C8453 APPLICANT TO.FILL IN INFORMATIONWITHIN-RED LINES -.USE BALL POINT PEN ONLY .
BUIL�DING`PROJECT IDENTIFICATION RMITN BER
,� BRLDENG , a APPLICATION &PERMIT
Ory ,rn` G�e.I'Q�la BUILDING-ELECTRICAL-PLUMBING-MECHANICAL 453 '
.OWNER4 •: .. ' PLAN CHECK VALIDATION
X x Ea [% -4� OTY. ELECTRIC PERMIT FEE
V
r L N'Z FNONP YT --0/ 4
EACTORa UTLETS•SWITCHES-RECEP' 10.00/1.00
• ' uc.No.
r LIGHTING FIXTURES 10.00/1.00
CONTRACTOR-
ADDRESS
., PPLIANCES-RESIDENTIAL ' , _ 4.00
••�'
' l • •' y PNONE PANELS ra't!A. ' `10.00 DATE OF APPLICATION
ARCHITECT• •,T• PANELS(OVER 200 AMP) ..20.00 PUN CN I: FEE .C.NO. ,
exOIHEER.• •'LIc.No. SIGNSTRANS- 3.00.
..
ARCH.OR ENO., - - SPECIAL CIRCUIT •. 5,00 PERMIT VALIDATION ,
ADDRESS S
, .'• .
./alp TEMP.METER.OR POLE INS. 20.00
' APPLICANTS MOTORS " SEE FEE SCH. +
ADDRESS
SERVICE CHANGE 20.00
w O o ' + LICENSED CONTRACTORS DECLARATION:, TEMP.POLE ; WOO VVV 777/ a s
i 1'hercby affirm that I dm licensed under provisions ofChapter 9, ISSUANCE DATE
,I- (commencing with Section 7000)of Division 3 of the Business and Ois BLDG. ELECT. PLG. MECH
ro :
m r" Pfessons iCode,and my license is in full force and effect. - ��v r ..101:1- License Class Lic.Number
a: '
G a f w Date Contractor f '
PNa AFf
BUILDING PERMIT .
¢¢m OWNER-BUILDER DECLARATION. 1 FORMATION ,
K 2 LL n - I hereby affirm that 1 am exempt from the Contractor's License MISC:- rREFER TO ORD
'to u.05 Lew for the following reason.(Sec.7031.5,Businessand Profnsions PERMIT ISSUANCE 10.00 a f/FT.
H-w Code:Any city or county which requirma permit toconstroct,alter, . A
e 2 C G 1(oProve,demolish„or repair any structuic,prior to its issuanoa,alto ELEC.CONTR. •' LIC.NO. ".'� A• .
ELEC.
s
Rail
requires the applicant for such permit to file a signed statement that TOTAL PERMIT TO, --
X$ he is licensed pursuant to the previsions of the Contractors License - C
f i1. Low(Chapter 9(commeneing with Section 7000)ofUivision 3 ofthe
i c Business and Profecalons Code)or that he is e.empl.therefram and CITY. PLUMBING PERMIT FEE• -
¢I.� the basis for.the alleged exemption.Any violation ofSeclion 703LS STORIES. TYPE CONSTR.
s 3 by any applicant for a permit subjects the applicant to a civil penalty + -
ofnot mom than rivehundred dollars(55001.): ALTER•DRAIN&VENT-WATER (EA.) 6.00
D 1,as owner of the property.or my cmployeeiiwslh wages as. -BACK FLOW PROTECT.DEVICE -4.00 OCC. ROUP. RES.UNITS•
their sole compensation,will do life work,and the stileturc h not r
Intended or offered for sale(Sac. 7044,Business and Professions DRAINS-FLOOR,ROOF,AREA,COND. 5.00
Cade:The Contractors License Law don not apply to an owner df '
property who,builds or improves themon,and who docs such work FIXTURES•PER,T.RAP 5.00 SD,FT.FLOOR AREA TOTAL ACREAGE
\� 1' himself or through his own employees,provided that such improve. GAS-EA.$VSTEM-11NC.40UTLETS 8.00 '
ments are not intended or offered for sale.If,however,the building
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 le.). of proving that he did not build or ins- RES IND CON PB Omar
Prove for purpose of sale.). - INDUSTRIAL WASTE INTER. 30.00
D, 1,as owner of 111e property,um excludnlY contrscting with. ' - ❑ - ❑, '❑. ❑ ❑:
•• licensmd contractors to construct the project(Sec.7044,Business LAWN SPRINKLERS-1 INC.5 V.B. 6.00 r ASSESS RS PARCEL NO.
and Professions Calc:The Contnclor'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 for such projects with a contractors)licensed pursuant to ,
,the Cntractor's Licence Law,
SEWER-SANITARY-STORM EA.200ft/10.00 .TRACT NO.:. .PARCEL NO.
0<1 am exempt tinder Sec. .B.b.P.C.for this WATER HEATER,W/VENT '6.00
rcawnv r. .. .
Ownsr Moolddell Date _ WATER SYSTEM5.00 '
',- ACC.OATE _ ACC.FILE NO.
•� WORKF,RS'COMPIiNSATION DECLARATION WATER TREATING EQUIP. 5.00 '
1 hereby affirm that 1 have a certificate of comunt to self-insure. I ZONING ENG.SITE+NO.
or.certificate of Workers Compensation Insurance,or a certified -
copy thereof(See.3800,Lab.C.). /
Polley No. Company ' .
Q O Certified ropy is hereby famished. FIRE SPRINK ENERGY T-24
ZZ D Certified copy. h..filed with'the city'inspection division. . REFER TO-ORD.
Q Applicant MISC.,-- Y,0 N❑ Y.13 .N❑
cc !2 i PERMIT ISSUANCE' 't :10.00 FLOOD ZONE ;A.L.U.C.
� - CIiRTIFICCOM COMPENSATION
'ROM WORKERS" '
Ill > COMPENSATION IIt SURANCE PLG.CONTR. y LIC.NO. PLG. N Y N '
d O (This seelidn need not Rv t5o I�iplemd if the permit is for one TOTAL ❑ ❑ ❑ ❑ .
Z hundred dollars(SIOO)or lesy 1
U O I certify that in the 1 fdmance of the work for which this per, CITU•• • MECHANICAL PERMIT ' FEE, FEE SUMMARY t.
LL mil is issued,1 shall IJol�mploy any person in any manner w os to ;• '
become subject t .life .driversCompensation Laws of California: sYa
O �s - 'BUILDING /,3
Date Applicant' ALTER OR ADD TO MECH. •5.00
} IS NOTICE TO APPLICANT: IL after making this Certificate of Ex.
2 emption,you should become subject to the Workeri Compensation APPLIANCE 5.00 PLAN CHECK p/f1^ '
provisions of the/Labor Code,you mnst•forthwilh<omply with FEE O
U such provisions oilthis permit shall he dimmed revoked. AIR HANDLING UNIT(TO IQGXIC.F.M.). 4.00
CONSTRUCTION LI? DING AC' CY AIR HANDLING UNIT(OVER 10jIDDC.FA) 6.00 SEISMIC FEE -
1 hereby affirm that then is a ebnatnnI lending agency for EXHAUST HOOD(WITH DUCT) 5.00
the performantt of the work for wRich,tgis permit is issued ISm. MICROFILM
3097,Civ.C.). "HEATING UNIT,(TO 100,000 B.T.U.) 8.00
s r Lenders Nome j HEATING UNIT(OV ER 100,000 B.T.U.) 50 ELECTRIC '
Lender's Address
1 certify that I have read this application and state that the above VENTILATION FAN(SINGLE) 4.00
information is correct.I agree to comply with all city and county PLUMBING
/ .ordinances and state laws relining to building construction,and . BOIIJ'A•CONP I3 H.P.Dr 100,000 B.T.U.) 8.00
hereby authorize representatives of this city to enter upon.the, BOILER-COMP(OvertOO,000STU)SEEFEESCH. MECHANICAL
above-mentioned property for inspection purposes.
' ,(We) agree to ave, indemnify and keep harmless the City of MISC.- - REFER TO ORD.
Cupertino against liabilities,judgments,casts and expenses'whleh CONST.TAX
may in any way accrue against aid City in conseq en of the PERMIT ISSUANCE 10.00
Sailing Of lifts permit. / MECH.CONT. LIC.NO. MECH. r S
\e-7//, yLA r TOTAL TOTAL' d 9
.lure o licant ntraclor Date
• OFFICE COPY ,
- - r
POST THIS CARD NEAR FRONT OF BUILDING
I'FRMI7 NUMBPR
CITY OF CUPERTINO 843
INSPECTION DIVISION
JOB INSPECTION RECORD
JOB ADDRESS
6NV PERMIT EXPIRATION
-/G// (/, / UNIT# LOT# PERMIT EXPIRES IF WORK
•
OWNER CONTRACTOR IS NOT STARTED WITHIN
INSPECTION DAT INSPECTOR INSPECTION RECORD 180 DAYS OF PERMIT ISSU.
FOUNDATION
ANCE OR 180 DAYS FROM
LASTCALLED INSPECTION.
UFER
PREGUNITE PERMIT VALIDATION
POUR NO CONCRETE UNTIL ABOVE HAS BEEN SIGNED
UNDERGROUND /SLAB
PLUMBING
ELECTRICAL ISSUANCE DATE
MECHANICAL BLDG. I ELECT. PLO. MECH.
❑ ❑ ❑ ❑
DO NOT POUR FLOOR UNTIL ABOVE HAS BEEN SIGNED BUILDING PERMIT
INFORMATION
WOOD FLOOR VALunnoN siFT.
PLUMBING
MECHANICAL
PERMIT TO
ELECTRICAL
FRAMING
STORIES TYPE CONSTR.
INSULATION
OCC.GROUP RES.UNITS
PLACE NO SUBFLOOR UNTIL ABOVE HAS BEEN SIGNED
SO,FT.FLOOR AREA TOTALACREAGE
ROOF
DIAPHRAGM
BUILDING USE
RES IND CON PB Ober
•(`APPLY NO ROOFING UNTIL ABOVE HAS BEEN SIGNED El El 0 ❑ ❑
ROUGH ASSESSORS PARCEL NO.
PLUMBING
TRACT NO. PARCEL NO.
GAS TESTE3 nt
MECHANICAL '
ACC.DATE ACO.FILE N0,
ELECTRICAL ,j"— _� FINALS DATE INSP.
FRAMING „S- _� SAN #
ZONING ENG.SITE N0.
INSULATION PLUMBING
GAS
FIRE FIRE SPRINK ENERGY T2
MECHANICAL Yo NF] Y ❑ N[D
COVER NO WORK UNTIL ABOVE HAS BEEN SIGNED HEATING
aaoo zoNE A.L.0 c.
LATH-INTERIOR ELECTRICAL
LATH-EXTERIOR FIRE DEPT. Y EI NO Y O N❑
SHEETROCK IGRADE FEESUMMARY
SHEAR INTERIOR BUILDING Sr- -8S BUILDING
SHEAR EXTERIOR TEMPORARY APPROVALS
FIREWALLS ELECTRIC PLAN CHECK
GAS FEE -
NOITAPE OR PLASTER UNTIL ABOVE HAS BEEN SIGNED OCCUPANCY SEISMIC FEE
OCCUPANCYOF BUILDING IS NOT PERMITTED UNTIL BUILDING FINAL ISSIGNED BY BUILDING INSPECTOR. MICROFILM
ARRANGE FOR INSPECTION BY PHONING 252-4505, ELECTRIC
F� ONE WORKING DAY BEFORE REQUIRED INSPECTION. PLUMBING
:{ 0 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