11231 APPLICANT TO FILL IN'INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
BUILDING PROJECT IDENTIFICATION PERMIT NUMBER
BUILDING I APPLICATION & PERMIT
ADDRESSt 1 "tLLr.JR BUILDING-ELECTRICAL-PLUMBING-MECHANICAL11231
OWNER'SL- PLAN CHECK VALIDATION
. NAME 6TY: �. .ELECTRIC PERMIT FEE
PHONE
DNrRAcroRs OUTLETS-SWITCHES-RECEP 10.00/1.00
NAME �/yyy��
LICNC TJ.7 LIGHTING FIXTURES 10.00/1.00
CONTRACTORS APPLIANCES•RESIDENTIAL 4.00
ADD
as
11,,
` , MI PHONE PANELS 10.00 DATE Of APPLICATION
ARL ITECT - PANELS (OVER 200 AMP) - 20.00 PLAN CHECK FEE P.C.N0.
OR
ENGINEER N'
LIC.No, 6 SIGNS TRANS. 3.00 '
ADDRESSE SPECIALCIRCUIT 5.00 PERMIT VALIDATION
zlPEMP.METER OR POLE INS. 20.00
ADDRESS ADRESS MOTORS SEE FEE SCH.
_' • �
• SERVICE CHANGE 20.00
w O o LICENSED CONTRACTORS DECLARATION
a sw+u I hereby affirm that I am licensed under provisions of Chapter 9 ISSUANCE DATE
y Q y commencing with Section 7000)of Division 3 of the Business and BLDG. ELECT. PLG. MECH.
r o
License
Co Pamy license is in full f ® ❑ ❑
o i vo LicensemsC sec,Number
r w Date Canlmemr sISOh
a sc f BUILDING PERMIT
W g
OWNER-BUILDER DECLARATION . I %RMATION
o MISC.- REFER TO ORD
is ;w H I hereby affirm that 1 am exempt from the Contractor's License
w 0A Lew for the following reason.(Sec.7071.5,Businessand Professions
PERMIT ISSUANCE 10.00 _ "Lu I S/F7.
fw0 Code:Any city orcounty which requires a permit to construct,alter,
toe <0 improve,demolish,or repair any structure,prior to its issuance,also ELEC.CONTE. LIC.NO. ELEC. Z P
i -
0,
requires the applicant for such permit to file a signed statement that TOTAL P RTO
w$w he is licensed pursuant to the provisions of the Contractor's License '/ r"1
Hi > Law(Chapter 9(commencing with Section 7000)of Division 3 of On, �J�/Jy7/O-V '{/Y�.-M
f 4 o Business and Professions Code)or that he is exempt therefrom and OTY. PLUMBING PERMIT FEE
M 1- the basis for the alleged exemption.Any violation of Section 7031.5 STORIES TYPE CONSTR.
,i3 - by any applicant for a pemsit subjects theapplicant toa civil penalty ALTER-DRAIN -WATER IEA.) 5.00
of not more than five hundred dollars(4500),):
❑ 'I,as owner of the property,or my employees with wages as BACK F LOW PROTECT. DEVICE 4.00 Oce.GROUP RES.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:The Contractor's License Law does not apply to an owner of
property who builds or improves thereon,and who docs such work F IXTUR ES-PER TRAP 5.00 SO,FT.FLOOR AREA TOTAL ACREAGE
himself or through his own employees,provided that such improve.
mems are not intended or offered for sale,If,however,the building GAS-EA.SYSTEM-I1NC.4OUTLETS 6.00
or improvement is sold within one year of completion, the owner- GAS EASYSTEM-OVER 4 IEA) 200 BUILDING USE
builder will have the burden of proving that he did not build or im- - . . . RES IND ' CON PB Omer
prove lot purpose ol'sale.). INDUSTRIAL WASTE INTER. 30.00 ❑ ❑ ❑ ❑ ❑
❑ 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 PARCEL NO.
and Professions Code:The Contractor's License Law does not apply O/
'�► - to an owner of property who builds or improves thereon,and who LAWN SPRINKLERS-OVER 5(EA.) 1.00 3/ r 9-�
contracts for such projects with a contrucloll s)licensed pursuant to
the Contractor's License Law. SEWER-SANITARY-STORM EA.200ft/10.00 TRACT NO. PARCEL NO.
❑ I am exempt under Sec. ,BAP.C.lot t his WATER HEATER W/VENT 6.00
reason
Owner Date - WATER SYSTEM - 5.00
ACC.DATE ACC.FILE N0.
WO RKERS'COMPENSA'1'ION DECLARATION WATER TREATING EQUIP. 5.00
I hereby affirm that I have a cerlificulu of consent fo,dpinsure, ZONING ENG.SITE NO.
or a certificate of Workers'Compensation Insurance,or a certified
copy thereof(Sec.3800,Lab.CJ.
Policy No: Company_a�
❑ Certified copy i ICreby f he I � FIRE SPRINK ENERGY T-24
Certified c i fie 1 e ins rfrJivision.
Z pp anl� r.�d+' _ _ MISC.- REFER TO ORD. Y ❑ IN ' Y ❑ N❑
C 1:RTI FICAI'E OF 17X EM PTI 1 17 ROM WORK I:RS' PERMIT ISSUANCE 10.00 FLOODZONE A.L.U.C.
LU COMPENSATION INSURANCE. PLG.CONTE. LIC.NO. TPLG,
0- O (This section need not be completed if the permit is for one OTAL Y❑ 'N❑ Y❑ N❑
Z) Z hundred dollars 1$100)or less.)
L) O 1 certify that in the performance of the work lot which this per- CITY. MECHANICAL PERMIT FEE FEE SUMMARY
U. F mit is issued,I shall not employ any person in any manner so as to
U, become subject to the Workers'Compensation Laws of California.
w Date Applicant BUILDING
a ALTER OR ADD TO MECH. 5.00 Y`S
} rn NOTICE TO APPLICANT: IL after making Workers'
Cert 1ompe sa I'>x-
Z emotion,you should become subject m the Workers'Compensation APPLIANCE 5.00 PLAN CHECK
provisions the Labor Code, you must forthwith comply with FEE
V such provisioio ns or this permit shall be deemed revoked. AIR HANDLING UNIT TO 10/100 C.F.M.) 4.00 •
CONSTRUCTION LENDING AGENCY AIR HANDLING UNIT(OVER 10=011RM.) 6.00 SEISMIC FEE 7S
1 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 Mued(Sec. HEATING UNIT(TO 100,000 B.T.U.) 8.00 MICROFILM
3097,CP.C.).
Lender's Name
Lender's Address HEATI NG UN IT(OVER 100,000 B.T.U.)9.50 ELECTRIC
1 certify that 1 have read this application and slate that the above VENTILATION FAN ISINGLEI 4.00
information is correct.I agree to comply with all city and county PLUMBING
ordinances and state laws relating to building construction, and BOILER-COW(3 H.P.or 100,000 B.T.U.) 6.00
hereby authorize representatives of this city to enter upon the
above-mentioned properly for inspection purposes. BOILER•COMP(Over 100,000 BTU)BEE FEE SCH. MECHANICAL
(We) agree to save, indemnify and keep harmless the City of MISC.- REFER TO ORD.
Cupertino against BabiliH judgments, costs and expenses which CONST.TAX
may in y wa cr gainst said City 1. enc of the PERMIT ISSUANCE 10.00
gran Ihi i MECH.CONT. LIC.NO. MECH.
Ute TOTAL TOTAL
o I Commcmr 17.? a
OFFICE COPY
POST THIS CARD NEAR FRONT OF BUILDING
PERMIT NUMBER
CITY, OF CUPERTINO 11231
INSPECTION DIVISION
JOB INSPECTION RECORD
PERMIT EXPIRATION
JOB ADDRESS 1yS .-/I DIo Hi k, UNIT# LOT# PERMIT EXPIRES IF WORK
YOWNER CVQf ♦ CONTRACTOR K.D. S , & IS NOT STARTED WITHIN
INSPECTION DATE INSPECTOR INSPECTION RECORD
180 DAYS OF PERMIT ISSU-
ANCE180 DAYS FROM
FOUNDATION `t-Z i4 � wd Qe LAST
CALAL LED INSPECTION.
LIFER L4-SC(� ILkf�RID�(Lw�LI
PREGUNITE C� -� �,y"C �+ DE.I( Lv&l PERMIT VALIDATION
o-k-f'4 pig• [� c L _,,,
POUR'NO CONCRETE UNTIL ABOVE HAS BEEN SIGNED
UNDERGROUND, SLAB 2�ec. d ll
PLUMBING j rz -
ELECTRICAL - - TOP I PARTIAL Illy,rp (p [, - ISSUANCE DATE
MECHANICAL lZ— ((��` �,JV "I �. BLDc. ELE T.- PLc. MECH.
11
00 NOT POUR FLOOR UNTIL ABOVE HAS BEEN SIGNED BUILDING PERMIT
INFORMATIOW
' - WOOD FLOOR' VALUATION _ SIFT,
PLUMBING' - _ - - '
MECHANICAL � �'-��
PERMIT TO
I ELECTRICAL6N IviN
FRAMING
- STORIES TYPE CONSTR.
INSULATION - -
^ti.l
I
OCC.GROUP • RES.UNITS
IP.L^ACE,NO SUBFLOOR UNTIL ABOVE HAS BEEN SIGNED
ROOF 50,FT,F LOOP AR EA TOTAL ACREAGE
DIAPHRAGM I 'I euaDlON USE
RES IND CON PB OIM1er
' WAPP.L•Y NO ROOFING UNTIL ABOVE HAS BEEN SIGNED 1:1 0 El El 0
ASSESSORS PARCEL NO.
r.i ROUGH ' :. /•J/.� c. /.
PLUMBING
GAS TEST - TRACT NO. PARCEL No.
MECHANICAL - .1
I y- ACC,GATE ACC.FILE NO.
- ELECTRICAL FINALS DATE INSP. -
FRAMING - - SAN * -
ZONING ENG.SITE NO.
'INSULATION - PLUMBING
GAS
FIRE SPRINK ENERGY 24
MECHANICAL IN
COVER NO WORK UNTIL ABOVE HAS BEEN SIGNED HEATING 9 "� "�
LATH-INTERIOR ELECTRICAL 4 -�A �¢ FLOOD ZONE A.L.u,D
LATH-EXTERIOR FIREDEP O+ ISV L YQ N�r � N❑
SHEETROCK _ GRADE FEE SUMMARY
SHEAR•INTERIOR BUILDING
SHEAR EXTERIOR
TEMPORARY APPROVALS BUILDING
FIREWALLS � JELECTRIC PLAN CHECK -
- GAS FEE
J'
L10 TAPEGR PLASTER UNTIL ABOVE HAS.BEEN SIGNED OCCUPANCY 11 E SEISMIC FEE p %
OCCUPANCY OF'BUILDING IS NOT PERMITTED UNTIL BUILDING FINAL IS SIGNED BY BUI DINGI CTOR. MICROFILM
Uj ARRANGE FOR INSPECTION BY PHONING 252.4505, ELECTRIC
1 ONE WORKING DAY BEFORE REQUIRED INSPECTION. PLUMBING
z PLEASE GIVE JOB ADDRESS WHEN PHONING.
z — SEE PERMIT FOR EXPIRATION DATE — MECHANICAL
IMPORTANT! CONST.TAX w
,1 PLEASE REVERSE SIDE RE TOTAL
CALLING FOR FINAL IN INSPECTION.
OFFICE COPY