12688 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
�• PERMIT NUMBER
BU I LDING PROJECT IDENTIFICATION
BUILDING APPLICATION & PERMIT 12688
rn ,nI BUILDING - ELECTRICAL-PLUMBING-MECHANICAL 12 6 8 8
MOwrve 's I 1 u PLAN CHECK VALIDATION
NAME OTY. ELECTRIC PERMIT FEE
1_� PNONE
CONTRALTO 'S
NA EUTLETS-SWITCHES-RECEP 10.00/1.00
C ct►J LIC.NO. 4 Z5 LIGHTING FIXTURES 10.00/1.00
A OGRESACTOR's q7 105 PPLIANCES-RESIDENTIAL 4.00
OGRESS
SO ` 1111 ' PHONE PANELS 10.00 DATE OF APPLICATION
C11
OR PANELS (OVER 200 AMP) 20.00 PLAN CHECK FEE P.C.N0.
FNGINEER
vm. 0. SIGNS TRANS. 3.00
ARCH.OR ENG. SPECIAL CIRCUIT SOO PERMIT VALIDATION
ADDRESS .
ZIP ITEMP.METER OR POLE INS. 20.00 gMf�
APPLICANT'S MOTORS SEE FEE SCH. r
ADDRESS PAID
SERVICE CHANGE 20.00 p Id� qq *yI�
woo LICENSED CONTRACTORS DECLARATION N M IP91-
a 2 1 hereby affirm Illal I am licensed under provisions of Chapter 9 ISSUANCE DATE
( ommcncing with Section 7000)of Division"�3 of the Business and PLG. MECH.
r i rofessions Cs(�:,a d my license is in full ropey_ f 7
License ass v Con Numbe T� ❑ ❑
0 )uta Cont moor
¢ x f BUILDING PERMIT
¢ o M O OWNER-BUILDER DECLARATION
wg: N 1 hereby affirm that I am exempt from the Contractor's License MISC.- REFER TO ORD INFORMATION
LL 0 e 'aw for the following reason.(Sec.7031.5,Business and Professions PERMIT ISSUANCE VALUATION $/FT.
-' Code:Any city or county whichrequiresa permit to construct,alter, 10.00
Q Q Q 0
improve,demolish,of repair an structure,prior to Its issuance,also ELEC.CONTR. LIC.N0. e
p P Y P ELEC. (DOS.
n S m¢ requires the applicant for such permit to file a signed statement that TOTAL
w he is licensed pursuant to the provisions of the Contractor's License PERMIT TO
ca> Law(Chapter 9(commencing with Section 7000)of Division 3 of the
a Business and Professions Code)or that he is exempt therefrom and OTY. PLUMBING PERMIT FEE
X r$ the basis for the alleged exemption.Any violation of Section 7031.5 06RIES TYPE CNSTR.
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(5500)):
❑ I,as owner of the properly,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 REB.UNITS
intended or offered for sale (Sec. 7044, Business and Professions DRAINS-FLOOR,ROOF,AREA,COND. 5.00
Code:The Contractor's License Law does not apply to an owner of
property who builds or improves thereon,and who docs such work FIXTURES-PER TRAP 5.00 SO.IT,FLOOR AREA TOTAL ACREAGE
himself or through his own employees,provided that such improve-
mentsarenot intended or offered for sale.If,however,the building GAS-EA.SVSTEM-I1NC.4OUTLETS 6.00
or improvement is sold within one year of completion,the owner- GAS•EA.SYSTEM•OVER 4 (EA.) 2.00 BUILDINGUSE
builder will have the burden of proving that he did not build or im
prove for purpose of sale.). INDUSTRIAL WASTE INTER. 30.00 REs IND PB Omar
❑ I,as owner of the property,am exclusively contracting with 0 ❑
licensed contractors to construct the project(Sec. 7044,Business LAWN SPRINKLERS- 1 INC 5 V.B. 6.00 ASSESS SPARCEL 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-OVER 5 IEA.) 1.00
contracts for such projects with a contractor(s)licensed pursuant to
file Contractor's License Law. SEWER-SANITARY-STORM EA.200ft/10.00 TRACT NO. PARCEL NO.
O lam exempt under Sec. - ,B.&P.C.for this WATER HEATER W/VENT 6.00
reason
Owner - Date WATER SYSTEM 5.00 ACC.DATE ACC.FILE NO.
WORKERS'COMPENSATION DECLARATION WATER TREATING EQUIP. 5.00
I hereb4th e a certificate of consent to self-insure,
cr a certiompensation Insurance,or a certified ZONING ENG.SITE NO.
oWtRr .C.). 9Po oy 0 IRS y furnished. FIRE SPRINK ENERGY T 24
z ZQplic-C;71"
d with the ci y ins ection divisi
O MISC.- REFER TO ORD, v� N� Y ❑ N❑
CiRTIFICATI: F IiXIiMPTION FROM KERS' PERMIT ISSUANCE 10.00 FLOOD ZONE A.L.U.C.
L COMPENSATION INSURANCE PLG.OONTR, LIC.NO. PLG.
1 0 (This section need not be completed if the permit is for one TOTAL Y❑ N Y❑ N❑
:D Z hundred 1011ors(51011 or less)
U O I certify that in the performance of the work for which this per- OTV MECHANICAL PERMIT FEE FEE SUMMARY
LL t- mit is issued,1 shall not employ any person in any manner so as to
O w become subject to the Workers'Compensation Laws of California.
y Date Applicant ALTER OR ADD TO MECH. 5.00 BUILDING
} N NOTICE TO APPLICANT: If,after making this Certificate of Ex
f" ? emplion,you should become subject to the Workers'Compensation APPLIANCE 5.00 PLAN CHECK
provisions of the Labor Code, you most forthwith comply with FEE
U Snell provisions or this permit shall be deemed revoked, AIR HANDLING UNIT(TO 10=11F.M.) 4.00
CONSTRUCTION LENDING AGENCY AIR HANDLING UNIT(OVER 10=C.FM.) 6.00 SEISMIC FEE t
1 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. HEATING UNIT(T0 100,000 B.T.U.) 8.00 MICROFILM
3097,Cs.C.).
Lender's Name H EATI NG UNIT(OVER 100,000 B.T.U.)9.50
Lender's Address ELECTRIC
I certify that 1 have read this application and state tthe above VENTILATION FAN (SINGLE) 4.00
information is correct. I agree to comply with all cityy and county PLUMBING
ordinances and state laws relating to building construction, and BOILER-COW(3 H.P.or 100,000 B.T.U.) 6.00
hereby authorize representatives of this city to enter upon the BOILER-COMP low,100,000 BTUI SEE FEE SCH. MECHANICAL
above-mentioned property for inspection purposes.
(We) agree to ve, indemnify and keep harmless the City of MISC.- REFER TO ORD.
Cupertino again iahilities,judgments, costs and expenses which pERMIT ISSUANCE 10.00 CONST.TAX
may t
By accrue against said City in consequence of the
grandf tl' e(m1 MECH.CONT. LIC.NO. MECH.
11t-a-:1TOTAL TOTAL
of Applicant/Contractor Date
OFFICE COPY
POST THIS CARD NEAR FRONT OF BUILDING
., PERMIT NUMBER
CITY OF CUPERTINO 12688
INSPECTION DIVISION
•� JOB INSPECTION RECORD
PERMIT EXPIRATION
JOB ADDRESS 19310 Pruneridge UNIT# LOT#
PERMIT EXPIRES IF WORK
OWNER H.P. CONTRACTOR TeCCOn IS NOT STARTED WITHIN
INSPECTION DATE INSPECTOR INSPECTION RECORD 180 DAYS OF PERMIT ISSU-
ANCE OR 180 DAYS FROM
LASTCALLED INSPECTION.
UFER
PREGUNITE PERMITPMN
POUR NO CONCRETE UNTIL ABOVE HAS BEEN SIGNED APR
r2'21967
UNDERGROUND /SLAB
PLUMBING "
ELECTRICAL ISSUANCE DATE
MECHANICAL BLDG, ELECT. I PLG. MECH.
❑ ❑ ❑ ❑
DO NOT POUR FLOOR UNTIL ABOVE HAS BEEN SIGNED BUILDING PERMIML
INFORMATION
WOOD FLOOR nwnnoN $/FT.
PLUMBING
MECHANICAL
PERMIT TO
ELECTRICAL n
-
FRAMING II
INSULATION STORIES TYPE.CONSTR.
OCC.GROUP RES.UNITS
PLACE NO SUBFLOOR UNTIL ABOVE HAS BEEN SIGNED
ROOF SO FT,FLOOR AREA TOTAL ACREAGE
S DIAPHRAGM
BUILDING USE
RES INO CON PB 01ner
APPLY NO ROOFING UNTIL ABOVE HAS BEEN SIGNED ❑ ❑T ❑ ❑
ASSESSORS PARCEL NO.
ROUGH
PLUMBING SZET11
TRACT rv0. PARCEL NO
GAS TEST .
MECHANICAL
ELECTRICALFINALS DATE INSP. ACC.DATE ACC.FILE NO.
FRAMING SAN *
INSULATION PLUMBING ZONING ENG.SITE NO.
GAS'
FIRE SPRINK ENERGY T 24
MECHANICAL Y ❑ NO) r ❑ NE-1
COVER NO WORK UNTIL ABOVE HAS BEEN SIGNED HEATING
LATH—INTERIOR. ELECTRICAL FLOOO2ONE A,L.U,C.
LATH—EXTERIOR' FIRE DEPT. - Y❑ N� v I] N�
SHEETROCK - GRADE FEE SUMMARY
SHEAR INTERIOR BUILDING
SHEAR EXTERIOR TEMPORARY APPROVALS BUILDING
FIREWALLS ELECTRIC PLAN CHECK
GAS FEE
NO TAPE OR PLASTER UNTIL ABOVE HAS BEEN SIGNED OCCUPANCY SEISMIC FEE
OCCUPANCY OF BUI LDING IS NOT PERMITTED UNTI L BUILDING FINAL ISStGNED BY BUILDING INSPECTOR. MICROFILM
I �
ARRANGE FOR INSPECTION BY PHONING 252-4505, ELECTRIC
F ONE WORKING DAY BEFORE REQUIRED INSPECTION. PLUMBING
- o� PLEASE GIVE JOB ADDRESSMAiN PHONING. "
Z MECHANICAL
l - SEE PERMIT FOR EXPIRATION DATE -
r
IMPORTANT! A CONST.TAX
PLEASE READ REVERSE SIDE BEFORE TOTAL
CALLING FOR FINAL INSPECTION.
OFFICE COPY