13110 . '& .APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALLPOINT PEN 0RLY ••
BUILDING PROJECT IDENTIFICATION PERMIT NUMBER
lAou"';z"
DILGI-, �S M ,( 0.
APPLICATION & PERMIT
13110
v(7 i TiNo CI;- 1BUILDING - ELECTRICAL-PLUMBING-MECHANICALWNER'$ sli PLAN CHELK VALIDATION
AME r.' CITY. ELECTRIC PERMIT FEE
(N(�,tM/Ls- PHONE 7
CONTRACTOR s l
NAME .�.�,f l OUTLETS 10.00/1.00 a ell
_
T_ GI-L ./�". 5 LIGHTING FIXTURES 10.00/1.00 3 Ob
LIC.NO.
CONTRACTOR'S ',;gpPLIANCES-RESIDENTIAL 4.00 - 160
/Z S,f/!A(aG4 Y PHONE - PANELS 10.00 (� - DATE OF APPLICATION
ARRCHITECT{♦.�/�"✓/� yry, pANELS (OVER 200 AMP) 20.00 PLAN CHECK FEE P.C.NO.
ENGINEER/ � �LU
�, LL Le No. SIGNS TRANS. 3.00
., ARCH.OR EN 5.00 PERMIT VALIDATION
$Gfn// q�
ODRESs g/a6-12,0. Lal RCUIT SPECIAL CI �.�
�218d ZIPEMP.METER OR POLE INS. 20.00
APPLICANT'BL�
AOOR ss MOTORS SEE FEE SCH.
(Q� /.�1F/lJUMn✓G3`L flK/HI SERVICE L'HANGE 20.00
woo , LICENSED CONTRACTORS DECLARATION /�- CUped{u
a a w I hereby affirm that I am licensed under provisions at Chapter 9 y�" ISSUANCE DATE
N a w (commencing with Section 7000)of Division 3 ofBusiness and BLDG. ELECT, PLG. MECH.
H N z Professions Code,f�8 my license is in full force d1J1 tq
Z O O e License Cpss�(/ Lin.Contractor ®-
9 T H °w_. Dale-�(�'y(�-o¢�(_Contmctor x� �
< , 2 a - ' ` BUILDING PERMIT
ce m w 4 WNER-BUILDER DECLARATION INFORMATION
F. ;u N I hereby affirm that I am exempt from lire Contractor's License MISC.- REFER TO ORD
iu .. 0 4 Law for the following reason.(Sec.7031.5,Businessand Professions PERMIT ISSUANCE 10.00 VALUATION SIFT.
� -0 Code:Any city orcounty which requires a permit to construct,alter, J �� . - 1
Q ia a M improve,demolish,or repair any structure,prior to its issuance,also ELEC.CONTR. LIC.NO. !/ I/ds�
ELEC. q9 H
-a a, requires the applicant for such permit to file a signed statement that TOTAL X117 -' PERMIT TO
wOy he is licensed pursuant to the provisions of the Contractor's License
F z Q
Law(Chapter 9(commencingwith Section 7000)of Division 3 ofthe
s 4 O Business and Professions Code)or that he is exempt therefrom and CITY. PLUMBING PERMIT FEE
re H $ the basis for the alleged exemption.Any violation of Section 7031.5 STORIES TYPE CONSTR.
T ; by any applicant for a permit subjects lite applicant to a civil penallyALTER-DRAIN&VENT-WATER (EA.) 5.00
V N�
of not more than five hundred dollars(5500).):
❑ 1,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 Q
intended or offered for sale(Sec. 7044, Business and Professions I DRAINS-FLOOR,ROOF,AR EA,COND. 5.00 3
Code: The Contractor's License Law does not apply to an owner of
property who builds or improves thereon,and who does such work FIXTURES-PER TRAP 5.00 6Z O.- SFT.FLOOR AREA TOTAL ACREAGE
himself or through his own employees,provided that such improve-
mre fi
mes anot intended or offered for sale.If,however,the building -7--GAS-EA.SVSTEM-11NC.40UTLETS 6.00 O
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 am- RES IND CON PB Other /
prove for purpose of sale.). INDUSTRIAL WASTE INTER. 30.00
❑ 1,as owner of the property,am explusively contracting with
licensed contractors to construct the project(Sec.7044,Business I LAWN SPRINKLERS- 1 INC 5 V.B. 6.00 ASSESSORS PARCEL NO.
and Professions Code:The Contractor's License Law does not apply L / p
to an owner of properly who builds or improves thereon.and who LAWN SPRINKLERS-OVER 5 IEA.) 1.00 3 Lf� /N _621191
contracts for such projects with a contractors)licensed pursuant to 1 SEWER-SANITARY V.STORM EA.200ft/10.00
the Contractors License Law. t] ^ TRACT NO. PARCEL NO.
❑ lam exempt under Seo-,B&P.C.for this I IWATER HEATER W/VENT 6.00
reason
Owner Dare WATER SYSTEM 5.00 S� ACC.DATE ACC.FILE NO.
WORKERS'COMPENSATION DECLARATION WATER TREATING EQUIP. 5.00
1 hereby affirm that I have a certificate ofconsent to self-insure, ZONING ENG.SITE NO.
or a certificate of Workers'Compensation Insurance,or a certified
copy thereof(Sec.3800,Lab C.L
Policy No. Company
O [1 Certified copy is hereby furnished. FIRE SPRINK ENERGY T 24
Z Z ❑ Certified copy is filed with the city inspection division. MISC.- REFER TO ORD. YE] NE] Y E) NE]
H � Applicant
PERMIT ISSUANCE 10.00 ll FLOODZONE A.LU.C.
� � CIiRTI FICCObPE EXEMPTION FROM WORKERS'
11J COMPfiNSATION INSURANCE PLG.CONTR. LIC.NO. PLG. pf Q-Q
d0 TOTAL D Y� N� YC] N�
(This section need not be completed if the permit is for one
D Z hundred dollars(YI00)or less.)
U O 1 certify hat in the performance of the work for which this per- QTY. MECHANICAL PERMIT FEE FEE SUMMARY
LL F- mil is is..55��ii I hall not employ any perwn in any manner so as to
V becomeJf Workers'Cir en'lio L cos of I'fo ia.
w Date- Applicam_ ALTER OR ADD TO MECH. 5.00 BUILDING
} h NOTICE 0 I'1' ICANT: If,after making this Certificate of E.-
l.- Z onfuu n,you should become subject to the Workeri Compensation APPLIANCE 5.00 PLAN CHECK
�ht provisions of the Labor Code, you must forthwith comply with AIR HANDLING UNIT IT
10,000 C.F.M.) 4.00 FEE
such provisions of this permit shall be deemed revoked. �[
CONSTRUCTION LENDING AGENCY AIR HANDLING UNIT(OVER 10SMC.F.M.) 6.00 SEISMIC FEE �(
f I hereby affirm that there is a construction lending agency for EXHAUST HOOD (WITH DUCT) 5.00
0fy the perlormance of the work for which t^his_p�er nnil is issued(Sec. MICROFILM
3097,Civ.C.). �'8�'� HEATING UNIT(TO 100,000 B.T.U.) 8.00
Lender's Name - HEATING UN IT(OV ER 100,000 B.T.U.)9.50 ELECTRIC
Lender's Address -,,
I certify lhatl havercadthisap catiol an state that thea ove VENTILATION FAN
(SINGLE) 4.00
information is correct.I agree to comply with all city and county BOILER-COMP 13 H.P.or 100,000 B.T.U.) 6.00 PLUMBING
ordinances and Slate laws rotating to building construction, and
hereby stithorize representatives of this city to enter upon the BOILER-COMP 10ver 100,000BTUI SEE FEESCH. MECHANICAL
above mentioned properly for inspection purpows.
(We) agAamerue
. indemnify and keep harmless the City of MISC.- REFER TO ORD. Oa
Cupertino es,ju gments, costs and expenses which CONST.TAX
may in anagai st said City in cons luence of the PERMIT ISSUANCE 1000 O-
manling ofMECH.CONT. LIG NO. MECH.
(� TOTAL .3/' 0 TOTAL /3 3,Z
)�\ Signa re o Applicant/Contractor Date
OFFICE COPY - _
POST THIS CARD NEAR FRONT OF BUILDING
PFRM1LT NUMBER
CITY OF CUPERTINO 13110
1' * INSPECTION DIVISION
JOB INSPECTION RECORD
PERMIT EXPIRATION
JOB ADDRESS 10695 MERRIMAN ROAD UNIT# Lor#
PERMIT EXPIRES IF WORK
OWNER REED SPARKS CONTRACTOR IC&C INC. IS NOT STARTED WITHIN
INSPECTION DATE INSPECTOR INSPECTION RECORD 180 DAYS OF PERMIT ISSU-
ANCE OR 180 DAYS FROM
FOUNDATION p-2.0' LAST CALLED INSPECTION.
UFER —j�D-�C
PERMIT VALIDATION
PREGUNITE �l-vu✓
POUR NO CONCRETE UNTIL ABOVE HAS BEEN SIGNED
UNDERGROUND /SLAB
PLUMBING ( _ % �1 y Of CUgeIT<Ido / /f
ELECTRICAL — ISSUANCE DATE
BLDG. ELECT. I PLG. MECH,
MECHANICAL Dq
DO NOT POUR FLOOR UNTIL ABOVE HAS BEEN SIGNED 6—� BUILDING PERMIT
INFORMATION
WOOD FLOOR VALUATION siFT.
PLUMBINGQvoro
-
p
MECHANICAL O •�%- PERMIT TO
ELECTRICAL SSWL
FRAMING -J�7 444 TYPE CONSTR.
INSULATION to I- 8
OCC,GROUP RES.UNITS
PLACE NO SUBFLOOR UNTIL ABOVE HAS BEEN SIGNED -
• 50.FT,FLUOR AREA TOTAL ACREAGE
ROOF 3330/
DIAPHRAGM
BUILDING USE
RES IND CON PS 011-
APPLY NO ROOFING UNTIL'ABOVE HAS BEEN SIGNED - El El ❑ 0
ASSESSORS PARCEL NO,
ROUGH
PLUMBING
TRACT NO. PANCEL NO
GAS TEST
MECHANICAL FILE NO.
-
ACC DATE ACC.
ELECTRICAL FINALS DATE INSP.
FRAMING SAN # ZONING ENG.SITE NO.
INSULATION 1- _ PLUMBING
GAS
FIRE SPR INK ENERGY L]<
MECHANICAL v [D NE] r ❑ No
COVER NO WORK UNTIL ABOVE HAS BEEN SIGNED HEATING
FLOOD ZONE A.L.U.C.
LATH-INTERIOR 11_ ELECTRICAL
LATH-EXTERIOR FIRE DEPT. F] N� ❑ N❑
SHEETROCK C ccpf }L '• GRADE FEE SUMMARY
SHEAR INTERIOR BUILDING BUILDING
SHEAR EXTERIOR Z TEMPORARY APPROVALS l
FIREWALLS ELECTRIC 0_ _-5 PLAN CHECK
GAS
FLEE
-a�- .,�
NO TAPE OR PLASTER UNTIL ABOVE HAS BEEN SIGNED OCCUPANCY SEISMIC FEE
OCCUPANCYOF BUILDING IS NOT PERMITTED UNTIL BUILDING FINAL IS SIGNED BY BUILDING INSPECTOR, MICROFILM N- E
ARRANGE FOR INSPECTION BY PHONING 252-4505, ELECTRIC
11 ONE WORKING DAY BEFORE REQUIRED INSPECTION.
PLUMBING
0 PLEASE GIVE JOB ADDRESS WHEN PHONING.
Z MECHANICAL ' 2
- SEE PERMIT FOR EXPIRATION DATE -
IMPORTANT! CONST.TAX
PLEASE READ REVERSE SIDE BEFORE TOTAL
CALLING FOR FINAL INSPECTION. -
OFFICE COPY
�r