16542 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
BUILDING PROJECT IDENTIFICATION PERMIT NUMBER
BUILDING APPLICATION & PERMIT
ADDRESS 16542
L �{ P BUILDING -ELECTRICAL-PLUMBING-MECHANICAL
o V / N
OWNE 5 PLAN CHECK VALIDATION
""�- CITY. ELECTRIC PERMIT FEE
HONE
LDNrRAcions
NAME OUTLETS-SWITCHES-RECEP 10.0011.00
LIC.ND. LIGHTING FIXTURES 10.00/1,00
Dora
ADDRESS APPLIANCES-RESIDENTIAL 4.00
PHONE PANELS 10.00 DATE OF APPLICATION
ARCHITECT PANELS (OVER 200 AMP) 20,00 PLAN CHECK FEE P.C.N
OR O.
ENGINEER
ua NO, SIGNS TRANS. 3.00
aoo Ess END SPECIAL CIRCUIT S,QQ PERMIT VALIDATION
ZIP TEMP. METER OR POLE INS. 20.00 _,a/�'�
aPPuCANT's MOTORS SEE FEE SCH. / `^^' "
ADDRESS l
SERVICECHANGE 20.00 9
o o LICENSED CONTRACTORS DECLARATION /
4 U U I herchy affon that I am licensed Linder provisions of Chapter 9 ISSUANCE DATE t`
yaw (comntenemg with Section 7000)of Division 3.1 the Business and DG. ELECT. PLG. MECH.
F N z Professions Code,and my license is in full force and effect. El El
o w - License Class Lie m
Nuber
O rD Date COnlractm
a y f BUIL NG PERMIT
w OWNER-BUILDER DECLARATION MATION
a0A MISC.- REFER TO ORD
X
Su. se 1 hereby affirm tool 1 am exempt from the Contractor's License LUATION $/FT.
FLL
0 J Law for tire following reason.(Sic,7031.5.Businessand Professions PERMIT ISSUANCE 10.00 'k
Code:Any city or county whidt rnluiresa permit to construct,aper, ��
aimprove,demolish,or repair any structure,prior to its issuance,also ELEC.CONTR. LIC.NO. ELEC.
Es Ic requires the applicant for such permit to file a signed statement that TOTAL
K
PERMIT TO �'^^
n m u- he is licensed pursuant to the provisions of the Contractor's License
His- Law(Chapter 9(cunmtencing with Sect ion 7000)of Division 3 of the �.( �z�v7
a Business and Professions Code)or that he is exempt therefrom and OTV. PLUMBING PERMIT FEE
F Do the basis for the alleged exemption.Anv violation of Section 7031.5 TORIES TYPE CONSTR.
aim by any applicant fur a permit subject,lire applicant tor6,il penalty ALTER-DRAIN -WATER (EA.) 5.00
of not more than five hundred dollars($500).):
❑ I,as owner of the property,or my employees with wages as BACK F LOW PROTECT.DEVICE 4.00 OCC,GROUP RES.UNITS
their sole compensation,will do the work,and the structure is not
inleaded or offered for sale (Sec. 7044. Business and Professions DRAINS-FLOOR,ROOF,AREA,CONO. 5.00
?- Code:The Contractor's License Law docs not apply to an owner of
/
property who holds or improves thereon,and who does such work FIXTURES-PER TRAP 5.00 SO.FT,FLOOR AREA TOTAL ACREAGE
himself or Through his own employees.Provided that such implore- -
mems are not mended or emplored for talc.lf,ed that s the building GAS-EA.SYSTEM-1 1NC.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 or im-
ProveforPurposeofsale.). INDUSTRIALWASTE INTER. 30.00 RES IND CON PB Omar
❑ I,as owner of the pipe Its,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 License Law docs 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 contracmrls)licensed pursuant to
the Contractor's license Law. - SEWER-SANITARY-STORM EA.200ft/10.00 TRACT NO. PARCEL NO,
O I am exempt under Sec. B.&P.C.for reit WATER HEATER W/VENT 6.00
reason
Owner Dale ( WATER SYSTEM 5.00 ACC.DATE ACC.FILE NO.
WORKFRS'COMPENSATION DECLARATION WATER TREATING EQUIP. 5.00
1 hereby affirm that 1 have acertificale of consent toself-insure. ZONING
sr a certificate of Workers'Compensation Insurance or a certified ENG.SITE NO.
Copy thereof(Sec.3800,Lab.C.).
Policy No.__Cmnp:my
0 ❑ Certified copy is hereby furnished FIRE SPRINK ENERGY T 14
z Z .'❑ Cerlified copy is fled with the city i,,ir,inn division.
O Applicant MISC.- REFER TO ORD, v❑ N❑ v [:] N❑
K h CIiRTIPICA'I'C OF EXEMPTION FROM WORKERS' PERMIT ISSUANCE 10.00 FLODD ZONE a.L.u.c.
W > COMPENSATION INSURANCE PLG.CONTR. LIC.NO. PLG.
Q. a (This section need not be completed if the permit is fill tire ne TOTAL V❑ N❑ Y[:] N❑
Z hundred dollars 15100)or less.)
U O 1 certify(fiat in the performance of the work for which it"'pef-r
MECHANICAL PERMIT FEE FEE SUMMARY
LL H mit is issued,1 sall nut employ:uty person in any mannero a to
become subject to the Workers Compensation Laws of California.0 w Date Applicant BUILDING AN ALTER OR ADD TO MECH. 5.00 W NOTICli yo shouldAPPLIbeco': Isubjecr to king This Cerlifmpeate sc Gx-movisio,you should bor Code. youIo Ise Worthen' comply withumnAPPLIANCE 5.00 PLAN CHECK provisions of the Labor Code. you must IONL.kc comply wish FEE such provisions or this permit shall he deemed revoked. AIR HANDLING UNIT(TO 10,000QF.M) 4.00
CONSTRUCHON LENDING AGENCY AIR HANDLING UNIT(OVER 10MC.RM.) 6.00 SEISMIC FEE 1 hereby affirm that there is a construction landing agency forEXHAUST HOOD (WITH DUCT) 5.00
the performance o1'the work for which this permit is issued(Sec. HEATING UNIT (TO 100,000 e.T.U.) 8.00 MICROFILM
3097,Civ.C.).
Lender's Name HEATING UNIT(OV ER 100,000 B.T.U.)9.50 ELECTRIC
Lender's Address
I certhy that I have read this application and suite that the above VENTILATION FAN (SINGLE) 4.00
ordinances n correct. 1 agree to comply with all Listity and county BOILER-COMP(3 H.P.or 100.000 B.T.U.) 6.00 PLUMBING
ordinances and stale laws relating c m y with
construction, and
hereby authorize representatives of this city to enter upon the BOILER-COMP (Over 100,000 BTUI SEE FEE SCH. MECHANICAL
above-mentione,l 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
may an any way accrue against said City in consequence of the PERMIT ISSUANCE 10.00
rantingn(t"' noiL MECH.CONT. LIC NO. MECH.
C(C('-�-J7.�01 Chir Q (o ' 8 TOTAL TOTAL oS^.
Signature of Apploan a
Contractor LL
OFFICE COPY
POST THIS CARD NEAR FRONT OF BUILID ING•
PERMIT NUMBER
CITY OF CUPERTINO . 16542
-INSPECTION DIVISION
JOB INSPECTION RECORD
PERMIT EXPIRATION
JOB ADDRESS . 0 O M-6-VAI UNIT# _LOT#
PERMIT EXPIRES IF WORK -
OWNER - I--L CONTRACTOR - IS NOT STARTED WITHIN
INSPECTION DATE INSPECTOR INSPECTION RECORD 180 DAYS OF PERMIT ISSU
FOUNDATIONANCE OR 180 DAYS FROM
NOTE: LASTCALLED INSPECTION. '
UFER ALL GRADING AND DRAINAGE SHALL BE INSTALLED
PREGUNITE TO COMPLY WITH THE APPROVED PLANS AND CITY OF Porn+n VALIDATION
CUPERTINO STANDARDS.
GARAGESLABS
POUR NO CONCRETE UNTIL ABOVE HAS BEEN SIGNED -
UNDERGROUND /SLAB
PLUMBING ,
ELECTRICAL ISSUANCE.OATS
SLUG ELECT I PLG. MECR
MECHANICAL
El El ❑ ❑
DO NOT POUR FLOOR UNTIL ABOVE HAS BEEN SIGNED P^v BUILDING PERMIT
WOOD FLOORINFORMATION
uATION SIFT.
PLUMBING Of`"` \JUS
MECHANICAL
ELECTRICAL .0 PEV+nnT TO
FRAMING
INSULATION TORIES TYPE CONSTR
OCC GR[)UP HES UNITS
PLACE NO SUBFLOOR UNTIL ABOVE HAS BEEN SIGNED
ROOF NOTE:NO FINAL INSP.SHALL BE MADE BEFORE SO FT FLOUR AREA TOTAL<CRLAGL
DIAPHRAGM THE CONSTRUCTION TAX IS PAID _
BUILDING USE
ROOF SHEATHING RES IND CON PB o,n.,
- APPLY NO ROOFING UNTIL ABOVE HAS BEEN SIGNED FINALS DATE INSP. ❑ 0 ❑ ❑ ❑
ASSESSORSPARCEL NO
ROUGH SAN.#
PLUMBING ELECT.ENERGY '
rHncT Na. PnHcEL No
TUBS&SHOWER PAN PLUMBING ENERGY
MECHANICAL MECH.ENERGY
ACC DATE ACC FILE NO
ELECTRICAL BUILDING ENERGY '
FRAMING ELECT.FINAL TEST ZONING ENG.SITE NO.
INSULATION - PLUMBING
I GAS TEST GAS
FIRESPRINK ENERGY T.24
MECHANICAL v [:] N
COVER NO WORK UNTIL ABOVE HAS BEEN SIGNED HEATING NE ❑. �
FLOOD ZONE ALuc
EXTERIOR SHEAR ELECTRICAL RELEASE
INTERIOR SHEAR FIRE DEPT. Y❑ N0 1 Ll N❑
SHEETROCK GRADE FEESUMMARY
EXTERIOR LATH BUILDING
INTERIOR LATH TEMPORARY APPROVALS Bu1LDING
SCRATCH COAT ELECTRIC PLAN CHECK pI
FEE
o «
• GAS
NO TAPE OR PLASTER UNTIL ABOVE HAS BEEN SIGNED OCCUPANCY SEISMIC FEE
OCCUPANCYOF BUILDING IS NOT PERMITTED UNTIL BUILDING FINALISSIGNED BY BUILDING INSPECTOR. MICROFILM
LU ARRANGE FOR INSPECTION BY PHONING 252-4505, ELECTRIC
ONE WORKING DAY BEFORE REQUIRED INSPECTION. PLUMBING
Z PLEASE GIVE JOB ADDRESS WHEN PHONING.
- SEE PERMIT FOR EXPIRATION DATE - MECHANICAL
IMPORTANT! CONST.TAX
PLEASE READ REVERSE SIDE BEFORE TOTAL 9 6,C
CALLING FOR FINAL INSPECTION. `=
OFFICE COPY