16010 ,APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY'
BUILDING PROJECT IDENTIFICATION .PERMIT NUMBER ^
-u'cENs - APPLICATION & PERMITAGV
.
1 BUILDING—ELECTRICAL—PLUMBING—MECHANICAL 16010
OWNER'S �I G� PLAN CHECK VALIDATION
NAME /41` OTY. ELECTRIC PERMIT FEE
PHONBrjif/(/ U -
NAMe ACTORS UTLETS-SWITCHES-RECEP 10.00/1.00
L C.No. 142- LIGHTING FIXTURES 10.00/1.00
CONTRACTORS APPLIANCES-RESIDENTIAL 4.00
PHONE I PANELS 10.00 DATE OF APPLICATION
4RC"ITEC1 PLAN CHECK FEE P.C.,NO.
OR PANELS (OVER 200 AMPI 20.00
ENGINEER ��.
LIC.NO. SIGNSTRANS. 3,00
nooa'EOR
W LNG. SPECIAL CIRCUIT S.QQ PERMIT VALIDATION
ZIP TEMP.METER OR POLE INS. 20.00
APPLICANT'S '----
ADDRESS MOTORS SEE FEE SCH.
SERVICE CHANGE 2 0
H O o
LICENSED CONTRACTORS DECLARATION t•".1 l
¢ i w I hereby affirm that 1 am licensed tinder provisions of Chapter 9 ISSUANCE GATE
y e w (commencing with Section 7000)of Division 3 of the Business and BLDG. ELECT. PLG. 'MECH.
� Professions Cod , hulicense is in full force'qd fl
O O - License Clay Lia Numbe `1 e
H z 41
F r i o Dalc=s2 Cnntraclor r � S Q
El 1:1
re ¢w a OWNER-BUILDER DECLARATION @0
�t BUILDING PERMIT
° ' " MISC.— REFER ORD INFORMATION
S:
S I— I hereby allirm that 1 art exeanpt from the Contractor's License -
H u- Law for the following mason.(Sec.703 LS,Businessand Professions PERMIT ISSUANCE j _
VA WAn ON
Cade:Any city or county which requires permit to construct,alter, '
EL X,Q 0 improve,demolish,or repair any structure,prior to its issuance,also ELEC.C TR. .LIC.rv0. ELEC.TOTAL CIOn °u requires the applicant for such permit to file a signed statement that,
w9 he is licensed pursuant to the provisions of the Contractor's License PERMIT TO
Fie
Law(Chapter 9(crommencing with Section 7000)of Division 3olthe , may
F i 4 Business and Professions Code)or that he is exempt therefrom and OTY. PLUMBING PERMIT FEE E�
¢ I-m the basis for the alleged exemption.Any violation ofSectiun 7031.5 STORIES TYPE CONSTR.
US any applicant for a permit subjects the applicant toa civil penalty ALTER-DRAIN -WATER (EA.) 5.00
of not more than five hundred dollars(55007.):
❑ I,as owner of the property,or my employees with wages as BACK FLOW PROTECT.DEVICE 4.00 OCC.GROUP RES.UNITS
sole emnpensatice,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 huilds or improves thereon,and who does such work FIXTURES-PER TRAP _500 SO.FT.FLOOR AREA TOTAL ACREAGE
himself or through ties own employees,provided that such improve.
meets are not intended or offered for sale.If,however,the building GAS-EA.SYSTEM-1 INC.4 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 ire- GAS-EA.SYSTEM-OVER 4 (EA.) 2.00 BUILDING USE
Prove for purpose of sale.). - RES IND CON PB GO.,
❑ 1,as owner ol'the property,am exclusively contracting with INDUSTRIAL WASTE INTER. 30.00
licensed contractors to construct the project(Sec 7044,BusinessLAWN 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 properly who builds or improves thereon,and who LAWN SPRINKLERS-OVER 5(EA.) 1.00 r
contracts for such projects with a cuntmetons)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.fur this
asml a WATER HEATER W/VENT 6.00
Owner D:oe WATER SYSTEM 5.00 ACC.DATE ACC FILE NO.
WORKERS'COMPENSATION DECLARATION WATER TREATING EQUIP, 5.00
1 hereby atfirm that I have a certificate of consent to sell-insure,
or a certificate of Workers'Compensation Insurance,or a certified ZONING ENG.SITE N0,
copy thereof(Sec.3800,Lab.CJ.
Policy No. Company
0 ❑ Certified copy is hereby furnished. FIRE SPRINK ENERGY T-24
z Z Certi c CopIa fled with 1)c city inspection division.
O App cuntf, 1 r �.om➢_n MISC.- REFER TO ORD. ' Y 0 N Y ❑ No
W CERTIFICATE OF EXEMPTION 17ROM WORKERS' PERMIT ISSUANCE • 10,00 FLOOD ZONE A.L.U.D.
LU > COMPENSATION INSURANCE PLG.CONTR. LIC.NO. PLG.
CL Z (This section need not be completed if the permit is for one TOTAL Y 0 N Y [:] N
hundred dollars(SI00)or less.)
U O 1 certify that in the performance of the work for which this per- OTV. MECHANICAL PERMIT FEE FEE SUMMARY
LL H mit is issued,1 shall not employ any person in any manner so as to
Ow become subject tothe Workers'Conipenxal ion Laws of California.
C. Date Applicant ALTER OR ADD TO MECH. 5.00 BUILDING
} N NOTICE TO APPLICANT: If,after making this Certificate of Ex-
F ?, eruption,you should become subject to Die Workers Compimsatlon APPLIANCE 5.00 - PLAN CHECK
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 10MC.F.M.) 4,00
CONSTRUCTION LENDING AGENCY AIR HANDLING UNIT(OVER 10=C.F.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 Nam
Lender's Address'-,S—
HEATI NG UN IT(OVER 100,000 B.T.U.)9.50 ELECTRIC
1 certify that I have read this application and stale city
it Ilse above VENTILATION FAN (SINGLE) 4.00 17
information is correct 1 agree to comply with all city and county PLUMBING
ordinances and slate laws relating to building construction, and BOILER-COMP(3H.P.Dr10O,000B.T.U.) 6.00
hereby authorize representatives of this city to color upon the BOILER-COMP (Over 100,000 BTU)SEE FEE SCH. MECHANICAL
above-mentioned property for inspection purposes.
(We) agree to save, indemnify and keep harmless the City of MISC.- REFER TO ORD.
upertino against liabilities,judgments, costs and expenses which CONST.TAX
itoy in any way accrue against said City in consequence of the PERMIT ISSUANCE 10.00
runiting of th''pgTm t 1 �Q/�, MECH.CONT. LIC.NO. MECH,
.1l 11//1'lL A IIS ni( TOTAL
.=-rte ractor Y1lQ� (3,I TOTAL
Ignature of Apphcanl Cont actor Ualc
OFFICE COPY
POST THIS CARD NEAR FRONT OF BUILDING - _ PERMIT NUMBER
" . CITY 01" COPERTINO 16010
INSPECTION DIVISION
JOB INSPECTION RECORD
• J�/�, I PERMIT EXPIRATION
•JOB ADDRESS "L',�'V�' ���j 94 UNIT# _LOT#
PERMIT EXPIRES IFWORK
OWNER ER,/ /.5-� CONTRncTOR off- 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
PR EGUNITE. TO COMPLYWITH THE APPROVED PLANS AND CITY OF «� PLRNIIT VALIDATION
CUPERTINO STANDARDS:• r.
GARAGE SLABS - ..--�-
POUR NO CONCRETE UNTIL ABOVE HAS BEEN SIGNED
UNDERGROUND /SLAB
PLUMBING - %f' % c
ELECTRICALel\ly 0 ISSUANCE DATE
MECHANICAL BLDG- ELECT. PLG.. MECR.I
❑ ❑ � ❑ ❑ '!
DO NOT POUR FLOOR UNTIL ABOVE HAS BEEN SIGNED BUILDING PERMIT
INFORMATION
WOOD FLOOR VALIATION' SIFT
PLUMBING -
., - MECHANICAL
ELECTRICAL PERMIT TD
r�G .
FRAMING - C
INSULATION - STORIES TYPE CONSTR,
OCC GROUP RES UNITS,',
PLACE NO SUBFLOOR UNTIL ABOVE HAS BEEN SIGNED 'f ' '- •! .
ROOF NOTE:NO FINAL INSP.SHALL BE MADE BEFORE so cr.FOOD AREAroTAL ACR6AGE:j
AGE;
DIAPHRAGM
THE CONSTRUCTION TAX IS PAID.
_ "
b . La,. `1
+ Bw LOIuse - ,7,1,1�71
ROOF SHEATHING RES �,INO CON PB
APPLY NO ROOFING UNTIL ABOVE HAS BEEN SIGNED LS DATE INSP. ❑ .❑ ❑ ❑ U
ROUGH 1pffl
- ASSESSORS PARCEL NO;).fl, t
T
PLUMBING ERGY
TRAGI N0. . PAR LEL NO
TUBS&SHOWER PAN ENERGY. - t
MECHANICAL RGY' - -ELECTRICAL - ENERGYACC.,DATE ACC.FILE NOFRAMING AL TE ST20NING - ENGSATE NO.
INSULATION
GAS TEST GAS 't
FIRE SPRINK ENERG >T24
MECHANICAL �+
COVER NO WORK UNTIL ABOVE HAS BEEN SIGNED HEATING lY ❑ <1 ,D N❑
- EXTERIOR SHEAR ELECTRICAL RELEASE FLOOD ZONE A C.
INTERIOR SHEAR. FIRE DEPT. - Y❑ •. N❑ �v„��5�,',: '.N❑
SHEETROCK GRADE FEE SUMMARY
EXTERIOR LATH JUUILDING BUILDING
'• -INTERIOR LATH - TEMPORARY APPROVALS
SCRATCH COAT ELECTRIC PLAN CHECK • t'
I GAS FEE
NO TAPE OR PLASTER UNTIL ABOVE HAS BEEN SIGNED OCCUPANCY SEISMIC FEE ”" •.
OCCUPANCY OF_B UI LDING IS NOT PERMITTED UNTIL BUILDING FI NA LISSIGNED BY BUILDING INSPECTOR. MICROFILM -
yt '
ARRANGE FOR INSPECTION BY PHONING 252-4505, ELECTRIC
Fu–'
� ONE WORKING'DAY BEFORE REQUIRED INSPECTION. PLUMBING
Z PLEASE GIVE JOB ADDRESS WHEN PHONING.
— SEE PERMIT FOR EXPIRATION'DATE — MECHANICAL
C . .
IMPORTANT! coNsr.TI
PLEASE READ REVERSE SIDE BEFORE TOTAL
CALLING FOR FINAL INSPECTION.
OFFICE COPY I