12276 APPkICANT TO FILL IN INFORMATION WI THIN RED LINES'- USE,BALL POINT PEN ONLY
BU)LDI NG PROJECT IDENTIFICATION PERMIT NUMBER
BUILOIWl APPLICATION & PERMIT 2276
ADDRESS
oll MILK BUILDING-ELECTRICAL-PLUMBING-MECHANICAL
OWNER'S I! PLAN CHECK VALIDATION
fF NAME OTU. tr ELECTRIC PERMIT FEE j (
! Lool`k llis 3 PHONE -{"-{tl nEW.�p / �,a
NAME cTOR's - UTLETS-SWITCHES-RECEP 10.00/1.00 -1 34-1!2'"
NAME _
aVr1Q:t� (!btla)�IPzIC�►Suc.rvo. 49GP11�0 LIGHTING FIXTURES 10.00/1.00 �j-yt)'
CONTRADTors�r`A /�1� /j ,a APPLIANCES-RESIDENTIAL 4.00 Ov f
ADDRESS �3I`� 20 `\SIV'
Ib9 p30Xal rVt0$65•�'7D1>v Aylii- PANELS 10.00 DATE OF APPLICATION
ORLH1TECT PANELS (OVER 200 AMP) 20,00 PLAN CHECK FEE P.C.NO.
OR
ENGINEER A �.'-!
N x'Mi3 uc.No. SIGNS TRANS. 3.00
ARCH.OR ENG. SPECIAL CIRCUIT 6.00 PERMIT VALIDATION
ADDRESS �,,,,y,� ,,
Sl Il0 lc�M C ZIP QrzUTA EMP. METER OR POLE INS. 20.00 PAID
APPucarvrs -
ADDRESS MOTORS SEE FEE 2CH.
'/JMN
SERVICE CHANGE F~00
w a Lo LICENSED CONTRACTORS DECLARATION `5 l
<u, 1 hereby affirm that I am licensed under provisions of Chapter 9
G w (commencing with Section 7000)of Division 3 of the Business and BLDG. ELE T. I' MECH.
H G i Professions Cod nd my license is in full fore t ❑in Cum ❑ ❑ ❑
o Z D License I ss Lie.Number
Date Contractor
a r f BUILDING PERMIT
a w u OWNER-BUILDER DECLARATION INFORMATION
c MISC.- REFER TO ORD
F
3: w 1 hereby affirm that I am exempt from the Contractor's License VALUATION $/FT.
r `:o. Law for the following reason.(Sec.7031.5,Business and Professions PERMIT ISSUANCE .10.00 </0'
m0 Code:Any city Dreamily which requires a permit to construct,alter,
rt 2 ¢2 improve,demolish,or repair any structure.prior to its issuance,also ELEC.CONTR. LIQ NO. ELEC. o
al >mIF requires the applicant for such permit to file a signed statement that TOTAL PERMIT TO
w he is licensed pursuant to the provisions of the Contractor's License
H 2 r Law.(Chapter 9(commencing with Section 7000)of Division 3 ofthe /Y-1J 11
f 4 o Business and Professions Code)or that Ise is exempt therefrom and DTV. PLUMBING PERMIT FEE
M f the basis for the alleged exemption.Any violation of Section 7031.5 STORIES TYPE CONSTR.
y ; by any applicant for a permit subjects the applicant toacivil penalty 'ALTER-DRAIN&VENT-WATER (EA.) 5.00
of not more than five hundred dollars(5500).1: s
❑ 1,as owner of the property,or my employees with wages as BACK FLOW PROTECT.DEVICE 4.00 OCC.GROUP RES.UNITS
their sole compensation,will do the work.Stil the structure is not
intended or offered for sale(Sec. 7044, Business and Professions DRAINS-FLOOR,ROOF,AREA,COND. 5.00
Code:The Contractor's License Law does not apply to an owner of
property,who builds'or improves thereon,and who does such work S FIXTURES-PER TRAP 5.00 = SQ FT.FLOOR AREA TOTAL ACREAGE
himself or through his own employees,provided that such improve-
mentsI are not intended or offered for sale.If,however,the budding
or improvement is sold within one year of completion,the owner- . -
builder will have the burden of proving that he did not build or am. - GAS-EA.SYSTEM-OVER 4(EA.) 2.00 BUILDING USE
D CON PB Other
IN
prove for purpose of sale.). INDUSTRIAL WASTE INTER. 30.00 RES
IN
❑ 1,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 PARCELNO.
and Professions Code:The Contractor'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 contractor(s)licensed pursuant to SEWER-SANITARY-STORM 0.00 TRACTNO. PARCEL NO.
the Contractor's License Law.
❑ lam exempt under Sec.-,BAP.C.for this WATER HEATER W/VENT 6.
reason
Owner Data WATER SYSTEM ACC.DATE ACC.FILE NO. -
WORKERS'COMPENSATION DECLARATION WATER TREATING EO - 5.0
1 hereby affirm that'l have a certificate ofconsent to sefiNasure, ZONING ENG.SITE NO.
or a certificate of Workers'Compensation Insurance,or a certified -
copy thereof(Sec,3800,Lab.C.).
Policy No. Company'
❑ Certified copy is hereby furnished. FIRESPRINK ENERGY TQ4
Z Z. ❑ Certified copy is filed with the city inspection division. MISC.- REFER TO ORD.
O Applicant - Y N� Y N�
CC -
Lu rn- PERMIT ISSUANCE 10.00_ CERTIFICATE EXEMPTION FROM WORKERS' ZONE A.L.u.c.
W � COMPENSATION INSURANCE:' PLG.CONTR. LIC.NO. PLG.
C'a (This section need not be completed if the permit is for one TOTAL Y N Y[] N❑
Z hundred done"(S 100)or less.)
U O I certify that in the,performance of the work for which this per. CITYMECHANICAL PERMIT FEE FEE SUMMARY
LL F mei is issued,I shall not employ��aaj/(1�rrr5)��,I�(((Forlorn,in any manner so as to
U becom s 'e; u the Workers'^�L rsaf n ws of California.
W Date Applicant ALTER OR ADD TO MECH. 5.00 BUILDING
} N NOTICE TO APPLICANT: If,after making this Certificate of Ex-
L.. Z emptiom,you should become subject to the Workeri Compensation APPLIANCE 5.00 PLAN CHECK
provisions of the Labor Code, you most forthwith comply with FEE
U such provisions or this permit shall be deemed revoked, AIR HANDLING UNIT ITO 10MC.F.M.) 4.00
CONSTRUCTION LENDING AGENCY AIRHANDLING UNIT(OVER 10,01MC.F.M.) 6.00 SEISMIC FEE
I hereby affirm that there is a construction lending agency for EXHAUST HOOD(WITH DUCT) •5.00
the performance of the work for which this permit is issued(Sec, HEATING UNIT(TO 100,000 B.T.U.) '8.00 MICROFILM
3097,Civ.C.).
Lender's NameHEATING UNIT(OVER 100,000 B.T.U.)9.50 ELECTRIC O00
Lender's Address
I certify that l have read this application and state that the above VENTILATION FAN (SINGLE) 4.00 /
00
information is correct.I agree to comply with all city and county PLUMBING 7-&
ordinances and state laws relating to building construction,and BOILER-COMP(3 H.P.or 100,000 B.T.U.) 6.00
hereby authorize representatives of this city to enter upon the BOILER-COMP (Our,100,000 BTU)SEE FEE SCH. MECHANICAL
above-mentioned properly for inspection purposes.
(We) agree to save, indemnify and keep harmless the City of MISC.- REFER TO ORD.
Cupertino against liabilities,judgments, costs and expenses which' CONST.TAX
may in any way Seems against said City in consequence of the PERMIT ISSUANCE 10.00
9 per ilt. MECH.CONT. LIC.NO. MECH.
M.IS-00I TOTAL TOTAL 3 yS
Signalure0 Applicant/Contractor Data -
OFFICECOPY _ __
ADDITIONAL PERMIT FEES
BUILDING PROJECT I DENT[FICATION VALUATION
BURGESS
ADDRESS /
OWNER'S
n „AME L,S+ b FEE SUMMARY
M\CF1AFi
CONTRACTORS BU I LbI NG
.-+�-
NAME
/ A'011 PLAN CHECK
ADDRESS ORs .� tL$ E� '• FEE
ADDRESS I1 ^^
?10'. L'D k'Ntl(LO 2D. FNCNE AL5• • SEISMIC FEE
OTY. ELECTRIC PERMIT FEE
UTLETS-SWITCHES•RECEP ELECTRIC Q
LIGHTING FIXTURES
PLUMBING
APPLIANCES-RESIDENTIAL
I PANELS tno A, — �f,A.� MECHANICAL
SIGNS
SIGNS TRANS. TOTAL.
SPECIAL CIRCUIT
EMP.METER OR POLE INS. ' PERMIT VALIDATION )
MOTORS SEE FEE SCH.
O SERVICE CHANGE
)- ° TOTAL ✓� J' 17
= N ISSUA CE DATE
LU > DTV. PLUMBING PERMIT FEE BLDG. ELECT. PLO. C.
� 2 ALTER-DRAIN&VENT-WATER (EA.) ❑ ❑ ❑ ❑
00 BACK FLOW PROTECT.DEVICE
UL
0 w DRAINS-FLOOR,ROOF,AREA.COND.
} y FIXTURES-PER TRAP
)-.. ? GAS.EA,SYSTEM-I INCA OUTLETS
() GAS-EA.SYSTEM-OVER 4(EA.)
INDUSTRIAL WASTE INTER.
LAWN SPRINKLERS-1 INC 5 V.B.
LAWN SPRINKLERS-OVER 5(EA.)
SEWER-SANITARY-STORM EA.7001[/
WATER HEATER W/VENT
WATER SYSTEM
WATER TREATING EQUIP.
TOTAL
DTV. MECHANICAL PERMIT FEE
ALTER OR ADD TO MECH.
_ APPLIANCE
AIR HANDLING UNIT ITO I0=C.F.M3
AIR HANDLING UNIT(OVER 100C.F.M.)
EXHAUST HOOD(WITH DUCT)
HEATING UNIT(TO 100,000 B.T.U.)
HEATING UNIT(OVER 100,000 B.T.U.)
VENTILATION FAN(SINGLE)
BOILER-COMP(3 HAD,100,000 B.T.U.)
BOI LER-COMPlow• ,Og000 BTU)SEE FE E SCH.
TOTAL
POST THIS CARD NEAR FRONT OF BUILDING
PFRMIT NUMBER
`ot,. V CITY OF CUPERTINO 12276
INSPECTION DIVISION
JOB INSPECTION RECORD
PERMIT EXPIRATION,_
Y �
JOB ADDRESS UNIT# LOT#
PERMIT.EXPIRES IF WORK
OPREGUNITE
- NTRACTOR NOT STARTED WITHIN
S TO DATE INSPECTOR IN CTI RECORDBO DAYS OF PERMIT ISSU•
ON 1^fib &• O / "4 da -� ANCE'OR 180 DAYS FROM
LASTCALLED INSPECTION.
PERMIT VALIDATION
,
POUR NO CONCRETE UNTIL ABOVE HAS BEEN SIGNED
UNDERGROUND SL B
PLUMBING
ELECTRICAL ISSUANCE DATE
MECHANICAL BLDG. ELECT. PLG. MECH.
13
00 NOT POUR FLOOR UNTIL ABOVE HAS BEEN SIGNEDINFORMATION .
BUILDING PERMIT
WOOD FLOOR , VALUATION $/FT.
PLUMBING • - •,
MECHANICAL
ELECTRICAL PERMIT TO
/ Ap/ T/In
FRAMING .. STORIES TYPE CONSTR.
INSULATION ,
OCC.GROUP, RES,UNITS
A PLACE NO SUBFLOOR UNTIL ABOVE HAS BEEN SIGNED sa,Fr.aooR.AREA TOTAL ACREAGE
ROOF,
DIAPHRAGM - BUILDING USE
RES IND CON PB OMP"
APPLY NO ROOFING UNTIL ABOVE HAS BEEN SIGNED 1:1 ❑ 11 1:) ❑ASSESSORS PARCEL No..
ROUGH
PLUMBING 3-'t 0,19 TRACT NO. PARCEL NO.
GAS TEST
MECHANICAL.. '�-�•8? -
ELECTRICAL FINALS DATE INSP. ncc pnrE Acc.ELLE No.
FRAMING 6,,4 - l SAN zoNlNc ENG.SITE NO.
(^ INSULATION Pgov. .eeT $-yO.BZ PLUMBING
GAS
MECHANICAL 360 1
, FIRE SPRINK ENERGY T$A
I COVER NO WORK UNTIL ABOVE HAS BEEN SIGNED" HEATING Y ❑ Y ❑ NE]_ LATH—INTERIOR 1, ELECTRICAL; FL000 ZONE
,ILL.U.C.
LATH—EXTERIOR FIRE DEPT: Y❑ "❑ v ❑ "❑
SHEETROCK La"G4 GRADE FEE SUMMARY
SHEAR INTERIOR BUILDING -
SHEAR EXTERIOR TEMPORARY APPROVA BUILDING
FIREWALLS ELECTRIC PLAN CHECK
GAS . FEE
xN0 TAPE OR PLASTER UNTIL ABOVE HAS BEEkRP100 JOCCUPANCY SEISMIC FEE
OCCUPANCY OF BUILDINGIIS NOT PERMITTED LINTILBUILDI NG FINAL ISSIGNED BY BUILDING INSPECTOR. MICROFILM
ARRANGE FOR INSPECTION BY PHONING 252.4505, ELECTRIC
• o� 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 REVERSELSIDE BEFORE TOTAL
CALLING FOR FINAL INSPECTION. F'
OFFICECOPY _ -