13525 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
`
"BUILDING PROJEC41DENTIFICATIO� PERMIT NUMBER
APPLICATION & PERMIT I
f - 1'C BUILDING - ELECTRICAL-PLUMBING-MECHANICAL
11 r+ PLAN CHECK VALIDATION
SW] X32! QTY. ELECTRIC PERMIT FEEnq S vHONE77(� G �,xiOR'a --- \\III
NAME OUTLETS-SWITCHES
10.00/1.00
Llc.rvo. LIGHTING FIXTURES 10.00/1.00
CONTRACTORS `APPLIANCES-RESIDENTIAL 4.00
ppp�DppE� �J �/�J
vNONF�Z /�J / PANELS 10.00 DATE OF APPLICATION
ARCHITECT • PANELS (OVER 200 AMP) 20.00 PLAN CHECK FEE P.C.NO.
oR • •
ENGINE
- 11,114 uc.No, 6 SIGNS TRANS. 3.00
ARCH.OR ENG. PERM TY ALIDATION
' AooREss //� � SPECIAL CIRCUIT .5.00 �
�j I( e♦;f fl ZIP rrEMP.METER OR POLE-INS.an 20.00 sn 1. 1
APPLICANTS MOTORS - $YSEE FEE SCH. /ms``'" -
SERVICE CHANGE , '\ _ 20.00 P nPjpO
woo LICENSED CONTRACTORS DECLARATION
¢u 1 hereby affirm that I am licensed under provisions of Chapter 9 bat. Pa\QQ \ ISSUANCE DATE
wQ H (commencing with Section 7000)of Division 3 of the Business and \ ,BLDG. ELELT. - ,PLG. MECH.
P. o z Profession Co an en Li is in full fur e' ff^c[ - (`.\
z a. - Lice���{� Lia Number. � - LL7�
O Z H. ate�J./ Contractor_ 3 _
a n E � 1 - BUILDING PERMIT
¢ ¢w < OWNER-BUILDER DECLARATION INFORMATION
w3 LL y 1 hereby affirm that 1 am exempt from the Contractor's License MISC.- REFER TO ORD
a. oa ' Law for the l'ollowingreason.(Sec.7031.5.Businessand Professions PERMIT ISSUANCE 10.00 VALUATION $/FT.
� - v,I Code:Any city or county which requires a permit to conslrucLalteq
Q Q Q 0 Improve,demolish,Uf repair any structure,prior to Its Issuance,also ELEC.CONTR. LIC.NO. EL
EC. /p
o¢ requires the applicant for such permit to file a signed statement that TOTAL, V r. PERMIT TO
w m he is licensed pursuant to the provisions of the Contragor's Licensed L
Hi> Law(Chapter9(commencing with Section 7000)of Division 3 ofthc JW1�N��
a Business and Professions Code)or that he is exempt therefrom and OTY. PLUMBING PERMIT FEE
f Z O
¢ �$ the basis for the alleged exemption.Any violation of Section 7031.5 STORIES TYPE CONSTR.
dg _ by any applicant Icor a permit subjects the applicant to a civil Penalty ALTER-DRAIN& VENT-WATER (EA.) 5.00
of not more than five hundred dollars 0500).):
❑ 1,as Owner of the property,or my employees with wages asggCK FLOW PROTECT.DEVICE 4.00 OCC.GROUP RES.UNITS
their sole compensation,will Jo the work,and the structure is not
intended of offered for sale(Sec. 7044, Business and Professions DRAS-FLOOR,ROOF,AR EA,COND, 5.00
Code:The Contractor's License Law docs not apply to an owner of
properly who builds or improves.Omrcon,and who does such,work FIXTUINRES-PER TRAP 5.00 SO.FT.FLOOR AREA TOTALACREAGE
himself or through his own employees,provided that such improve- GAS-EA.SYSTEM-1 INCA OUTLETS 6.00
Rents are not intended or offered for sale.If,however,(lie building
oe improvement is sold within one year of completion,the owner- GAS-.EA.SYSTEM-OVER 4 (EA.) 2.00 BUILDING USE
builder will have the burden of proving that he did not build or int- RES IND CON PB Omer
prove for parpou f,de.). INDUSTRIAL WASTE INTERv.9✓ 30.00
❑ .I,as owner of the property,ten 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 docs not apply
to an owner of property who builds or improves thereon,and who LAWN SPRINKLERS-O_VEER 5x(EA.) 1.00
contracts for such projects with a contractor(s)licensed pursuant to
the Contractor's License Law. SEWER-SANITARY-STORNI EA.200ftl,f0b TRALTNO. PARCELNO.
D I ast exempt under Sec. .BAP.C.Icor this WATER HEATER W/VENT.h 0 us'F 6.00
reason
Owner _ Date WATER SYSTEM, 5.00 ACC.DATE ACC.FILE NO.
WORK ERS'COMPENSATION DECLARATION WATER TREATING EQUIP, 5.00
1 hereby affirm that 1 have a certificme of consent In self-insure. ZONING ENG.SITE NO.
or a cetlificme of Workers'Compensation Insurance,or a certified -
opymereor(See.3800,Lab.C.).S��UOjp
Policy No. Company
Q ❑ Cer iOed copy is hereby furnished. FIRE SPRINK ENERGY T 24
z �4 Ccrtif Y ee�ith the cit spemion division. MISC.- REFER TO ORD. ❑ ❑ ❑ ❑
A plicanlI_ Y N Y N
10.00 'N
� -
CERTIFICATE OF IiXEA1 P'I'ION PROM WORKERS' PERMIT ISSUANCE CI FLOOD ZONE 'A.L.D.C. ,
LU COMPENSATION INSURANCE PLG.CONTR. LIC.NO. PLG. O! Y❑ N Y❑ rv❑,
d 0 Tuis section need not be completed if the Permit is for one TOTAL
Z hundred dollars($100)or less.)
U O I certify amt in the Perfonnance'of Die work Icor which mix per- QTY. MECHANICAL PERMIT FEE FEE SUMMARY
mit is,issued,I Shull not cnmploy any person in any anu nef so as to
Ow become subject to the Workcrs'Compensalion Laws of California. BUILDING
Date Applicant 5
ALTER OR ADD TO MECH. .00
�- rail NOTICE 1'0 APPLICANT: If,after staking this Certificate of Ex-
? emption,you should become subject to the Workers'Compensation JAPPLIANCE 0V 5.00 PLAN CHECK
provisions of the Labor Code, you must forthwith comply witFEE
U such provisions or this permit shall be deemed revoked. AIR HANDLING UNIT(T0.10p00QF.M.) 4.00
CONSTRUCTION LENDING AGENCY AIR HANDLING UNIT(OVER 10=C.F.M.) 6.00 SEISMIC FEE
1 hereby affirm that there is a construction lending agency for EXHAUST HOOD(WITH DUCT)' 5.00
the ped'onnxnce of the work for which this permit is issued(Sec. MICROFILM '
3097,CN.C.), " HEATING UNIT(70(,100,000 B.T.U.) 8.00
Lender's Name HEATI NG UN I T'(OV E R 100,000 B.T.U.)9.50 ELECTRIC Ob
Lender's Address
I certify that I have read this application and state that the above VENTILATION FAN (SINGLE) 4.00 91.information is correct. I agree to comply with all city and county PLUMBING O
i� BOILER-COMP I3 H.P.or 100,000 B.T.U.) 6.00
ordinances and state lows representatives
to building construction, and
hereby authorize representatives of this city m enter upon the BOILER-COMP (Over 100,000BTU)SEE FEESCH. MECHANICAL a
above-mentioned property for inspection purposes. p
(We) agree.to Save, indemnify and keep harmless the City of MISC.- r•L REFER TO ORD.
Cupertino against liabilities,judgments, costs and expenses which CONST.TAX
may in any way way accrue againsg Bald City colucqucnce f the PERMIT ISSUANCE 0 10.00 "4-
',J 6,m1urvofAI)pfic
Of this penniL MECH.CONT. LIG NO. MECH.
OTALt Zr� TOTAL
ractor Dale s /
OFFICE COPY r`/
' . POSTTHISCARDNEAR- FRONTOFBUILDING
PF RMT NUMBER
CITY OF •CUPERTINO ' 13525
INSPECTION DIVISION '
r'4A
JOB INSPECTION RECORD.
PERMIT EX
10725 ORLINE COURT EXPIRATION- 10725
JOB ADDRESSI UNIT# LOT#
PERMIT EXPIRES IF WORK
' OWNER - S'. LIAD CONTRACTOR T&F IS NOT STARTED VI
INSPECTION DATEINSPECTOR INSPECTION RECORD 180 DAYS OF PERMIT ISSU-
FOUNDATION - , ANCE OR 180 DAYS FROM
LAST CALLED INSPECTION.
UFER -
PREGUNITE 'PERMIT VALIDATION
f POUR NO.CONCRETE UNTIL ABOV,E,HAS BEEN SIGNED" JAI - •;'�
UNDERGROUND1,SLAB
PLUMBING
4 •
ELECTRICAL ' .t) 0 .'ISSUANCE DATE
BLDG. ELECT. PLG. MECH,
MECHANICAL ` '
v� ,{
DO NOT POUR FLOOR UNTIL ABOVE HAS BEEN SIGNED BUILDING PERMIT
'
- - WOOD FLOOR vALUAT00IN s/FT.,
PLUMBING
MECHANICAL '
i"PERMrc i0 -
ELECTRICAL - " � L'„i ; .! "' " •"
FRAMING '
_ STORIES TYPE CONSTR.
INSULATION - " ' - - -•L: /:
OCC.GROUP, RES,UNITS
IRVACE NO SUBFLOOR UNTIL ABOVE HAS BEEN SIGNEDF _ -
5U_ r FLOOR ANEA TOTAL ACREAGE
'ROOF'
'A . Dl',PHRAGM - BUILDING USE
A t HEs IND CON PB 0""'
"APPLY NO ROOFING UNTIL ABOVE HAS BEEN SIGNED - ❑ ❑ ❑ ❑
ASSESSORS PARCEL NO.
ROUGH
PLUMBING `
- —� .� TRACT NO. PARCEL NO.
GAS TEST
MECHANICAL
'ACC.DATE ACC.FILE NO, .
ELECTRICAL •��` - FINALS DATE INSP.
#' '
FRAMING SAN " .ZONING ENG.SITE NO.
INSULATION , PLUMBING
GAS.
FIRE SPRINK ENERGYT:20
' - MECHANICAL ❑ , rv❑ v ❑ N❑
COVER NO WORK UNTIL ABOVE HAS BEEN SIGNED HEATING
FLOOD ZONE A.L.0 c.
LATH-INTERIOR ELECTRICAL "
LATH-EXTERIOR ` FIRE DEPT. Y❑ .N❑ yo- No
SHEETROCK GRADE - FEE SUMMARY,
SHEAR INTERIOR ' ' BUILDING IYOOL.
sH EARExTERIOR TEMPORARY APPR VALS
BUILDINGw;-
FIREWALLS ' ELECTRIC - PLAN CHECK
AS . . - FEE
NO TAPE OR PLASTER UNTIL ABOVE'HAS BEEN SIGNED OCCUPANCY - '.� SEISMIC FEE s'
OCCUPANCY OF BUILDING IS NOT PERMITTED UNTIL BUILDING FINAL ISSIGN ED BY BUILDING INSPECTOR. MICROFILM
ARRANGE FOR INSPECTION BY PHONING 252-4505ELECTRIC•
ONE WORKING DAY BEFORE REQUIRED-INSPECTION. PLUMBING YL' +
PLEASE GIVE JOB ADDRESS WHEN PHONING. `Z " .. .MECHANICAL
SEE PERMIT FOR.EXPIRATION'DATE
CONST.TAX
IMPORTANT! p
PLEASE"READ REVERSE SIDE BEFORE TOTAL (q�3y
CALLING FOR FINAL INSPECTION.
- _ ,OFFICE COPY • ' - -