16314 APPLICANT TO FILL IN INFORMATIONWITHIN RED LINES - USE BALL POINT PEN ONLY BUILDING PROJECT IDENTIFICATION .PERMIT NUMBER
BUILDING APPLICATION & PERMIT - /� �-
_L/_ 1) F"RE55
- -_ 981 4t Q,9 I/&rfi DICBUILDING—ELECTRICAL—PLUMBING—MECHANICAL ..
/ OWNER'S PLAN CHECK VALIDATION
NAME y1 /�iC z3 /
QTY. ELECTRIC PERMIT FEE �
PHONE ��r
CONTRACTOR'S ��/
NAME UTLETS-SWITCHES-RECEP 10.00/1.00 7Q
NO. /3 LIGHTING FIXTURES 10.00/1.00 S
CONTRACTOR'S - APPLIANCES-RESIDENTIAL 4.00
ADDRESS
PHONE ' PANELS 10.00 DATE OF APPLICATION
ANGINEERT ober Q"PeII'Y)Q Y1h A�f� — PANELS (OVER 200 AMP) 20.00 ' PLAN CHECK FEE P.C.NO.
r OR /�
ENGINEER
tiC-I 9Y
c.uO. SIGNS TRANS. 3.00
�- ADDDRESS ENO. SPECIALCIRCUIT 5.00 PERMIT VALIDATION
5611 Je55e UamNS Or, S. zIP ,SI EMP.METER OR POLE INS. 20.00 '
ADDRESS Ts
AMOTORS SEE FEE SCH.
APPLICANT
SERVICE CHANGE 20.00 '`
y/a
o o LICENSED CONTRACTORS DECLARATION //'/�. g ��
a v w I hereby affirm that I am licensed order provisions of Chapter 9 ISSUANC DATE
vi Q n (commencing will,Section 7000)of Division 3 of the Businessund' OG. ELECT. PLG. MEG..
H,n z Professions Code,and my license is in full force and effect.
o i w o License Class Lie.Number
Date Contractor
a y s �• ILDING PERMIT
¢ w u OWNER-BUILDER DECLARATION - INFORMATION
od MISC.— REFER TO ORD
K
;e.0 N I hereby affirm that I am exempt from Om Contractor's License p ION S/FT.
F LL e.ar Law for the following reason.(Sec.7031.5.Busmessand Professions PERMIT ISSUANCE ,AAO 69
Code:Any city or county which requires a permit in construct,alter.
nn
QQ4O Impr(]Ve,denlnhaM1,OrRpalranyslmQtlr2,pnOrtOIISISWanee.alf0 ELEQCONTR. LIC.NO. ELEC. 22 pC0
O LL requires the applicant for such permit to file a signed statement that TOTAL / PERMIT TO
F
m he Is licensed pursuant to the provisions of the Contractor's License ( -�--
Hz >
Law(Chapter 9(commencing with Section 7000)ofDivision3ofthe
a ADDITD
Business and Professions Code)or that he is exempt therefrom and QTY. PLUMBING PERMIT FEE
¢ H$ the basis for the alleged exemption.Any volul ion at SCclion 7031.$ STORIES TYPE CDN$TR,
i by any applicant for a permit subjects the applicant toa civil penalty ALTER-DRAIN&VENT-WATER (EA'.)
oIKt more than five hundred dollars(5500).):
Jf, I,as owner of the property,or my employees with wages as BACK FLOW PROTECT.DEVICE -4.00 OCC.GROUP REB.UNITS
their 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:Tha Contractor's License Law docs am apply to an owner of
40 propuity-who builds or improves thereon,and who does such work �' FIXTURES-PER TRAP .6A0 a 50.FT,FLOOR AREA TOTAL ACREAGE
himself re through his own employees,Provided that such improve- q -
ments mselfo not ommen dad oroffercd employees,
or provided that such
building GAS-EA.SYSTEM-1INC.4OUTLETS 6.00 I�
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 or im. RES INO CON PS Otnar
prove for purpose ofsale.). INDUSTRIALWASTE INTER. 30.00
❑ -I,as owner of the property,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 Contractors 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 contracmAs)licensed pursuant to
the Contractor's License Law. SEWER-SANITARY-STORM EA.200ft/10.00 TRACT NO. PARCEL NO.
❑ 1 am exempt under Sec. ,BAP.C.for this WATER,H EATER W/VENT 6.00
naso
Own r Date 1 WATER SYSTEM- 5.01) Ace.DATE ACC.FILE NO.
ORKE 'COMPF-NSATION DECLARATION WATER TREATING EQUIP. 5.00
I hereby affirm that I have a certificate of consent to self-insure. ZONING
or a certificate of Workers'Compensation Insurance,or a certified
ENG.SITE N0.
copy thereof(Sec 3800,Lab.G.). `
Policy No. Company
0 ❑ Certified copy is hereby furnished. FIRE SPRINK ENERGY T 24
Z2 D Certified copy is Filed with the city inspection division.
O Applicant MISC.- ' REFER TO ORD. Y❑ N❑ Y ❑ N❑
R W CER'I'IFICATEOF EXEMPTION FROM WORKERS' PERMIT ISSUANCE - PLDOD ZONE A.LU C.
LU
COMPENSATION INSURANCE PLG CONTR. LIC.NO. PLG. ,�../�
a- Z (This section need not be completed if tiro pennit is for one _ TOTAL sf� Y❑ N❑ Y ❑ N❑
hundred dollars IS 100)or less.)
U O 1 certify,that in the performance of the work for which this per- OTY. MECHANICAL PERMIT FEE FEE SUMMARY
F msn
LL mil is issued,1 shall.not employ any person in any nnner so as to
U become subject to the Workers'Comperadion Laws of California. a-O
0 y Date Applicant ALTER OR ADD TO.MECH. 5.00 PSEISMICFEE
adS.
} W NOTICE'TO APPLICANT: If,after making this Certificate of Ex.
F Z emption,you should become subject to the Workers'Compensation APPLIANCE 5.00
provisions of the Labor Code, you must forthwith comply with 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 IQOODC.EM.) 6.00 I hereby affirm that there is a construction lending agency far EXHAUST HOOD (WITH DUCT) 5.00the performance of the work for which this permit is issued(Sec.3097,CN.CJ. - HEATING-UNIT(TO 100,000 B.T.U.)• 8.00
Lender's Nalne HEATING UNIT(OVER 100,000B.T.U.)9.50
.. . Lender's Address 3/ d
I certify that I have read this application and state that the above VENTILATION FAN (SINGLE)
information is correct. I agree to comply with all city and county PLUMBING r7
�) ordinances and state laws relating to building construction, und BOILER-COMP H.P.or 100,000 B.T.U.) 6.00
hereby authorize representatives of this city to enter upon the BOILER-COMP(Over IOO,GOO BTU)SEE FEE SCH. MECHANICAL
above-mentioned property for inspection purposes. •�
(We) agree to save, indemnify and keep h5rmless the City m' MISC.- REFER TO ORD.
uperlino against liabilities,judgments, costs and expenses which' CONST.TAX
may'in any way accrue against said City in consequence of the PERMIT ISSUANCE
of flys permit. ' - MECH.CONT. LIC.NO. MECH.
g .
TOTAL TOTAL
ElInature of pplicant/Contractor Date
OFFICE COPY
POST,THIS CARD NEAR FRONT OF BUILDING
PER NUMBER .
CITY ' N'CUPERTINO
INSPECTION DIVISION 1631
JOB INSPECTION RECORD
] !"PERMI7,EXPIRATION
JOB ADDRESS' L-Nom Vif�g JJiC., UNIT# ' LOT# - '
- PERMIT EXPIRES IF WORK
OWNER F coNTHACTOR IS NOT STARTED WITHIN
INSPECTION DATE ' INSPECTOR - INSPECTION RECO RD - 180DAYS OFPERMIT•ISSU-
FOUNDATION , ' fL_G ��_ 'ANCE OR,180 DAYS FROM
NOTE: LAST CALLED INSPECTION. '
UFER ' - ALL GRADING AND DRAINAGE SHALL BE INSTALLED
PR EGUNITE 'TO COMPLY WITH THE APPROVED'PLANS AND CIN OF - PERMIT vn LrtlA TION;
;'
GARAGE SLABS
POUR NO CONCRETE UNTIL ABOVE HAS BEEN SIGNED ij>a�z?�91�p��M�ot� l N Z au
UNDERGROUNDVSLAB pote1-ok,'7U CW L2 ori=t7� �j ti {a sjk
PLUMBING - - 1, N51'�bl1:UL. SU,I4 L+D iL Gt3M� i ( " '
ELECTRICAL. ?t AJC 1`Yc�eU OI-;I`� �Y.r +.•� uCC['�DA� '
'ISSUANtlF E
MECHANICAL BG, ELECT I I CG MECR. -
k
DO NOT POUR FLOOR UNTIL ABOVE HAS BEEN SIGNED KlI BUILDING PERMIT
WOOD FLOOR,' a6l", INFORMATION
PLUMBING
VALUATION $(FT'
• � � � � - -
MECHANICAL
ELECTRICAL PEHMIT TO
FRAMING- -
INSULATION I - - STORIES TYPE CONSTH.
_.._._.-•_ - - .. , .00C GROUP' RES UNITS
PLACE NO SUBFLOOR UNTIL ABOVE HAS BEEN SIGNED- .
'ROOF" sn FT FLOOR AREA TOTAL ACREAGE
NOTE NO FINAL INSP.SHALL BE MADE BEFORE
DIAPHRAGM - THE CONSTRUCTION TAX IS"PAID, y'�j 0 _
+ * BUILDING USE
ROOF SHEATHING ` RES IND CON PB Ou„•, '
�T APPLY"NO ROOFING UNTIL:ABOVE HAS BEEN SIGNED. FINALS DATE - 'INSP. ❑- ❑ ❑- ED ❑'
ASSESSORS PARCEL NO
- -. ,ROUGH SAN.N
. PLUMBING - '� - . ,.ELECT.ENERGY
TRACT NO. PARCEL NO.
TUBS&SHOWER'PAN - PLUMBING ENERGY
MECHANICAL - MECH.ENERGY -
` ELECTRICAL �, BUILDING ENERGY Acc.DATE Acc.FILE No.
FRAMING .'� Q , ELECT.FINAL TEST .j0 -
ZONING ENG.SITE NO.
INSULATION _ p, -�;a PLUMBING .
GAS TEST GAS ”
FIRE svRINK'• ENERGY T 2
'MECHANICAL I-tq '
• COVER NO WORK UNTIL ABOVE HAS BEEN SIGNED HEATING - v "❑ Y❑ "❑
EXTERIOR SHEAR" - ELECTRICAL RELEASE .�0�. FLOOO zoNE a.L JC .
INTERIOR SHEAR FIRE DEPT. - Y❑ N❑ v ❑ N❑
SHEETROCK " - GRADE - ' FEE SUMMARY
EXTERIOR LATH, - - BUILDING -
BUILDING
' INTERIOR LATH TEMPORARY APPROVAL
SCRATCH COAT '\ ELECTRIC - .PLAN CHECK ,
GAS ., - •FEE
NO TAPE OR PLASTER UNTIL ABOVE HAS BEEN SIGNED OCCUPANCY' SEISMIC FEE
OCCUPANCYOF BUILDING IS NOT PERMITTED UNTIL BUILDING FINAL ISSIGNED BY BUILDING INSPECTOR. MICROFILM "
W' ARRANGE"FOR INSPECTION BY PHONING 252-4505, ELECTRIC ,ZO;
I- bNEWORKI'NG,DAYBEFORE REQUIRED. INSPECTION. PLUMBING
Z
�: PLEASE GIVE JOB ADDRESS WHEN PHONING.
SEE PERMIT FOR EXPIRATION DATE .` ; MECHANICAL S0
IMPORTANT!. . '-CONST.TAX
PLEASE READ REVERSE SIDE BEFORE ;',
• CALLING FOR FINAL INSPECTION. TOTAL a5�,
OFFICE COPY