERS'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 thereaf(Sec.3800,Lab.C.).
Policy No. Company� �� l/,Q—
O ❑ Certifede y t ereby furnished.' FIRE SPRINK ENERGY T-Z4
Z Z .❑ Certif filed with,the cit ins or division.
FO Appiiamt. MISC.- REFER TO ORD. ' Y[] N� Y ❑ NE]
IV CC W CERTIFICATE OF EXEMPTION FROM WORKER PERMIT ISSUANCE 10.00 FLOOD ZONE A.L.U.L.
ION
LLL COMPE> (This Section need not be compile ed INSURANCE
thepermitis for one PILO.CONTR. LIC.N0. TOTAL Y N V N
LG
CL Q
:3 Z hundred dollars(8100)or less.) -
U O 1 certify that in the performance of the work for which this per. QTY. MECHANICAL PERMIT - FEE FEE SUMMARY
LL h mit is issued,I shall not employ any,person in any manner so as to
Q W become subject to the Workers'Compensation Laws of California.
Q. Date Applicant ALTER OR ADD TO MECH. 5.00 BUILDING r
} m - NOTICE TO.APPLICANT: If,after making this Certificate of Ex_
F 2 emplion,you should become subject to the Workers'Compensation APPLIANCE 5.00 PLAN CHECK
provisions of the Labor Cade, you must forthwith comply with FEE
'such provision's or this permit shall be deemed revoked. AIR HANDLING UNIT(TO 10AOD ,101,00
CONSTRUCTION LENDING AGENCY ' AIR HANDLING UNIT(OVER 10 .RM.) 6.00 SEISMIC FEE r
I hereby affirm that there is a construction lending agency for EXHAUST HOOD(WITH DUCT '
T110
the performance of the work for which this permit is issued(Sec. MICROFILM
3097,Civ.CJ.- HEATING UNIT(TO 100,0 .U. 6.00
Lender's Name
Lender's Address 1 H EATI NG UN IT(OV ER 100,000 B, fl ELECTRIC
I certify that I have read this application and state that the above VENTILATION FAN (SINGL 4,00
N••:� information is correct.I agree to comply with all city and county PLUMBING
ordinances and state laws relating to building Construction, and BOILER-COMP(3 H.P.or 100,000 B.T.U.) 6.00
hereby authorize representatives of this city to enter upon the BOILER-COMP(Over 100,000 BTU)SEE FEE SCH. MECHANICAL .ov
above-mentioned property for inspection purposes.
(We) agree to save, indemnify and keep harmless the City of MISC.- REFER TO ORD. - /
Cupertino against liabilities,judgments, costs and expenses which PERMIT ISSUANCE 10.00 CONST.TAX
may in any way accrue against said City in consequence of the
gra ft MECH.CONT. LIC.NO. MECH.
TOTAL
nC TOTAL
/IAAi `
nature o/A cant/ o�trac[or a � � I/•✓
OFFICE COPY I r�� 2(\
POST THIS CARD NEAR FRONT OF BUILDING
C PFRMITNUMBER
CITY .OF CUPERTINO
" W INSPECTION DIVISION ' 8490
JOB INSPECTION RECORD .
� � n/ ,,•�'/l/'_1/� �� 7 �+/J �PERMIT EXPIRATION["I
JOB ADDRESS 7525 wv' /`7/Y/LTJ owl , LOT# •'PERMIT. EXPIRESIFWORK
� 5
. ._ _ ;qqq/�
OWNER CONTRACTOR - ., IS NOT STARTED WITHIN
I,
INSPECTION DATE INSPECTOR INSPECTION RECORD T 180 DAYS OF PERMIT ISSU-
FOUNDATION ANCE OR 180 DAYS FROM
I
LIFER '
LASTCALLED INSPECTION.
PREGUNITE - - - PERMIT VALmnTION
POUR NO CONCRETE UNTIL ABOVE HAS BEEN SIGNED
UNDERGROUND /SLAB
PLUMBING
ELECTRICALl Issunrvl DATE -
MECHANICAL - - - B ELE .T PLG. c
DO NOT POUR FLOOR UNTIL ABOVE HAS BEEN SIGNED t. �BUIVIDINGPERMITf
WOOD FLOOR INFORMATION Y
VALUATION + B/FT.
PLUMBING - - -
- - MECHANICAL
✓ ,
ELECTRICAL ,,,rrr111 �.PER TeTO p'
I'
FRAMINGE�• C. '/C
INSULATION - STORIES TYPECONSTR. •-
OCC GROUP FES.UNITS
rPLACE NOISUBFLOOR UNTIL A AS BEEN SIGNED
j! ROOF SO.FT.FLOOR AREA TOTAL ACREAGE'
DIAPHRAGM"
Y ( - BUILD USE
RES IND CONON PB Olner
- -'APPLY NO-ROOFING UNTIL ABOVE HAS BEEN SIGNED 0 ',a'S rI .v i3 ucR ❑4l ❑ ❑• ❑ ❑
ROUGH , !'ASSESSORS FARCE L NO.
PLUMBING n •,� 4 �_ ;,x
GAS TEST TRACT NO. PARCEL N0. 1 .
MECHANICAL
ELECTRICAL ., qyg FINALS DATE INSP. ACC.DATE . ACC.FILE No
FRAMING tm SAN.# -
INSULATION PLUMBING zoNlNc 'ENG.slTeNo:
- GAS
MECHANICAL . FIRE SPRINK ENERGY T.2E
COVER NO WORK UNTIL ABOVE HAS BEEN SIGNED HEATING Y.❑ . N❑ Y ❑ N❑
FLOOD ZONE, A.L.0 C.
LATH—INTERIOR ELECTRICAL - _r _
LATH—EXTERIOR - FIRE DEP_T.. Y❑ NE) Y ❑ N❑
SHEETROCK — GRADE FEE SUMMARY ' .
SHEARINTERIOR BUILDING
SHEAR ExTERIORTEMPORARY APPROVALS .euILOwG
' FIREWALLS ELECTRIC - PLAN CHECK f
GAS FEE
NO TAPE OR PLASTER UNTIL ABOVE HAS BEEN SIGNED OCCUPANCY SEISMIC FEE . F.•+
OCCUPANCY OF BUILDING IS NOT PERMITTED UNTIL BUILDINGFINAL IS SIGNED BY BUILDING INSPECTOR. ;
MICROFILM.
ARRANGE FOR INSPECTION BY PHONING'252-4505, ELECTRIC
O� ONE WORKING DAY BEFORE REQUIRED INSPECTION. P�uMewc '
PLEASE GIVE JOB ADDRESS WHEN PHONING.
Z`' — SEE PERMIT FOR EXPIRATION DATE—, MECHANICAL
IMPORTANT! CONST.TAX
PLEASE READ REVERSE SIDE,BEFORE ,.TOTAL
CALLING FOR FINAL INSPECTION. _
OFFICE COPY „