17668 �APPMCANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALLPOINT PEN ONLY
• / BUILDING PROJECT IDENTIFICATION PERMIT NUMBER
BUILDING APPLICATION & PERMIT - k•
17668 aoDREss I 1/7 6 68 yu{
BUILDING - ELECTRICAL-PLUMBING-MECHANICAL �
OWNER'S c��• _ _
DTV.
N ME //� PLAN CHECK VALIDATION
1 ^, 1 ELECTRIC PERMIT FEE
V PHONE'f I -,01-1 1_
CONTRACTOR'S
NAME ., =SWITCHES-RECEP 10.00/1,00 .D D LIC.NO. LIGHTING FIXTURES 10.00/1.00 l v�%•
CONTRACTOR'S .a, - RESIDENTIAL ' 4.00
ADDRESS: P APPLIANCES.='
PHONE - PANELS 10.00 4'r DATE OF APPLICATION
ARCHITECT r PLAN CHECK FEE P.C.'NO.
on PANELS (OVER 200 AMP) 20.00
ENGINEER
' LIC.NO SIGNS TRANS. � 3.00 '
moo ESS crus SPECIAL CIRCUIT 5.00 PERMIT VALIDATION `
ZIP rEMP.METER OR POLE INS. 20.00
APPLICANTSMOTORS SEE FEE SCH. J 1
ADDDREDRESSS
SERVICE CHANGE 20,00
o o 'LICENSED CONTRACTORS DECLARATION
-a u I hereby ufl'Inm that I(unl licensed under provisions of Chapter 9 ISSUANCE DATE
I" fcolinnencln9 will;Section 7000)of Division-3 Of Ole Business and -
rA a: A - BLDG. ELECT. PLG! MECH.
i -
0 0,n o License Class Li,.Number
Uatc Contractor
Q y f J yD .{� ...
¢ ¢ w 40 OWNER-BUILDER DECLARATION Cly, Of CupB1Y O BUILDING PERMIT
MISC. REFER TO ORD INFORMATION
N
;LL H I hereby of@m that I'am exempt from the Cnntradoi s License l M VALUATION $/FT.
u_o¢ Law for the following reason.(Sec.7031.5,RuMmessand Professions r�V
- g PERMIT ISSUANCE 10.00,
Code:Any city or county which requirespermit to construct,alter,
<Q improve,Demolish,or repair any structure,prior to its issuance,also ELEC.CONTR. LIG NO.
ELEC.
O S, requires the applicant for such permit to file a signed statement that - TOTAL :�_q•0 PERMIT TO
w$w he is licensed pursuant to the provisions of the Contractor's License T1
rz >
Law(Chapter 9(commencing will,Section 7000)of Fneslon 3 of the r 1111
4 o Business andProfessions Codc)or that he is exempt therefrom and OTV. PLUMBING PERMIT FEE r '1 I
¢ F the basis for the alleged exemption.Any violation of Section 7031,5 _STORIES I TYPE CONSTR.
d by any uPpllcanf for a permit subjects Ole applicant to a civil penalty ALTER-DRAIN -WATER (EA.) 5.00
o'mol more than five hundred dollars($5001):
I,as owner of thc'limperty,or my employees with wages as BACK FLOW PROTECT.DEVICE 4,00 OCC.GROUP RES.UNITS
th it wle'com Pcnsation,will do the work,and the structure is not
intended oroffered for sale (Sec. 7044, Business and Professions DRAINS-FLOOR,ROOF,AR EA,CON D. 5.00
Code:The Contractor's License Law neonot to an owner of -
property who builds or improves thereon,
who and who toes such work FIXTURES-PER TRAP 5.00 50.FT.FLOOR AREA TOTAL ACREAGE
himself re through his own employees,provided that such improve"
memprovemtintended proffer ed f year o l completion the the owner- GA$-EA.SV$TEM-11NC.40UTLETS 6,00
or J build r will have
is sold within one year of completion,the owner- GAS-EA.SYSTEM-OVER 4(EA.) - 2.00 BUILDING USE
builder will have the harden of proving that he Aid not moil,or int- � RES IND CON PB - •Omer
Prpvcfor Purpnu pfsale). INDUSTRIAL WASTE INTER. 30.00 ❑ ❑ ❑ ❑ ❑
LY(-as owner of the properly,am exclusively'contracting with
licensed contractors to construct the project(Sec. 7044,Business LAWN SPRINKLERS-1 INC 5 V.B. 6.00 ASSESSORS PARCEL NO.
and Professions Code:The Contractor's Lirmnse Law does not apply
to an owner of property who builds or improves thereon,and who LAWN SPRINKLERS-OVER 5(EA.) 1.00contracts for such projects with u emuruclor(s)licensed pursuant to SEWER-SAN V-STORM EA.200ft/10.00 r
the Cpn lmctprs License Law. - TRACTNO. PARCEL NO.
,I. I ❑ I am exempt undSr,Sc,. ,B. .P.C.for Ills, WATER HEATER W/VENT '6.00
rause
Own, Date - WATER SYSTEM 5.00 ACC.DATE - ACC.FILE No.
ORKERS'COM :N ATIONDECLARA'HON - WATER TREATING'EQUIP. .5.00
I.hereby affirm that I have a certificate of conscul W sol&insure,
or a certificate of Workers'Compensation Insurance,or a certified ZONING ENG.SITE NO.
copy thereoc(Sec.3800,Iab.C.). _
Policy No. Company -
O ❑ Certified copy is hereby furnished FIRE$PRINK ENERGY T$4
~ 0
Z ❑ Certified copy is filed with Om city inspection division' MISCa -'' REFER TO ORD. ❑ ❑ ❑ ❑
' O Applicant
.- � V N V N
m PERMIT ISSUANCE 10.00
Li -
Cl:R'I'IFICAMPHNRA I ON INS PROM WORK ERS' FLOOD ZOrvE a.L.I1C:
(L COMPENSATION INSURANCE PLG,CONTR. LIC.NO. PLG
Z ('Phis section need not be conlplelcd If the permit is for one _ TOTAL Y❑' ,N❑ Y ❑ N❑
hundo,d dollars 0100)or less.) _
U O I certify [hat in the performance of[tie work for which this per- DTV MECHANICAL PERMIT FEE FEE SUMMARY -
LL I- ndl Is Issued,I shall not employ any persrio In any manner so as to I
O W beco I,•s mj t t ,e Workers' ',lion Law f ali'ornf t.
D:ac_y rt. pr, pplicant— - BUILDING
C.
`1 , ALTER OR ADD TO MECH. 5.00 �y D
} to NOT'ICC'I'O ANIL CANT: If,of • making this CvrQfiq1ta c x-
F ? empifm,,you should become subject to the Workers'Corepensation APPLIANCE' 5.00 PLAN CHECK
U
Provisions
rovis of the
llLabor Code, you must Roll with comply with
FEE
such p permit shall be deemed revoked. AIR HANDLING UNIT(TO 1Q000C-F.M.) 4.00
CONSTRUCTION LENDING AGENCY AIR HANDLING UNIT(OVER 10=C.F.M.) 6.00 SEISMIC'FEE
I hereby affirm that there is a construction lending agency for EXHAUST HOOD WITH DUCT) 5.00
the performance of the work I'or which this permit is issued(Sec. MICROFILM
3097,Cw.C.L HEATING UNIT(TO 100,000 B.T.U.) 8.00
Na...
Lenders Na...Address
Lender's Ne tl HEATI NG UN IT(OVER 100,000 B.T.U.)9.50 , ELECTRIC l0D
"
F•' I cert fly that l have read this applical on and state that the above VENTILATION FAN (SINGLE) 4.00 '.
into rnmlion is correct. I agree to comply with elf city and county PLUMBING
s ordinances and state laws relating to building construction, and BOILER'.COMP Q H.P.Of 100,000 B.T.U.) 6.00 •�'r--
hereby authorize representatives of this city to enter upon the BOILER-COMP (Over 100,000 BTU)SEE FEE SCH.
above-memioned property for inspection purposes. MECHANICAL
(Wc) agree to save, indemnify and keep harmless the City of MISC.- REFER TO ORD.
- Germine against liabilities,judgments, costs and expenses which' CONST.TAX
Pay in any way accrue against Said City in consequence of the PERMIT ISSUANCE 10.00
I f his permit MECH.CONT. LIC.NO. MECH.
TOTAL TOTAL
Sign re of A,plicaa.Manfiracto, Date
OFFICE COPY -
-,POST-THIS CARD NEAR FRONT OF`BUILDING
PERMIT NUMBER
CITY OF CUPERTINO 17668
INSPECTION DIVISION`
JOB INSPECTION RECORD
PERMI E RIRATION
JOB.AODR BSS UNIT#- _LOT# (
M EXPIRES.'IF WORK
OWNER CONTRACTOR ' +:- D
15 NOT S7ARTE -WITHIN
INSPECTION DATE INSPECTOR INSPECTION RECORD 180 DAYS of PERMIT ISSU-
ANCE OR 180 DAYS FROM
NOTE: + - LAST CALLED INSPECTION.'
UFER, ALL•GRADING AND DRAINAGE SHALL BE INSTALLED. -
TO COMPLY WITH THE APPROVED PLANS AND CITY OF • PERMIT VALIDATION
PR EGUNITE +, CUPERTINO STANDARDS. ,.r•. [�
GARAGE,SLABS '' " ' L PAIS7• "'�"''/""jP rl
_ POUR NO CONCRETE UNTIL ABOVE HAS BEEN SIGNED
''UNDERGROUND'/SLAB, ' "' MAY 1_'1 1989
PLUMBING.
ELECTRICAL City Of Cupertino ISSUANCE DATE .
MECHANICAL ,BLDG. ELECT ?LG. MECH
DO NOT POUR FLOOR-UNTIL ABOVE HAS BEEN SIGNED BUILDING PERMIT
WOOD FLOOR INFORMATION
VALUATION $IFT.
• PLUMBING -i� - �V�qq �
MECHANICAL
ELECTRICAL - PERMIT TD
FRAMING- y ,, v (( T �'h'
INSULATION + ' STORIES I, TYPE CONSTR.
- OCC.GROUP RES.UNITS
',PL"ACE NO,SUBFLOOR UNTIL ABOVE HAS BEEN SIGNED -
$Il,IT ILOOFAR[F TOTAL ACRlPGl
'ROOF NOTE:NO FINAL INSP.SHALL BE MADE BEFORE
DIAPHRAGM
THE CONSTRUCTIO� N TAX IS PAID. -
-
BUILDING USE
ROOF SHEATHING' RES; IND CON PB -Ooi;,
_APPLY NO ROOFING UNTIL ABOVE HAS BEEN SIGNED FINALS DATE INSP. ❑ ❑ ❑ ❑ ❑
,ASSESSORS FARCE L NO. .
ROUGH SAN.#
PLUMBING -- ELECT.ENERGY
P' PLUMBING ENERGY TRACT NO, + PARCEL NO
TUBS&SHOWER RAN •
MECHANICAL` —/ �., MECH.ENERGY '
ACC„DATE ACC.FILE NO
ELECTRICAL , ,7 .BUILDING ENERGY
FRAMING �I'•� a ELECT.FINAL TEST
PLUMBING ' ZONING, ENG:SITE NO.
INSULATION ] ”
GAS-TEST
MECHANICAL .' '- - -FIRE SPRINK ENER GY T@A
COVER NO WORK UNTIL ABOVE HAS BEEN SIGNED HEATING Y ❑ y❑ Y 0,
N❑
EXTERIOR SHEAR' - - Q$�
ELECTRICAL RELEASE - FLooD zoNE aL,u.c.
INTERIOR SHEAR;I,•r FIRE DEPT. Y❑ - N❑ Y ❑ N❑
SHEET.ROCK GRADE.' FEE SUMMARY.,
EXTERIOR .LATH BUILDING,1". L
INTERIOR LATH " "TEMPORARY APPROVALS' .. BUILDING SVD
SCRATCHCOAT,' . ELECTRIC I,' .. PLAN CHECK
GAS FEE
NO TAPE OR PLASTER.UNTIL ABOVE HAS BEEN SIGNED OCCUP,ANCV SEISMIGFEE
OCCUPANCYOF BUILDING IS NOT PERMITTED UNTIL BUILDING FINALISSIGNED BY BUILDING INSPECTOR, MICROFILM'
-------------------------------
ARRANGE:FOR INSPECTION BY PHONING 252-4505, ELECTRIC :0
UI, ONE.WORKING DAY.BEFORE_REQUIRED INSPECTION
0 ;!-. PLEASE GIVE JOB ADDRESS,WHEN PHONING. PLUMBING --'
Z'. . - • ,
SEEPERMIT, FOR :EXPIRATIONDATE— MECHANICAL
IMPORTANT! CONST. TAX
PLEASE READ REVERSE SIDE BEFORE TOTAL .
'CALLING FOR FINAL INSPECTION.
OFFICE COPY
,