16145.1tpPLICANT TO FILL IN INFORMATION'WITHINIRED LINES = USE BALL POINT PEN ONLY
BU LDI NG PROJECT IDENTIFICATION -
APPLICATION & PERMITADDRESS
BUILDING -ELECTRICAL' -PLUMBING -MECHANICAL..
PERMIT NUMBER -.
t Lc
11 45
BUILOING
Jo
OWxER'S rte'^�
DTV. ELECTRIC PERMIT FEE •
PLAN CHECKVALIDATION
.R{,' /I,
�. 4�r v�`YY 1 �-II
- ,
,
-
. C➢NTIi CTORS -
NA Mn �n7nn �[p �
l,��!-1\JW Llc.rvo. 1
'OUTLETS - SWITCHES -RECEP 10.00/1.00
LIGHTING FIXTURES ,10.00/1.00
CNTRADDRESS ORs
A
PPLIANCES- RESIDENTIAL - 4.00
PANELS '10.00
PHONE
DATE OF APPLICATION
ARCHITECT
DR
ENGINEE
,79=C. NO.
PANELS (OVER 200 AMPI 20.00
PLAN CHECK FEE P.C. NO.
-
SIGNS TRANS. 3:00
ARCH. OR ENG.
ADOR s
SPECIAL CIRCUIT 5.00lift-
PERMIT VALIDATION
EMP. METER OR POLE INS. : 20.0f FpaW
o'L w
�' + U.
A
ADDRESS /T ,. ��/�• fy _ _
MOTORS SEE FEE SCH.
SERVICE CHANGE
- ISSUANCE DATE
' ICfiNSIiD CONTRACTORS DECLARATION
I hemb� 'inn llulI, um licensed tinder provisions of Chapter 9
lcom ittal g, - If -SC on 70001 of Division 3 of the Business and
Professions Code, d i a. is in full fore d
\
License Clas Lic. Number
BLDG.
ELECT.
PLG. 'MECH.
Date Contractor Gam-
BUILDING PERMIT
INFORMATION
WNE -B ER DECLARATION
I hereby affirm that I am exempt from the Commclor s License
Law for the following reason. (Sec. 7031.5, Busmessano Professions
Code: Any city or county whichrequiresapermil to construct,alter,
improve, demolish, or repair any structure, prior to its issuance, also
ruluires Lhc epplicmht for such permi( to file u signcil s(utcmmD that
hews licensed pursuant
en the provisions of the )o(Division License
3 of the
Law (Chapter 9 (commencing with Section is exempt
7000)o(Division t therefrom
Business and Professions Codas or that he is exempt therefrom and
t
'
MISE.- - REFER TO ORD
- PERMIT ISSUANCE 10.00
VALUATION$/FT.
If 1 f 1
�•W
O
ELEC. CONTR. LIC. NO. _
',
ELEC.
TOTAL
QTY. PLUMBING PERMIT FEE I
STORIES
TYPE CONSTR.
the basisfor the alleged exemption. Any violation on -Section
penally
by any applicant l'pru hundred clodurst 5000.)icam poll civil penally,
of not more than five hundred dollure ($500).):
-
ALTER-DRAIN-WATER(EA.) 5,00
' ❑ 1, as owner of the property, or my employees with wages its
their sole compensation, will do the work, and the structure is not
BACK FLOW PROTECT. DEVICE 4.00
OCC. GROUP
RES, UNITS
DRAINS -FLOOR; ROOF, AREA, COND. 5.00
intended or offered for sale (Sec. 7044, Business and Professions
Code: The Contractor's License Law does not apply to an owner of
properly who builds or improves thereon, and who docs such work
himself or through his own employees, provided that such improve -
mprove-mentsmenotintendedorofferedlor sale. If, however, the building
plants me not irtenced or Offered I.,
FIXTURES - PER TRAP 5.00
SO. FT FLOOR AREA
TOTAL ACREAGE
'GAS-EA.SYSTEM-I INC.40UTLETS 6.00
or improvement is sold within one year of completion,the owner
budder will have the burdemof proving that he did not build or dm-
prove for purpose of tile.).
❑ I.d as owner Ole property, am exclusively contracting with
GAS - EA. SYSTEM - OVER 4 (EA.) 2.00
BUILDING USE
RES IND CON Pa OMer
❑ El 1] ❑ -
INDUSTRIAL WASTE INTER. 30.00
rs
licensed contractors Code: I construct the project (Sec: 7044; Business
License Lawsth does not apply
and Professions prthe who
to improves thereon; and who
owner of property who ha co
LAWN SPRINKLERS - 1 INC 5 V.B. 6.00
LAWN SPRINKLERS -OVER 5 (EA.) 1.00
gSSESSORS PARCEL NO.
tr
contracts for such projects with a contructor(s) licensed pursuant to
contractor(s)
the Coillracsor's License Law.
SEWER -SANITARY -STORM EA,200ft/10.00
TRACT N0.
PARCEL NO.
❑ I am exempt under Sec. ,B.&P.C. for this
WATER HEATER W/VENT 6.00
Date
WATER SYSTEM 5.00
'.ACC.DATE
ACC. FILE NO,
WATER.TREATING EQUIP. 5.00
WORK 17RS'COMPENSATION DECLARATION
-
I hereby affirm that 1 have a certificate of consent to sell -toque,'
,it R certificate of Workers' Comp"ea .o nsurance, a certified
-
'
ZONING
ENG. SITE N0.
copy thcrcof(Sec. 3800,. La b.C.) /i /1/I)
y No. Company �1'
MISC.- - REFER TO ORD.
FIRE 9PRINK
y ry�
ENERGY T24
y ❑"'N11
C. py rehy furnished.'
' ertif � 'tl the ci(y'inspec(imt division.
AP licunt V(/IIa _
CERT1//FICA '1'17 OF EXEMPTION FROMWORKERS'
PERMIT ISSUANCE 10.00
FLOODZONE
A.L.U.C.'
' COMPENSATION INSURANCE
('Phis section need not he romphical If (ha pennll Is fpr one
V ❑ NO
YE], N
PLG. CONTR. - LIC. NO.PLG.
TOTAL'
h a ndual' dollars IS 100) or less.)
1 certify that do the perforinance of the work for which this per-
mit is issued: I shall not employ any person in any manner so as to
QTY. MECHANICAL PERMIT FEE
FEE SUMMARY '
BUILDING
become subject to the Worker's' Compensation Laws of California.
Data Applicant
NOTICE TO APPLICANT: II', after making this Certificate of IN,
.ALTER OR ADD TO MECH. 5.00
- APPLIANCE - 5,00 '
P,LAN CHECK'•
FEE
a 46)
e Workers:Copensalion
Pilon, you should becocsubiect to thm
cm m
Provisions of the Labor Code, you must forthwith Comply Will
such provisions or this permit slmll,be deemed revoked.
AIR HANDLING UNIT '(TO 10MC.F.M.) 4.00
AIR HANDLING UNIT(OVER 10=C.F.M.)6.00
SEISMIC FEE,
rvV
.. CONSTRUCTION LENDING AG17NCY
' I hereby affirm at (here in a construction lending agency far
the perfonnance of a work for wltdclh Ods permit is issued IS".
3097,C C)
EXHAUST HOOD (WITH DUCT)„ 5.00
MICROFILM
HEATING UNIT (TO 100,000 B.T.U.)' 8.00
Lender's Name
Ijenderi Address
h
HEATING UNIT 100,000 B.T.U.19.50
ELECTRIC
'
VENTILATION' FAN (SINGLE) 4.00
! I certify that I have read (his application and slate (hat the above
nformation'is correct. I agree to comply with all city and county
ofdinwhces•and state laws relating In building construction, and
hereby authorizerepresentatives of this city to enter upon the
above-mentioned property for inspection purposes.
PLUMBING,
t "
BOILER- COMM H.P. or 100,000 B.T.U.)'6.00'
BOI LER-COMP (Over 100,000 BTU) SEE FEE SCH.
MECHANICAL
(We);agree to save, indemnify and keep harmless the City of
MISC. - REFER TO ORD.
-
Cupetldno against liabilities, judgments, costs and expenses which
inay in an accrue against said City in con eq uene of the
PERMIT ISSUANCE _ 10.00
CONST. TAX
ra t Init. - J
&VAATOTAL
MECH. CONT. LIC. NO. MECH.
-
TOTAL
�- S
Sign h e.af Applicant/Contractor
IT
OFFICE COPY::
1.-
POST THIS CARD NEAR FRONT OF BUILDING
OPVFOR
t
:. CITY OF CUPERTINO 4: ; A
PERMIT NUMBER -
:; ` 1615
INSPECTION DIVISION
•JOB INSPECTION RECORD =Gzi
''r.,
,)
- '// // // •_ -
0,
PERMIT EXPIRATION
•"
J08 ADDRESS `"'�'�� UNIT# LOT#
• -
-'
PERMIT;EXPIRES IF WORK ,
n
OWNER '— lJ P OC" CONTRACTOR �V C> ''.
IS NOT STARTED WITHIN.'
180. DAYS OF PERMIT ISSU-
ANCE OR 180,DAYS FROM
LASTCALLED INSPECTION.
a
SPECTION DATE INSPECTOR
INSPECTION RECORD
FOUNDATION
NOTE j - -
ALL GRADING AND DRAINAGE'SHALL BE INSTALLED
TO COMPLY, WITH THE APPROVED PLANSAND CITY OF
UFER -
PREGUNITE
PCHMI I VAuunnON, .
CUPERTINO STANDARDS.
-" - -
-
,/�p'� �L) �}� ,,
}} �.,-� .
GARAGE SLABS -
POUR NO CONCRETE UNTIL ABOVE HAS BEEN SIGNED-^•>
�� _ �;
• �,.I
„ UNDERGROUND'/SLAB -
PLUMBING,
' • 1:I. r - • ,
u ISSUANCE 'CArE
ELECTRICAL J •.
MECHANICAL -
BLDG , ELECT.
1'
PLG.- MecR.
s
00 NOT POUR FLOOR UNTIL ABOVE HAS BEEN SIGNED
a - t
1ILDING PERMIT
iR11 NFORMATION
VALUATION $(FT.
f: ,• —C'V •I-,T.�l
• ".' WOOD FLOOR
'PLUMBING':.
-
MECHANICAL
ELECTRICAL
` PERMI
�-o� ;r
FRAMING
V//`/
INSULATION - -
STORIES
TYPE CONST -r
,•
UCC.GNOUI”
RLS.UNIIS
AP,LACE NO SUBFLOOR UNTIL ABOVE HAS BEEN SIGNED
ROOF .
NOTE: NO FINAL INSP. SHALL BE'MADE BEFORE.
THE CONSTRUCTION TAX IS PAID '
- -
-
!INSP.
'50, Fr FLOOR AREA
TOTAL ACREAGE
DIAPHRAGM
ROOF SHEATHING'T '
BUILDING USE
RES IND. .CON PB Orn..
r❑ ' ❑ 1:1 11ROUGH'-
.'APPLY.NO ROOFING UNTIL ABOVE HAS BEEN SIGNED
' FINALS' DATE ,
SAN.N'
_ ASSESSORS PARCEL NO -
I
PLUMBING'.;
ELECT. ENERGY <
.TUBS & SHOWER PAN -
PLUMBING ENERGY
TRACT No
'
-PARCEL NO
MECHANICAL
MECH. ENERGY
E LECTRICAL - � -
BUILDING ENERGY"
ACC. DATE
ACC FILE. NO.
r -
-
FRAMING -
ELECT. FINAL TEST -
INSULATION
PLUMBING
•ZONING
ENc. SITE No'
GAS TEST - - -
GAS
MECHANICAL
FIRE SPRINK
Y ❑ NE
-ENERGYT2a
° ❑ N❑
COVER'ND WORKUNTIL ABOVE -HAS BEEN SIGNED
HEATING,
EXTERIOR SHEAR � _
ELECTRICAL RELEASE
FLDOU20NE•/
Y 1 NE
A UC.
♦ L' NL '
INTERIOR SHEAR
FIRE DEPT.
SHEETROCK
GRADE�r - -7
FEE SUMMARY
EXTERIOR LATH :
BUILDING
BUILDING
.INTERIOR LATH -
.TEMPORARY. APPROVALS .
SCRATCHCOAT,.
ELECTRIC'
PLAN CHECK,'
FEE
r
xLr�
�'.
- GAS
SEISMICFEE
••
NO TAPE OR PLASTER UNTIL ABOVE HAS BEEN SIGNED OCCUPANCY ' - r,' „" •
OCCUPANCYOF BUILDING IS NOT PERMITTED UNTIL BUIL DING FINALISSIGNEDB Y BUILDING INSPECTOR,
MICROFILM
ARRANGEFOR INSPECTION -BY PHONING 252-4505,j
ELECTRIC;r
F•� ONEDAY BEFORE REQUIRED INSPECTION.PLUMBING
,WORKING
o. PLEASE GIVE JOB ADDRESS WHEN PHONING:: .
MECHANICAL
Z.
- SEE FOR EXPIRATION- DATE -
'
-PERMIT
y ,.
CONST: TAX+�-'IMPORTANT!PLEASE
- :_ •1. -
READ REVERSE SIDE BEFORE.
J CALLING FINAL INSPECTION.ir •, ',
OFFICE�C
TOTAL ��,,,,.
ql.