18573 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
BUILDING PROJECT IDENTIFICATION PERMIT NUMBER
BU LDINc ' APPLICATION & PERMIT r,
ADDRESS 0 3/q /N J I/I S 7.1� k�"' 18573
'L/�- �f BUILDING - ELECTRICAL-PLUMBING-MECHANICAL
OWNEER'a - _ PLAN CHECK VALIDATION
NAM
�27d OTY- ELECTRIC PERMIT FEE
PRONE
CONTRACTOR S
rvAMe - OUTLETS-SWITCHES-RECEP 10.00/1.00 . p('
L C CaV5?euc.No_ LIGHTING FIXTURES 10.00/1.00
ADDRESS
Ald PPLIANCES-RESIDENTIAL 4.00
ADDRESS /r /.�I ''�// ./ ``'''')) ��((
if PRONE�(Q _�T PANELS 10.00 DATE OF APPLICATION
AOR HITecT PANELS (OVER 200 AMP) 20.00 PLAN CHECK FEE P.C.NO.
ENGINEER
Llc.NO. SIGNS TRANS. 3.00
ADDRESS exG SPECIAL CIRCUIT 5.00 _ PERMIT VALIDATION
J-
nP EMP.METER OR POLE INS. 20.00
APPUCANrs MOTORS SEE FEE SCH. "
ADDRESS
SERVICE CHANGE 20.00 ` I /I �kv-�/
w o o LICENSED CON'T'RACTORS DECLARATION v ((`��" l�
u u 1 hereby affirm that I am licensed under provisions of Chapter 9 ISSUANCE DATE
N z°' (commencingwith Section 9000)of Division 3 of the Business and
res
6 V, BLDG. ELECT. PLG. MECH.
r N z Professions Code,and my license is in full force and effect ❑
Z,i m License Class Lic.Number
Date Contractor
-i M
�1��
a u s - of wISmWN BUILDING PERMIT
cc W a OWNER-BUILDER DECLARATION -
c a u INFORMATION
wg H 1 hereby affirm that I am exempt from the Contractor's License MISC.- REFER TO ORD VALUATION
1- 0 J haw l'or the following reason.(Sec.703 L5,Business and Professions pERMIT ISSUANCE 10.00 i�6 $(FT.
� w > I Code:Any city or county which requiresa permit loconstruct, ler, - 6
Ii ¢ < 0 improve;demolish,or repair any structure,prior to its issuunce,ol ELEC.CONTR. LIC.NO. ELEC.
9 ¢ requires the applicant for Such permit to file a signed statement that - TOTAL 3- IOD PERMIT TO
e w he Is licensed pursuant to the provisions of the Contractor's License
H r Law(Chapter 9(commencing with Section 7000)of Division 3 of the
f i c Business and Professions Code)or that he is exempt therefrom and QTY. PLUMBING PERMIT FEE SAV
acro te hbasis for the alleged exemption.Any violation of Section 7031.5 .STORIES TYPE CONSTR.
a;m by any applicant for a permit subjects tiro applicant toacivil penalty ALTER-DRAIN -WATEfl (EA.) 5.00
of not more(Iran five hundred dollars(5500).):
❑ 1,as owner of the property,or my employees with wages as BACK FLOW PROTECT. DEVICE 4.00
their sole compensation,will do the work,and the structure is not OCC.GROUP RES.UNITS
intended or offered for sale(Sec. 7044, Business and Professions DRAINS-FLOOR,ROOF,AR EA,COND. 5,00
Code:The Contractor's License Law does not apply to an owner of
properly who builds or improves thereon,and who does such work FIXTURES-PER TRAP 5,00 y 5Q.FT,FLOOR AREA TOTAL ACREAGE
himsel f or throughhis ow neared fors providedthatsuch I buildio-
menlsum not intended oraffercd for sale, tatspelthe mproe- GAS-EA.SVSTEM-l1NC.40UTLETS 6,00
or in.provenleit Is sold within one year of completion, . . .00 the owner GAS-EASYSTEM-OVER 4 (EA) 2
builder will have the burden of proving that he did not the
or mi. BUILDING USE
prove for purpose of sale.). INDUSTRIAL WASTE INTER. 30.00 RES . IND CON PB Omar
❑ 1,as owner of the property,am exclusively contracting with ❑ ❑ ❑ ❑ ❑
licensed contractors to consroo 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
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
the Contractor's License Law. SEWER-SANITARY-STORM EA.200ft/10.00 TRACT NO. PARCEL NO.
❑ l um exempt under Sec. ;B.&P.C.for this WATER HEATER W/VENT 6.00
reason
Owner Date WATER SYSTEM 5.00 U 0 ACC.DATE ACG.FILE NO.
WORKERS'COMPENSATION DECLARATION WATER TREATING EQUIP. 5.00
1 horeby'affirm that I have a certificate of consent to ml4insdre,
or a certificate of Workers'Comp rnsulion Insurance,or II certlticd ZONING ENG,SITE NO.
copy thereof(Sec.3800,Lah.0.).
Policy No. Company
0 ❑ Certified copy is hereby furnished FIRE SPRINK ENERGY T-24
Z 2 ❑ Certified copy is fled with the city inspection division. MISC.- REFER TO ORO. ❑ ❑ ❑ ❑
F O Applicant V N V N
CC - CI:RTI FICATF,OF 1:X FM PfI ON I'ROM WO R K E RS' PERMIT ISSUANCE 10.00Z FLOODZONE A.L.U.C.
W > COMPENSATION INSURANCE PLG.CONTR. - LSC.NO. PLG. 9 ''��II �x
CL 0 ("I his section need not be completed if Ole permit is for one TOTALS O. w Y❑ N❑ Y❑ N❑
Z hundred dollars IS 100)or less
V O I certify that In the performance of the work for which this per, QTY. MECHANICAL PERMIT FEE FEE SUMMARY
LL U mit is issued, I shall not employ any person in any manner so as to
bccnm ubj mWorker' Imensa <R Calllo in.
D:non"I A locant BUILDING 19
} y NOTICE. TO APPLICANT': IL' c L, kit thus C tificatc of nix ALTER OR ADD TO MECH. 5.00 d
F Z enmtion,you should become s jen to Tho Workers'Compena:nimn APPLIANCE 5.00 PLAN CHECK
provisions of the Labor Code, you must forthwith comply with FEE
U such provisions or this permit shall be deemed revoked, AIR HANDLING UNIT(TO 10=C.F.M.) 4.00
CONSTRUCfION LENDING AGENCY AIR HANDLING UNIT(OVER 10=C.FM.) 6.00 SEISMIC FEE tIST
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. MICROFILM
3097,Civ.C.). HEATING UNIT(TO 100,000 B.T.U.) 8.00
Lender's Name VER 100,000 B.T.U.)9.50
Lender's Address HEATING UNIT(OELECTRIC 13, GQ
llcCitify that I have read this application and state Lear the above VENTILATION FAN (SINGLE) 4.00
intIn'ountu n is correct. [,agree to comply with all city tied county PLUMBING �- 00
ordinances and state laws rehiing to building construction, and BOILER-COMP(3 H.P.Or 100,000B.T.UJ 6,00
Imreby authorize representatives This city es enter upon the BOILER-COMP IOVe1100,000 BTU)SEE FEE SCH. MECHANICAL
ubo
by
property for inspection of this
purposes.
(We) agree to save, indenmify and keep harmless the City of MISC.- REFER TO ORD.
Cupertino against liabilities,judgments, costs and expenses whichCONST.TAX -1
may in any way accrue against said City in consequence of the PERMIT ISSUANCE 10.00
nmf a(lhis pe l' MECH.CONT. UC.NO. MECH. (y /
TOTAL TOTAL
Signa Applica t/Canractor Date
OFFICE COPY
POST THIS CARD NEAR FRONT OF BUILDING PERMIT NUMBER /
CITY OF CUPERTINO 18573
INSPECTION DIVISION
JOB INSPECTION RECORD
1 +! PERMIT EXPIRATION
JOB __3 —�i�(Sb UCS 6 �L UNIT# _LOT# PERMIT EXPIRES IFWORK
OWNER CONTRACTOR Gl7 IS NOT STARTED WITHIN
INSPECTION DATE INSPECTOR AN
NSPECTION RECORD DAYS OF PERMIT
- CE.OR 180 DAYS FROM
FOUNDATION
:NOTE: LAST CALLED INSPECTION.
UFER ALL GRADING AND DRAINAGE SHALL BE INSTALLED
PR EGUNITE TO COMPLY WITH THE APPROVED PLANS AND CITY OF PERMIT VALIDATION
CUPERTINO STANDARDS.
GARAGE.SLABS MID
POUR NO CONCRETE UNTIL ABOVE HAS BEEN SIGNED ^a
UNDERGROUND /SLAB 9O
PLUMBING Y
ELECTRICAL - M ISSUANCE DATE 3
MECHANICAL BLDG l[-ECT I FLO I MECH
DO NOT POUR FLOOR UNTIL ABOVE HAS BEEN SIGNED BUILDING PERMIT
INFORMATION
WOOD FLOOR VALUATI(1N Y=„ . $SFT.
PLUMBING - 3
MECHANICAL '
PERMIT T
ELECTRICAL
12,=
FRAMINGV
INSULATION SICHIPS ,TYPE' TNSTR.
UCC GROUP RES UNITS
PLACE NO SUBFLOOR UNTIL ABOVE HAS BEEN SIGNED -
ROOF NOTE:NO FINAL INSP.SHALL BE MADE BEFORE sn Fr FLooR ARrA TOTAL ACREAr,c
t - DIAPHRAGM THE CONSTRUCTION TAX IS PAID .
BUILDING USE
ROOF SHEATHING RCS IND CON PB Go—
APPLY NO ROOFING UNTIL ABOVE HAS BEEN SIGNED FINALS DATE INSP. ❑ El ❑ ❑ ❑
ASSESS(IHS PARCEL NO
ROUGH SAN,#
PLUMBING / - ELECT.ENERGY
TRACT NO. PARCEL NO
TUBS&SHOWER - PLUMBING ENERGY
MECHANICAL MECH.ENERGY -
ACC DATE ACC.FILE NO
ELECTRICAL BUILDING ENERGY
FRAMING ELECT.FINAL TEST
ZONING ENG,SITE N0.
INSULATION PLUMBING
GAS TEST GAS
FIRE SPgINK ENERGY T]J
MECHANICAL
COVER NO WORK UNTIL ABOVE HAS BEEN SIGNED HEATING r [D "❑ ` ❑ NEI
FLOOD ZONE AC U C.
EXTERIOR SHEAR ELECTRICAL RELEASE
INTERIOR SHEAR FIRE DEPT. Y❑ N ° ❑ "❑
SHEETROCK - GRADE FEE SUMMARY
EXTERIOR LATH BUILDING
,INTERIOR LATH TEMPORARY PPROVALS BUILDING !-3 0
SCRATCH COAT - ELECTRIC PLAN CHECK
GAS FEE
NO TAPE OR PLASTER UNTIL ABOVE HAS BEEN SIGNED OCCUPANCY I I SEISMIC FEE
OCCUPANCY OF BUILDING IS NOT PERMITTED UNTIL BUILDING FINA LISSIGNED BY BUILDING INSPECTOR. MICROFILM
ARRANGE FOR FOR INSPECTION BY PHONING 252-4505, `Y ELECTRIC
ONE WORKING DAY BEFORE REQUIRED INSPECTION. '
O PLEASE GIVE JOB ADDRESS WHEN PHONING. PLUMBINGa(j_ Zip
Z — SEE PERMIT FOR EXPIRATION DATE — MECHANICAL '
IMPORTANT! CONST. TAX
PLEASE READ REVERSE SIDE BEFORE /
CALLING FOR FINAL INSPECTION. TOTAL l0 „
OFFICE COPY