17250 ,T _APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
BUILDING PROJECT IDENTIFICATION - PERMIT NUMBER
BUILDING APPLICATION & PERMIT �j [O
aoDR ss I J
ENG -ELECTRICAL-PLUMBING-MECHANICAL >
OW E PLAN CHECK VALIDATION
NA V. ELECTRIC PERMIT FEE
PNOIN
CONTRACTOTIS UTLETS-SWITCHES-RECEP 10.00/1.00
//-- LIc. LIGHTING FIXTURES 10.00/1.00
CONTRACTORS PPLIANCES-RESIDENTIAL 4.00
PANELS 10.00 DATEOF APPLICATION
PPOCNI Ec PLAN CHECK FEE
PANELS (OVER 200 AMP) 20.00
OP..QNO.
' ENGINEER
LIG NO. SIGNS TRANS. 3.00
ADDRESS ARCH,08 ENG, SPECIALCIRCUIT 5.06 PERMIT VALIDATION
ZIP TEMP.METER OR POLE INS. 20.00
ADDRESSTS MOTORS SEE FEE SCH. L A1l41bRLrAf;i
SERVICE CHANGE ' 20.00
0¢ i
'02 LICEiNSED CONTRACTORS DECLARATION
Q 2 w I hereby affirm that I am licensed under provisions of Chapter 9 - - ISSUANCE DATE
r (commencing with Se tion 7000)of Division 3 of a Business an
w< e. BLDG. ELECT. PLG. MECH.
H 0 i Prol'essioraA y license is in full f, of f;'I,
z O License C Lic.Nmnbe I�
4 wt 0w Uatc 7.n L[ Contractor -
a m s ,7 / 1 u / BUILDING PERMIT
¢ 0 6 OWNER-BUILDER DECLARATION
X
; y I hereby Infirm that I am exempt from the Contractor's License
MISC.- Oily Of OORD INFORMATION
F LL 0 j Law I'or the following reason,(Soc.7031.5,Business unA Professiens PERMIT ISSUANCE 10.00 VALUATION $/FT.
Code:Anycilyorcounly which requires a permit to cunstneL alter, -
¢ ¢ Q Q improve,demolish,or repair any structure,prior to its issuance,also ELEC.CONTR. LIC.NO. ELEC.
DLL requires the applicant for such permit to file a signed statement that TOTAL
a w m he is licensed pursuant to the provisions of the Contractors License PERMIT TO
F i Q Law.(Chapter 9(rommencingwith Section 7000)of Division 3 ofthe �l�lis
T 0 Nosiness and Professions Code)or that he is exempt therefrom and OTY. PLUMBING PERMIT FEE � 111��
¢ H$ the basis(or the alleged exemption.Any violation ofSection 7031.5 STORIES TYPE CONSTR.
T by any applicant for a permit subjects the applicant to a civil penalty ALTER-DRAIN -WATER IEA.) 5.00
of net more than five hundred dollars 15500).):
❑ I,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
intended or offered for Sale (See. 7044, Business and Professions DRAINS-FLOOR,ROOF,AREA,COND. 5.00
Code:The Contractor's License Law does not apply to an owner of
properly who builds or improves thereon,and who docs such work FIXTURES-PER TRAP 5.00 SO.FT.FLOOR AREA TOTAL ACREAGE
himself or through his own employees,provided that such improve-
m
entss are not intended or offered fur sale.If,however,the building GAS-EA.SYSTEM-1 INC.4 OUTLETS 6.00
or improvement is sold within one year of completion,the owner- GAS-EASYSTEM-OVER 4 IEA.) 2.00
builder will have the burden of proving that he did not build or int .. BUILDING USE
prove for purpose of sale.). INDUSTRIAL WASTE INTER. 30.00 RES IND ' CON -PB Other ,
❑ 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 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 forsuch projects with acontmctor(s)licensed pursuant to SEWER-SANITARY-STORM EA.200ft/10.00
the Contractor's License Law. TRACT N0, PARCEL NO.
❑ lam exempt under Sec.-,B&P.C.for this WATER HEATER W/VENT 6.00
reason
Owner - Date WATER SYSTEM 5.00 ACC.DATE ACG FILE NO.
WORK ERS'COMPENSATION DECLARATION WATER TREATING EQUIP. 5.00
1 hereby affirm that I have a certificate ofcunsent to self-insure. ZONING
ar a cer' icate of Worker'Compen tio/n�Insur�/nce,ore tied ENG.SITE NO.
copy l?e�ab.C,. ( '
Polley pony
O ❑ etlil ie spy is hereby furnished.
Z Z C1 Cerlif d 'op f wi1, to -ity ' e'ion division.
- FIRE SPRINK ENERGY T-Z4
rap '
O APPlicant o MISC,- REFER TO ORD. ❑ N❑ : YQ N❑
W '454ICATF OF EXEMPTION FROM WORKERS' PERMIT ISSUANCE 10,00
FLOOD ZONE A.L:U.C.
W > COMPENSATION INSURANCE. PLG.CONTR, LIC.NO. .PLG,
CL Z (This section need,not be completed if the permit is for one IOTA V❑ N❑ v ❑ N❑
hundred dollars IS 100)or less.)
U O 1 certify that in the performance of the work for which this per- OTY. MECHANICAL PERMIT FEE FEE SUMMARY
LL F- mit is issued, I shall not employ any person in any manner so as to
O W become subject to the Workers'Compensation Laws of California.
Date Applicant BUILDING
>_ N NOTICES TO APPLICANT: If,after making this Cerificate of Ex- ALTER OR ADD TO MECH. 5.00
� Z emption,you should become subject to the Workeri Compensation APPLIANCE 5.00 PLAN CHECK
pro /10
visions of the Labor Code, you must forthwith comply with FEE
U such provisions or this permit shall he deemed revoked. AIR HANDLING UNIT ITO 160C.F.M.) 4.00
• CONSTRUCTION LENDING AGENCY AIR HANDLING UNIT(OVER 10=C.F.M.) 6.00 - ' SEISMIC FEE
I hereby affirm that there is a construction lending agency for EXHAUST HOOD(WITH DUCT) 5.00
rhe performance of the work for which this permit is issued(Sec.
3097,CIv.CJ. HEATING UNIT(TO 100,000 B.T.U:) 8.00 MICROFILM ,
Lender's Name
H EATI N G U N IT(OVER 100,000 B.T.U.)9.50
Lender's Name's ELECTRIC
I certify that I have read this application and stale that the above VENTILATION FAN (SINGLE). 4.00
ordiinfonances n correct I agree to comply wish all city and county BOILER-COMPO H.P.or 100,000 B.T.U.) 6.00 PLUMBING
ordinances and stole laws relating l0 building COn51NCu G and
hereby authorize representatives ec this city to enter upon the BOILER-COMP (OvSr 100,000 BTU)SEE FEE SCH. MECHANICAL
abavomentioned property for inspection purposes. "
(We) agree to save, indemnify and keep harmless the City of MISC.- REFER TO ORD.
upertino ago st liabilities,judgments, costs and expenses which CONST.TAX
By in any y accrue against Said City in consequence of the PERMIT ISSUANCE 10.00
ling this ennit. MECH.CONT. LIC.NO. MECH.
TOTAL TOTAL
IgA re Of Applicant/Contractor ate
OFFICE COPY ,
. , POST THIS CARD NEAR FRONT OF BUILDING
• J n - PERMIT NUMBER
CITY OF CUPERTINO• 17250
INSPECTION DIVISION
JOB INSPECTION RECORD
PERMIT EXPIRATION
JOBADDRESS ( V� '-1 'f"IY'�. UNIT# _LOT#. I
y-� PERMIT EXPIRES IF WORK
OWNER r , 1 CONTRACTOR ,/'�^ hl�m�l IS NOT STARTED WITHIN
INSPECTION DATE I INSPECTOR - INSPECTION RECORD 1BODAYS OFPERMIT ISSU-
FOUNDATION - - - - .ANCE OR 180 DAYS FROM
NOTE: LASTCALLED INSPECTION.
UFER- - ALL GRADING 'AND DRAINAGE SHALL BE-INSTALLED
TO COMPLY WITH THE APPROVED PLANS AND CITY OF PERMIT VALIDATION
PREGUNITE CUPERTINO STANDARDS.
r • - GARAGE SLABS
_ POUR NO CONCRETE UNTIL ABOVE HAS BEEN SIGNED ,
-UNDERGROUND /SLAB
PLUMBING,
" ELECTRICAL • ISSUANCE DATE
'MECHANICAL - BLDG .ELECT. PLG.-' MECH.
' APIN 2 81989 ❑ ;❑ ❑
DO NOT POUR FLOOR UNTIL ABOVE HAS BEEN SIGNED " BUILDING PEfiMIT
�V.
{� INFORMATAON
WOOD FLOOR' CUP
VALUATION , - BIFT.
PLUMBING
MECHANICAL - - -
- ( -
ELECTRICAL PERMIT TO
., � � � �j
FRAMING - J hmU1
. INSULATION r - _ - STORIES TYPE ONSTR
OCC�GHOUP RES,UNITS
PLACE NO SUBFLOOR UNTIL ABOVE HAS BEEN SIGNED '
$0 FT FLOOR AREA TOTAL ACREAGE
ROOF NOTE:NO FINAL INS P:SHALL BE MADE BEFORE
'•,
DIAPHRAGM' THE CONSTRUCTION TAX IS PAID
BUILDING USE
. ROOF SHEATHING - - - •• - RES IND CON PB - am..,
APPLY NO ROOFING UNTIL ABOVE HAS BEEN-SIGNED FINALSDATE INSP ❑- El ❑' 1:1 ❑
ASSESSORS PARCEL NO
ROUGH SAN.#
PLUMBING ELECT.ENERGY
TRACT NO. "PARCEL NO
TUBS&SHOWER PAN:` - PLUMBING ENERGY
MECHANICAL - MECH.ENERGY
- ACC.DATE ACC,FILF NO
ELECTRICAL -BUILDING ENERGY :-' _
FRAMING - ELECT.FINAL TEST
INSULATION - '' PLUMBING �V"�j_ ZONING ENG SITE NO.
.GAS TEST GAS
FIRESPRINK' ENERGY Th 24
' - MECHANICAL %•'" •.COY ❑ NE] Y 0 N[
COVER NO WORK UNTIL ABOVE HAS BEEN SIGNED HEATING,.
EXTERIOR SHEAR ELECTRICAL RELEASE FLOOD ZONE ALUC.
INTERIOR SHEAR FIRE DEPT: �Y❑ ' IN v ❑ ' N❑
SHEETROCK - i (TRADE' -' •x:' FEE SUMMARY
• EXTERIOR LATH BUILDING
INTERIOR LATH - TEMPORARY APPROVALS' BUILDING
SCRATCH COAT ELECTRIC - PLAN CHECK
• GAS FEE '
NO TAPE OR PLASTER UNTIL ABOVE HAS BEEN SIGNEDOCCUPANCY SEISMIC FEE
OCCUPANCY OF BUILDING ISNOT PERMITTED UNTI L,BUILDING FINAL IS SIGNED By BUILDING INSPECTOR. MICROFILM
ARRANGE FOR INSPECTION BY PHONING 252-4505, ELECTRIC
o� ONE WORKING DAY BEFORE REQUIRED INSPECTION. PLUMBING CC)
PLEASE GIVE JOB ADDRESS WHEN PHONING:
z
- SEE PERMIT FOR EXPIRATION DATE - . •MECHANICAL
IMPORTANT! CONST.TAX
PLEASE READ REVERSE SIDE BEFORE TOTAL' 1y
CALLING FOR FINAL INSPECTION.''
OFFICE COPY