17865 APPt4CANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
BUILDING PROJECT 1 DENTI FICATI ON PERMIT NUMBER
BUILDING APPLICATION & PERMIT 17865
t ADDRESS C.
' O n BUILDING - ELECTRICAL-PLUMBING-MECHANICAL
OWNERS /' L �x^< , PLAN CHECK VALIDATION
.� /t��[ LL O7Y. ELECTRIC PERMIT FEE
dam If {q.7J OL'//'J�PMONE 37
Home ACTOR'S re OUTLETS-SWITCHES-RECEP 10.00/1.00 A
J4 �s Y LIC,No, LIGHTING FIXTURES 10.00/1.00
CONTRACTOR'S N PPLIANCES-RESIDENTIAL 4.00
CONTRAS
PHOrvE PANELS 10.00 DATE OF APPLICATION
ORDHrtsci PANELS (OVER 200 AMP) 20.00 PLAN CHECK FEE P.C.No.
R
ENGINEER
LIC.NO, ISIGNS TRANS. 3.00
ARCH.OR ENG. SPECIAL CIRCUIT 5.00 PERMIT VALIDATION
ADDRESS
ZIP TEMP.METER OR POLE INS. 20.00 c
APPLICANT (
S MOTORS SEE FEE SCH.
ADDRESS
SERVICE CHANGE 20.00 f ,l --rte �If�
o o LICENSED CONTRACTORS DECLARATION �' •�
a u w I hereby affirm that I am licensed under provisions of Chapter 9 ISSUANCE DATE
H G m (commDivision
encing with Section 7000)of 3 of the Business and BLDG. ELECT. PLG. ME
F ol z Professions Coda' 1 my license is in full fore•' it effect. I�j Ls
y1 1 O
z O w- License Class V_/_Lic.Number
v
O m F Dam-Contractor /�
w ¢ OWNER-BUILDER DECLARATIONINFORMATION
VI BUILDING PERMIT
o a O MISC. REFER TO ORD
w 3 LL y I hereby affirm Thal 1 run exempt Dont lire Contractor A License - VALUATION
FLLoj Law for the following reason.(Sec.703LS,Businfssand Professions PERMIT ISSUANCE 10.00 ,QQ
Code Any city or county which requimse permit reconstruct,alter,
RQ improve,demolish,or repair any structure,prior to its issuance,also ELEC.CONTE. LIC.NO. ELEC. /
DLL re,Lii,cx the applicant for such permit In file a signet)statement that TOTAL / ��(/ PERMIT O
n w m he is licensed pursuant to lire provisions of the Contractor's License
Fzi
Law(Chapter 9(commencing with Section 7000)of Division 3 ofthe e(� /� eG�
- a Business and Professions Code)or that he is exempt therefrom and GTY. PLUMBING PERMIT FEE
H Do the basis for the alleged exemption.Any violation of Section 7031.5 STORIES TYPE CONSTR.
by any applicant for a permit subjects ore applicant to a civil penally ALTER-DRAIN -WATER IEA.) 5.00
of not more than five hundred dollars(8500).1:
O I,as owner of the properly.or my employees with wages as BACK FLOW 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 (Sec. 7044. Business and Professions DRAINS-FLOOR,ROOF,AREA,COND. 5.00
Code:The Conimctoi s License Law docs mol 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 re through his own employees,provided that such improve-
mess are through
et or offered employees.
or pevidedt atsuhc hulloing GAS-EA.SYSTEM-1INC.4OUTLETS 6.00
or improvement is sold within ane year of complclion,the owner- GAS-EA.SYSTEM-OVER 4 IEA.) 2.00 BUILDING USE
builder will have the burden of proving that he did not build or int-
prove for purpose of sale.). INDUSTRIAL WASTE INTER. 30.00 RES IND CON PB Other
❑ L as owner of the property,run 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 PtoNssions Coda The Contractor's License Law docs not apply
to an owner of property who builds or improves thereon,and who LAWN SPRINKLERS-OVER 5(EA.) 1.00
contracts for such project,with a contractorls)licensed pursuant to
the Contractor's License Law. SEWER-SAN ITAR V-STORM EA.2001t/10.00 TRACT NO. PARCEL NO.
O I wn exempt under See-,B&P.C.for this WATER HEATER W/VENT 6.00
reason
Owner Date WATER SYSTEM 5.00 ACC.DATE ACC.FILE NO.
WORK ERS'COMPENSA97ON DECLARATION WATER TREATING EQUIP. 5.00
I hereby infirm that I have a certificate of consent to eclfinsure' ZONING ENG.SITE NO.
or a cerlificarc of Workeri CompcneaHer In summce.'or a Certified
copy 11wo of(See 3800,Lab.0).
Policy No. Company
0 O Certilied copy is hereby furnished. FIRE SPRINK ENERGYT-24
z -L l.'ertlfed apy IS Bl' �It[, Illm city fRApef I I01h division.
O A h Cant 1 / `� /k ;� MISC.- REFER TO ORD. Y ❑ N❑ Y ❑ N❑
� N CL'RRTTIIFIICCATIF OF Ii XFMPIION FROM WORKERS' PERMIT ISSUANCE 10.00 FLOOD ZONE A.L.U.C.
LU >_ CCdFPFNSA7'ION INSURANCE PLG.CONTR. LIC.NO. PLG.
CIL ❑ 1'fhis section need mot be completed if the permit is for oto, TOTAL Y❑ N❑ Y [D NC]
0 Z hundred dollars($100)or less.)
U O I certify that in the performance of the work for which this per- GTY. MECHANICAL PERMIT FEE FEE SUMMARY
LL F mil is issued,I.shall not employ any person in any manner so as to
U W become subject In the Workers'Compensmian Laws of Califora ia. BUILDING
Dale Applicant ALTER OR ADD TO MECH. 5.00
} to NO3'10E TO APPLICANT: If,after making this Cenifieate of Ex.
F Z eruption,yell should benmw subject to the Werkeri Cnmpensmion APPLIANCE 5.00 PLAN CHECK
provisions of the Labor Code. you must forthwith comply will h FEE
U such provisions or this permit shall be deemed revoked. AIR HANDLING UNIT(TO 10.000QF.M.) 4.00
CONSTRUCfION LENDING AGI7NCY AIRHANDLING UNIT(OVER l0A00C.F.M.) 6.00 SEISMIC FEE
I hereby aflirin that there is a construction lending agency liter 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,is Na 1. / was
Lender's Name HEATING UNIT(0 100,000 B.T.U.19.50 ELECTRIC J U
Lender's Address
I certify that I have read this application and stale Item rhe above VENTILATION FAN (SINGLE) 4.00
information is correct. I agree to comply with all city and county V PLUMBING
ordinances and slate laws relating to building construction, and BOILER-COMP(3 H.P.or 100,000 B.T.U.) 6.00
hereby aulhuriec representatives of this city to enter upon the BOILER-COMP (Over 100,000 BTU)SEE FEE SCE. MECHANICAL _00
above-mentioned property I'or inspection purposes.
(We) agree to save, indemnify and keep harmless the City of MISC.- REFER TO ORD.
Cupertino against liabilities,judgments, casts and expenses which PERMIT ISSUANCE 10,00 (2.0 0 CONST.TAX
may in any way accrue against said City in Consequence of the
ranting of[his permit MECH.CONT. LIC.NO. MECH.
TOTAL TOTAL cI S_O
Signature of Applicant/Contmetor Date
OFFICE COPY
' y POST THIS CARD NEAR FRONT OF BUILDING
PEFM111i NUMBER
CITY OF CUPERTINO
INSPECTION DIVISION 17.865
�, JOB INSPECTION REC7 /� / �D��1
\ ( fJ / PERMIT EXPIRATION
JOB ADDRESS /Q N.nr' Wd UNIT# LOT#
/� Jl' PERMIT EXPIRES IF WORK
OWNER u• DUVI Pne DN�ll�! CONTR ACTORI\l S p p IS NOT STARTED WITHIN
�j
INSPECTION DATE INSPECTOR INSPEC ION RE ORD 180 DAYS OF PERMIT ISSU.
FOUNDATIONNOTE: ANCE OR 180 DAYS FROM
' UFER � ALL GRADING AND DRAINAGE SHALL BE INSTALLED LAST CALLED INSPECTION.
PREGUNITE TO COMPLY WITH THE APPROVED PLANS AND CITY OF PERMIT VALIDATION
CUPERTINO STANDARDS. I
GARAGE SLABSPAID
POUR NO CONCRETE UNTIL ABOVE HAS BEEN SIGNED
UNDERGROUND /SLAB ':'' q 1989
PLUMBING ' '
ELECTRICAL City of Cupertino CE DATE
MECHANICAL REELECT
El [CECT ElPIEGm cH
DO NOT POUR FLOOR UNTIL ABOVE HAS BEEN SIGNED BUILDING PERMIT
INFORMATION
WOOD FLOOR VALUATION SIFT.
PLUMBING '
MECHANICAL '
ELECTRICAL ILS JC YP17LWIUO iII
FRAMING ( �l� '✓1
S1UN1[5 TYPE CONSTR
INSULATION .,
OCC GROUP RES UNITS
PLACE NO SUBFLOOR UNTIL ABOVE HAS BEEN SIGNED
III IT rLooR nRPn TOTALACREAGE
ROOF NOTE:NO FINAL INSP.SHALL BE MADE BEFORE
DIAPHRAGM THE CONSTRUCTION TAX IS PAID
BUILDING USE
ROOF SHEATHING HEs IND CON EB oro.
El El 0 0 El
APPLY NO ROOFING UNTIL ABOVE HAS BEEN SIGNED FINALS DATE INSP.
ASSESSORS PARCEL NO
ROUGH SAN.N
PLUMBING ELECT.ENERGY '
TRACT NO PARCELNO
TUBS&SHOWER PAN PLUMBING ENERGY
MECHANICAL MECH.ENERGY
ACC DATE ACC FILE NO
ELECTRICAL BUILDING ENERGY
FRAMING ELECT.FINALTESTTONING ENG.SITE NO.
INSULATION PLUMBING
GAS TEST GAS
FIRE SPNINK ENERGY T 2
MECHANICAL r ❑ NE] v N[]
COVER NO WORK UNTIL ABOVE HAS BEEN SIGNED HEATING
FLOOD ZONE A
EXTERIOR SHEAR ELECTRICAL RELEASE -1
INTERIOR SHEAR FIRE DEPT. ^2 v N[D L. N❑
SHEETROCK GRADE FEE SUMMARY
EXTERIOR LATH BUILDING
INTERIOR LATH TEMPORARY APPROVALS BUILDING
SCRATCH COAT ELECTRIC PLAN CHECK
FEE
GAS
NO TAPE OR PLASTER UNTIL ABOVE HAS BEEN SIGNED OCCUPANCY SEISMIC FEE
OCCUPANCYOF BUILDING IS NOT PERMITTED UNTIL BUILDING FINALISSIGNED BY BUILDING INSPECTOR. MICROFILM
ARRANGE FOR INSPECTION BY PHONING 252-4505,. ELECTRIC
IL ONE WORKING DAY BEFORE REQUIRED INSPECTION. PLUMBING
O� PLEASE GIVE JOB ADDRESS WHEN PHONING.
Z MECHANICAL ,Q
— SEE PERMIT FOR EXPIRATION DATE —
IMPORTANT! CONST.TAX q
PLEASE READ REVERSE SIDE BEFORE TOTAL ,
CALLING FOR FINAL INSPECTION.
OFFICE COPY
i