16952 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES,- USE BALL POINT PEN ONLY
BSIILDING PROJECT IDENTIFICATION PERMIT NUMBER
BUILDING APPLICATION & PERMIT " ^/
ADDRESS 10231 Mira Vista Ave BUILDING-ELECTRICAL-PLUMBING-MECHANICAL . , 16952
OWNER'S PLAN CHECK VALIDATION
NAME CITY. ELECTRIC PERMIT FEE
Loretta Dockir4
• CONTRACTOR'S
NAME 23 OUTLETS-SWITCHES-RECEP 10.00/1.00 �3 � E� (•�
Fairfield Constrkt%tion LIGHTING FIXTURES 0.00/1.00' ICL J
CONTRACTOR'S uernevi Q PPLIANCES-RESIDENTIAL 4.00 (rr,10
ADDRESS 1�' 11
P:0 • 'BOR •2040 PHON1707 $69- ANELS 10.00 DATE OF APPLICATION
ARCHITECT - PLAN CHECK FEE P.C. O.
OR PANELS (OVER 200 AMP) - 20.00 -
ENGINEER N/A .
LIC.NO. ISIGNS TRANS. 3.00
ARCH.OR ENG. PERMIT VALIDATION
ADDRESS - SPECIAL CIRCUIT 5.00
N/A - ZIP TEMP.METER OR POLE INS. 20.00
APPLICANT'S MOTORS SEE FEE SCH. l Yl ^
ADDRESS N/A ..-; W/
SERVICE CHANGE - 0.00
r
w
00 LICENSED CONTRACTORS DECLARATION rya
rt U U I hereby afNnmthal I am licensed under provisions of Chapter 9 ISSUANCE GATE
m z a (commencing with Section 7000)of Division 3 of the Business and
¢ - LUG. 'ELECT. -PLG. M .
F y i Professions Cade, d nay license is in full for'•' 'e - y„ '
o0 m o License las Lia Numbs/[ }t,?/sl' IWXII•
H ,n H j Date C011tr'JCIOY -
a BUILDING PERMIT
¢ ¢ w OWNIiR-RUILDf:R UECLARA'f10N
w3 LL N I hereby affirm that I am exempt from the Contractor's License MISC.- REFER TO ORD INFORMATION
u0¢ Law for the following reason.lScc.703LS,tlloinessand Professions PERMIT ISSUANCE 10.00 ��e)� VALUATION SOFT.
w N Code:Any city or county which requires permit to construct,alter,
IL 2 Q O improve,demolish,or repair any structure,prior to its issuance,also ELEC.CONTR. 1 LIC.NO. ELEC. I]
u statement that TOTAL 3z• PERMIT TO
a w 0 requires the applicant foNsch permit to file a signed s
se he is licensed pursuant t8 the provisions of the Contractor's License
F z Q Law.(Chapter 9(commencing with Section 7000)of Division 3 ofthe 1'11(
s 14 O Business and Professions Code)or that he is exempt therefrom and OTY. PLUMBING PERMIT FEE M 1 /1 WY1�
Ie 1-.,$ the basisfor the alleged exemption.Any violation of5ection 7031.5 STORIES TYPE CONSTR.
wain by any applicant for a Permit subjects the applicant to a civil penalty ALTER-DRAIN&VENT-WATER (EA.) 5.00 '
of not more than five hundred dollars(8500).1: -
•� ❑ I,as owner of the property,or my employees with wages as BACK FLOW PROTECT. DEVICE 4.00
P their sole compensation,will do the work,and the structure is not OCC.GROUP RES.UNITS
x intended or offered for sale (Sec. 7044, Business and Professions
DRAINS-FLOOR,ROOF,AREA,COND. 5.00
Code:The Contractor's License Law does andapplywho o on owner work -
himsertywthroho ug his oor w emplyeereoganJwhat such so,],hwoe- FIXTURES-PER.TRAP 5.00 X17 rf SO.FT.FLOORAREA TOTALACREAGE
himself re not through his own employees.provided that such improve-
omunts rimprovementissoldor withinred year of
the thebuilding GAS-EA.SYSTEM-1INC.4OUTLETS 6.00 (OW
or improvement is e b within one year of completion,the owner- GAS-.EA.SYSTEM.OVER 4 (EA.) 2.00 BUILDING USE
builder will have the harden of proving that Im did not build or im- RES IND CON PB Other
prove 1,aso neeose of sale.)., - INDUSTRIAL WASTE INTER. 30.00 ❑ ❑ ❑ ❑ ❑ �
- ❑ I,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 ASSESSORSPARCELNO.
and Professions Code:The Contractors License Law docs not apply
to an owner of properly who builds or improves thereon,and who LAWN SPA IN KLERS-OVER 5(EA.) 1.00
contracts for'suck projects with s contractor(s)licensed pursuant to
the Contractor's License Law. SEWER-SANITARY-STORM EA.200ft110.00 TRACT NO. PARCEL NO.
❑ I am exempt under Sec..,R&P.C.for this WATER HEATER 111 6.00 2,410 -'
reason
Owner _ Date ----- WATER SYSTEM - - 5.00 ACC.DATE ACC.FILE NO,
WORKERS'COMPENSAJION DECLARATION WATER TREATING EQUIP, 5.00
1 hereby affirm that I have a renificate of consent to scirinsure,
or a-certificate of Workers'Compensation Insurance,or a certified ZONING ENG.SITE NO.
copy IhercofdStJ
QPolicy Conpians_
StatFt Fund -
Certified copy is hereby furnished. FIRE SPRINK ENERGY T-24
Z Z pl Certif• _co a filed wp 'ty inspection division.
� O Apptic Jno MISC.- REFER TO ORD, v ❑ IN F-1 v ❑ N❑
0: w CF.RTIFICATEO- :XEMPTION'FROM WORKERS' PERMIT ISSUANCE 10.00 UIf PL000 zONE A.L.U.C. ,
LU > CONPIENSATION INSURANCE PLG.CONTR. LIC.NO. PLG.
CL Z (This section need not be completed if the permit is for one TOTAL �Z.Vy' Y❑ N❑ Y❑ N[_
hundred dollars(8100)nr less.)
U O 1 certify that in the performance of the work for which this per. QTY. MECHANICAL PERMIT FEE FEE SUMMARY
LL U mit is issued,1 shall not employ any person in any manner so as to
became subject to the Workers Compensation Laws of California.
GO Date Applicant ' BUILDING I
} N NOTICE TO APPLICANT: If„after nicking IIIN Certificate of Rx- ALTER OR ADD TO MECH. 5.00
Z emplion,you should become subject to the Workers'Compensation APPLIANCE' 5.00 PLAN CHECK
provisions of the Labor Code, you most forthwith conady'with FEE
C.1 such provisions or this permit shall be deemed revoked. AIR HANDLING UNIT(TO 10=11F.M.) 4.00
CONSTRUCTION.LENDING AGENCY ' AIR HANDLING UNIT(OVER 10400C.EM.) 6.00 SEISMIC FEE
1 hereby affirm that there is a construction lending agency for EXHAUST HOOD(WITH DUCT) 5.004.
the performance of Ilse rk for which this permit is issued(Sec. MICROFILM
3097,Civ.C). jV A- HEATING UNIT(TO 100,000 B.L 8.00 D
1 Lender's Name _ HEATINGUNIT(OVER100,060B.T.U.)950 3z. D
Lender'sAddress ELECTRIC
I certify that I have read thisapplication and state that the above VENTILATION FAN ISINGLE) 4.00
information is correct. I agree to comply with all city and county PLUMBING
1 ordinances and state lawsrelating to building construction, and BOILER-COMP 13 H.P.or 100,000 B.T.U.) 6.00
hereby authorize representatives i
this
of ths city to enter upon the
above-mentioned property for inspection purposes. ver L
BOI LER-COMP (O 100,000 BTU)SEE FEE SCH. MECHANICAL 32 OO
(We) agree to save, indemnify and keep harmless the City of MISC.- REFER TO ORD.
Cupertino against liabilities,judgments,costs and expenseswhich CONST.TAX Q��Q
may in any way accrue agar said City in consequence of the PERMIT ISSUANCE 10.00 _B
ran[in of lhi rmit� MECH.CONT. LIC.NO. MECH.
TOTAL32 06
206 TOTAL -M-3
Signature 01 A /Contractor Date
OFFICE COPY j
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POST THIS CARD NEAR FRONT OF BUILDING
PERMIT NumeeR
CITY OF CUPERTINO 1692
INSPECTION DIVISION
JOB INSPECTION RECORD
I � yr /q� PERMIT EXPIRATIO
JOB,ADDRESS_`02-31 - �—o sl;` - �}-vP UNIT# _LOT# 'fJ PERMITIEXPIRESI IRK '
OWNER a c � CONTRACTOR IS NOT STARTED WITHIN I
INSIIECTION DATE I INSPECTOR 'INSPECTION RECORD 180 DAYS OF PERMIT ISSU-
FOUNDATION q22@T 15UD25 - ANCE OR 180 DAYS FROM
NOTE:.
LIFER � � ALL GRADING AND DRAINAGE SHALL BE INSTALLED LASTCALLED INSPECTION.
PREGUNITE TO COMPLY WITH THE APP V NS AND CIN OF' PERMIT VALIDATION
CUPERTINOSTANDARDS.
GARAGE SLABS •I ( ,f
POUR NO CONCRETE UNTIL ABOVE HAS BEEN SIGNED 1
'l 1982
UNDERGROUND /-SLAB _
PLUMBING
ELECTRICAL ISSUANCE DATE
MECHANICAL `BLLDDG. ELECT PPL..O!. �yM,EECCH
00 NOT POUR FLOOR UNTIL ABOVE HAS BEEN SIGNED BUILDING PERMIT
INFORMATION
WOOD FLOOR VAIL TION SIFT.
PLUMBING v - �Q
MECHANICAL ti + " OVd
ELECTRICAL 1 71.1 PERMIT TO
•, FRAMING V` k ''
INSULATION ETCH I" TYPE CDNSTR
OCC.GROUP HES.UNITS
PLACE NO SUBFLOOR UNTIL ABOVE HAS BEEN SIGNED r
I"' - - ROOF NOTE:NO FINAL INSP.SHALL BE MADE BEFORE' sa.r/T.PLODI+nI :n Ta InL ncRenr,E
r DIAPHRAGM THE CONSTRUCTION TAX IS PAID. 6I
ROOF SHEATHING ! ' RES INIIDwunON usepB .I
111,1 1
APPLY NO ROOFING UNTIL ABOVE HAS BEEN SIGNED FINALS DATE INSP. 0 0 0 0 D ..
ASSESSORSPARCF:LNo
ROUGH SAN,; ,
_ PLUMBING ELECT,ENERGY
TURS'&BHOW PAN PLUMBING ENERGY TRACT NO. PARCEL No
MECHANICAL MECH.ENERGY
ELECTRICAL BUILDING ENERGY ACC DATE ACC FILE NO
FRAMING ELECT.FINAL TEST
20NING ENG.SITE NO.
' INSULATION �� Z PLUMBING - I
GAS TEST GAS
MECHANICAL FIRE SPRINK ENERGY T.jG
COVER NO WORK UNTIL ABOVE HAS BEEN SIGNED IHEATING El "E:l "�
FLOOD ZDNE A.L.UC
' EXTERIOR SHEAR ELECTRICAL RELEASE ...I
Y❑ N❑ VL N❑.
INTERIOR SHEAR - FIRE DEPT. L:
SHEETROCK IGRADE FEE SUMMARY
• EXTERIOR LATH t I BUILDING
INTERIOR LATH -TEMPORARY APPROVALS, BUILDING Q :�
SCRATCH COAT ELECTRIC - - PLAN CHECK
GAS
NO TAPE OR PLASTER UNTILABOVE HAS BEEN SIGNED JOCCUPANCY SEISMIC FEE 36 .
OCCUPANCY OF,BUILDING IS NOT PERMITTED UNTIL BUILDING.FINALISSIGNED BY BUILDING INSPECTOR. MICROFILM 7�1
ARRANGE FOR INSPECTION BY PHONING 252-4505, ELECTRIC :�<-`.�Q
H ONE WORKING DAY BEFORE REQUIRED'INSPECTION. PLUMBING
o PLEASE GIVE JOB ADDRESS WHEN PHONING.
z - SEE PERMIT FOR EXPIRATION DATE - MECHANICAL' 3,�. Q
10
IMPORTANT! CONST.TAx
PLEASE READ REVERSE SIDE BEFORE 7yC
CALLING FOR FINAL INSPECTION. TOTAL / L f
OFFICE COPY
• •.yam, •