17234 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
BUILDING PROJECT I DENTI FICATION .PERMIT NUMBER
„IL.'- ING APPLICATION & PERMIT .
A°gREss 17234
oZ $j /-�eYyy OSLt e. BUILDING-ELECTRICAL-PLUMBING-MECHANICAL
OWNER'S
_ PLAN CHECK VALIDATION
NAME
7im �
I-I'✓rte PHONEQTY. ELECTRIC PERMIT FEE
g73- Sot
CONTRACTOR'S
NAME I/ UTLETS-SWITCHES-RECEP 10.00/1.00
Vnl� uc.NO, LIGHTING FIXTURES 10.00/1.00 D ��
GONTRACTons
ADDRESS PPLIANCES-RESIDENTIAL 4.00
'PHONE PANELS 10.00 12, DATE OF APPLICATION
ARCHITECT - PLAN CHECK FEE P.C.NO.
on 867�TWI PANELS (OVER 200 AMP) 20.00 ._
E GINEE
'[d OL LIC.NO. ISIGNS TRANS. - 3.00
ADDRESS ENG. PERMIT VALIDATION
AD°REss _$asFv-�QQI e(} SPECIAL CIRCUIT 5.00
rafo q klJ ei zIPR 50110 TEMP.METER OR POLE INS. 20.00
APPLICANrs MOTORS SEE FEE SCH. -� -
ADDRESS
p61 Arm 6S a4L-. SERVICE CHANGE 20.00
G �a ✓L
W O LICENSED CONTRACTORS DECLARATION
Z
Qin I hereby affirm thol I.m licensed under provisions of Cliapter 9 ISSUANCE DATE
< m (commencing with Section 7000)of Division 3 of the Business and BLDG. ELECT. PLG. MECH.
R N z Professions Code,and my license is in full force and effect. ❑
oi,n W License Class Co ractor `, 19 \� ,
F m J Dale Contractor MAR V `5
a :e s BUILDING PERMIT
Ic M w ¢ OWNE R-BUI EDER DECLARATION
INFORMATION
MISC.- RE
u'x 0 `w 1 hereby affirm that I am exempt from the Contractor's License VALUATION
LL o j Law for the following reason.(Sec.7031.5,Business and Professions S/FT.
_ .PERMIT ISSUANCE 10.00 pj)
Code:Any city or county which requires a permit to construct,alter, O V n
Qir Q 0 Improve,demolish,or repair any stNCturc,prior to Its Issuance,ata° ELEG CONT0. L 0.NO. ELEC. �J V
A.
C u requites the applicant for such permit to filo u signed statement that TOTAL PER ITTp„�Iv i�10
w$w he is(Chapter
pursuant In the provisions o the700 )ofDivision License
H.i) Law(Csa nd Professions
Code)or Section sesemput therefrom
o of theVm
f z o Business and Professions Code)or that vi it exempt Sore 70 and QTV. PLUMBING PERMIT FEE
$ the basis for the alleged exemption.Any violation applicant to action malty STORI PE CONSTR.
i ; � by any applicant forapenre subjects thetoacivilpenalty ALTER-DRAIN -WATER (EA.) 5.00 '
of not more than five hundred dollars(S500).):
th❑ 1,as owner of the property,or my employees with wages as BACK FLOW PROTECT. DEVICE 4.00 OCC.GROUP RES.UNITS
eir sole compensation,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 Contractors 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 T.aF(�ORX,f:EA TOTAL ACREAGE
himself or through his own employees,provided that such improve. a^�
r menu ore not intended or offered for sale.If,however,the building GAS-EA.SYSTEM-I INC.4 OUTLETS 6.00 &
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 he did not build nr in RES IND CON PB Color
for purpose of sale.). INDUSTRIAL WASTE INTER. 30.00 ❑ ❑ ❑ ❑ ❑
❑ 1,as owner of the property,um exclusively contracting with
licensed contractors to construct the project(Sea.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 fur such projects with a contractors)licensed pursuant to
the Contractor's License Law. - ' SEWER-SANITARY-STORM EA.200ft/10.00 it 0 TRACT NO, PARCEL NO.
❑ l am exempt under Sec. ,B.&P.C.for this WATER HEATER W/VENT 6.00
Ceaum t�Q '
Owner Date WATER SYSTEM 5.00 1'Op
ACC.OATE ACC.FILE NO.
WORKERS'COMPENSATION DECLARATION WATER TREATING EQUIP. 5.00
I I hereby affirm that 1 have a certificate o(consent to self-insure,
or a certificate of Workers'Compensation Insurance,ora certified ZONING ENG.SITE NO.
copy thereof(Sec.3800,Lah.C.).
Policy No. Company
Q ❑ Gratified copy is berehy furnished. FIRE SPRINK ENERGY T-24
Z Z ❑ Certified copy is filed with the city inspection division. MISC.- REFER TO ORD. ❑ ❑ [:] ❑
F-' 2 Applicant MV N V N
ir H CERTIFICATE OF EXEMPTION FROM WORKERS' PERMIT ISSUANCE 10.00 f FLOOD ZONE A.L.U.C.
W > COMPENSATION INSURANCE PLG.CONTR. LIC.NO, PLG. ,,tt��
CLZ( 'th �is section need not he completed if the permit is for one TOTAL e 06 Y❑ N❑ Y❑ NE]dollars f S 1001 or less.)
U 0 I certify that in the performance of the work for which this per- QTY. MECHANICAL PERMIT FEE FEE SUMMARY
LL I- mil is issued,I shall not employ any person in any....haler so as to
O w become subject to the Worken'Compensation Laws of California.
n Date Applicant BUILDING y3s QQ
} ED NOTICI,TO APPLICANT: If,after making this Certificate of His- ALTER OR ADD TO MECH. 5.00
1-
Z emption,you should become subject to the Workers'Compensation APPLIANCE- 5.00 PLAN CHECK
provlslnns of the Labor Code, you must lorevoke comply with
FEE ` ��•
U such provisions or this permit shall be Jcenmd revoked. AIR HANDLING UNIT(TO 10,0000 F.M) 4.00
CONSTRUCTION LENDING AGENCY AIR HANDLING UNIT(OVER10=C.F.M.) 6.00 SEISMIC FEE .'6a0
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(Sec. MICROFILM
3097,Civ.C.). HEATING UNIT(TO 100,000 B.T.U.) 8.00 -
Lender's Name
Lenders AddressHEATINGUNIT(OVER 100,000B.T.U.0.50 ELECTRIC 36LS�)
c1 certify that 1 have read[his application and state that the above VENTILATION FAN (SINGLE) 4.00
in
is correct.1 agree to comply with all city and county PLUMBING
BOILER (3H.P.or 100,000 B.T.U.1 6.00 sq
ordinances and state laws relating to building construction, and v�
I hereby authorize representatives of this city to enter upon tlm 801 LER-COMP (Over 100,000 BTU)SEE FEE SCH. MECHANICAL
above-mentioned property for inspection purposes. S
(We) agree to save, indemnify and keep harmless the City of MISC. REFER TO ORD.
upertino against liabilities,judgments, costs and expenses which PERMIT ISSUANCE 10.00 CONST.TAX
ay in any way accrue against said City in consequence of the
ranting of this permit. MECH.CONT. LIF NO. MECH.
TOTAL TOTAL d-re-
&gnalure of Applicant/Contractor Date
OFFICE COPY
POST THIS CARD NEAR FRONT OF,B6 LDING PE R MIT NUMBER
CITY OF CUPERTINO
17234
INSPECTION DIVISION,
JOB INSPECTION RECORD
p PERMIT EXPIRA.TII plN
r.. . JOB ADDRESS—pSl�a l &'V- AVCNIT# '_'LOT# I jL I /
EEE
1 P RMI EXPIRES I FWORK
OWNER CONTRACTOR `�— IS NOT STARTED WITHIN
INSPECTION DATE INSPECTOR INSPECTION RECORD 180 DAYS OF PERMIT ISSU.
FOUNDATION ANCE OR 180 DAYS,FROM
NOTE: LASTCALLED INSPECTION.
LIFER ALL GRADING AND DRAINAGE SHALL BE INSTALLED
PREGUNITE - TO COMPLY WITH THE APPROVED PLANS AND CITY OF PERMIT VALIDATION.
GARAGE SLABS
CUPERTINO STANDARDS.
POUR NO CONCRETE UNTIL ABOVE HAS BEEN SIGNED •� r ��
UNDERGROUND /SLAB
MAR 1 11 ILI
PLUMBING
ELECTRICAL
City of (Ilipgrt*nfl ISSUANCE DATE
MECHANICAL BLDG ELECT I PLG. MECH
00 NOT POUR FLOOR UNTIL ABOVE HAS BEEN SIGNED BUILDING PERMIT
.WOOD FLOOR - INFORMATION
PLUMBING
VALUATION SIFT.
_ '
MECHANICAL -
�D
ELECTRICAL f ° j"'' j`5i�/}.��,•�
.FRAMING
INSULATION STO ITS TYPE CONSTR.
OCC.GHOUP RES UNITS
PLACENO SUBFLOOR UNTIL ABOVE HAS BEEN SIGNED P fila
/ ROOF 9O Fi, OONAHFA TOTALACFEAGE
Ll ROOF NOTE:Nqq��INACrl
NSP..S,/CYL E E E i'70 5 /`/�
DIAPHRAGM THE C0%TRUCTIQNMX CJ y^�y Lt •..�,^ .
AT,
u..Y BUILOIrvG USE
ROOF SHEATHING R RES IND CON PB Om.,
/ - APPLY NO ROOFING UNTIL ABOVE HAS BEEN SIGNED , i ❑ ❑ ❑ ❑ ❑
FINALS
ROUGH sAN.N 7
ASSESSORS PARCEL NO
PLUMBING ELECT.ENERGY
TUBS&SHOWER PAN
PLUMBING ENERGY TRACT No. PARCEL rvo.
MECHANICAL MECH.ENERGY
ELECTRICALACC.DATE ACC FILE NO
BUILDING ENERGY
FRAMING. ELECT:FINAL TEST \--
INSULATION PLUMBING zoNlNc ENC SITE No.
GAS TEST - GAS
. MECHANICAL FIRE SPRINK. ENERGY T.24
COVER NO WORK UNTIL ABOVE HAS BEEN SIGNED HEATING Y ❑ N❑. V ❑ N❑
EXTERIOR SHEARwo- ELECTRICAL RELEASE FLOOD?ONE A u.c
INTERIOR SHEAR FIRE DEPT. Y❑ N❑ Y ❑ N❑
SHEETROCK GRADE .
FEE SUMMARY
EXTERIOR LATH BUILDING
INTERIOR LATH TEMPORARY APPROVALS BUILDING Q'D
SCRATCH COAT ELECTRIC I I - PLAN CHECK,
. GAS FEE '.
NO TAPE OR PLASTER UNTIL ABOVE HAS BEEN SIGNED OCCUPANCY I I SEISMIC FEE
OCCUPANCYOF BUILDING ISNOTPERMITTED UIVTILBUILDING PINALISSIGNED BY BUILDING INSPECTOR. MICROFILM
ARRANGE FOR INSPECTION BY PHONING 252-4505, ELECTRIC Nl�v
• z ONE WORKING DAY BEFORE REQUIRED INSPECTION. PLUMBING. QD
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