16998 rAPPLICANT TO FILL IN INFORMATION WITHIN RED LINES = USE BALL POINT PEN ONLY
I BU I LDING PROJECT I DENT]FICATI ON PERMIT NUMBER
BUILDING APPLICATION & PERMIT q p
ADDRESS I 0
�. BUILDING - ELECTRICAL-PLUMBING-MECHANICAL
WNER'S PLAN CHECK VALIDATION
NAME OTY. ELECTRIC PERMIT FEE I
�• CONTRACTOR'$
NAME OUTLETS-SWITCHES-RECEP 10.00/1.00
LIc.No LIGHTING FIXTURES 10.00/1.00
r, N RAcroR'
ADDRESS APPLIANCES-RESIDENTIAL 4.00
WA 1611,0114,1111AI PHONE PANELS 10.00 DATEOF APPLICATION
ORRCH]TEcr PANELS (OVER 200 AMP) 20.00 - PLAN CHECK FEE P.C.No.
ENGINEER
CIC.No, SIGNS TRANS. 3.00
ADDDRESS END' SPECIAL CMCUIT 5,00 PERMIT VALIDATION
ZIP TEMP.METER OR POLE INS. 20.00
APPLICANTS - - MOTORS SEE FEE SCH. Y
ADDRESS
SERVICE CHANGE 20.00 /t
w o o LICENSED CONTRACTORS DECLARATION
u U I hereby affirm that I um licensed under provisions of Chapter 9 ISSUANCE PATE
m a varei (commencing with Section 7000)of Division 3 of the Business and - t. ELECT. PLG. MECH.
r z Professions Code,and my license is in full for' rap t(jed9- I'rrrlA{'II
z o o- License Class Lia �.It
9 w Dmet"A Cmu.clor j"AtA - Y Qt
J y Cupertino BUILDING PERMIT
¢ ¢o i
OWNER-BUILDER DECLARATION INFORMATION
E
3 LL N 1 hereby affirm that l am exempt from tire Contractor's License MISC.- REFER TO ORD
FLLO ¢ Law for the following reason.(Sec.7031.5,Business Professions PERMIT ISSUANCE 1000 .VALUATION $/FT.
,e N -t Code:Anycity orcounty which requires a permit to construct,alter, 00
Q to ¢ 2 Improve,demolish,or repair any structure,prior to Its Issuance,also ELEG CONTR. LIC.NO. ELEC SOOE
i o¢ requires the applicant for such permit to file a signed statement that TOTAL
w$ he is licenseduls
puanl-to the provisions of the Contractor's License PERMIT TO
i Law(Chapter 9(commencing with Section 7000)of Division 3 D fthe
io Business and Professions Code)or that he is exempt therefrom and OTY. PLUMBING PERMIT FEE �' - ll Ue1�+
Ie r the basis for the alleged exemption.Any violation of Section 7031.5 STORIES VePE CONSTR.
a;� by any applicant for a permit subjects file applicant to a civil penalty ALTER-DRAIN -WATER IEA.) 5.00
of not more than five hundred dollars($500).1:
❑ I,as owner of the property,or my employees with wages as BACK F LOW PROTECT. DEVICE 4.00 "*I „' OCC.GROUP RES.UNITS.
their sole compensation,will do the work,and Ore structure is not
intended or offered for sale (Sec. 7044, Business and Professions DRAINS-FLOOR,ROOF,AREA,CON D. 5.00 y
Code:'The Contractor's License Law does not apply to an owner of -
property who builds or improves thereon,and Who does Snell work FIXTURES-PER TRAP 5.00 SO.FT.FLOOR AREA TOTAL ACREAGE
himself or through his own employees,provided that such improve.
si ments are not intended or offered for sale.If,however,the building GAS-EA.SYSTEM-I INC.4 OUTLETS 6.00
or improvement is sold within one year of completion,the owner- GAS EASYSTEM OVER 4 IEA) 200
builder will have the burden of proving that he did not huild or in,- - . - . .
- BUILDING USE
prove for purpose of sale.). INDUSTRIAL WASTE INTER. 30.00 RES IND CON' PB Omar
❑ I,as owner of lire property,all]exchlsively con trecling with
licensed contractors to construct the project(Sce.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 lhenon,and who LAWN SPR INKLERS-OVER 5IEA.) 1.00
contracts for such projects with a contractor(s)licensed Dorsa°rat m SEWER-SANITARY-STORM EA.200ft/10.00
the Contractor's License Law. TRACT NO. PARCEL NO.
laexempt
xe
❑ lam xemp[under Sec.-,BAP.C.for this
reason WATER HEATER W/VENT 6.00
Owner Date WATER SYSTEM 5.00
ACC,GATE ACC.FILE N0.
WORK ERS'COMPENSATION DECLARATION WATER TREATING EQUIP. 5.00
I hereby affirm tmt I have a certificate of consent to self-insure. ZONING ENO.SITE NO.
or a certificate of Workers'Compensation Insurance,ora cerfil'ied
copy tl f I.ec 3 00,LahC.).
I'oliLfi No m hnpuny�h1-1"CMW1-�
❑ Cenilicd copy is hereby unhnhed' FIRE SPRINK ENERGY T-24
Z Z ❑ Cerli"( " i;Cflllpd wit t�ciy nspe lion division. MISC.- REFER TO ORD.
O Applicant L/IA f+ O' Al y [:] N[ y NC]
~
'Lu rCERTIFICATEOP EXEMPTION FROM WORKERS' PERMIT ISSUANCE 10.00
FLOOD ZONE A.L.U.C.
W 2: 1 (70MPIiNSTION INSURANCE
PLG.CONTR. - LIC.No. PLG,
0. Z( This section need not he completed if the permit is for one TOTAL Y❑ N Y I] N
hundred dollars is 100)or Ices.)
U O I certify that in the performance of the work for which this per- OTV MECHANICAL PERMIT FEE FEE SUMMARY
LL F mit is issued. I shall not employ any person in any manner so as no
O W bccI,ryryryi�e.�tp¢��l;ykh Workers'�Cp{h}p�.ys'Il i�yh Lawso u f rnia.
y Dulc/7.3V_EYApplleant/lfi .!&&�.".-"` ALTER OR ADD TO MECH. 5.00 PBUILDINGIr�,D0
>- W NOTICE TO APPLICANT: If,after making this Certificate of fixemption,you should hecome subject to tlm Workers'Compensation APPLIANCE 5.00 provisions of the Labor Code, you must forthwith comply withsuh provisions or this permit shall be deemed revoked AIR HANDLING UNIT(TO 10=C,F.M.) 4.00CONSTRUCTION LENDING AGENCY AIR HANDLING UNIT(OVER 10=C.EM.) 6.00 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.3097,Civ.C.). HEATING UNIT(TO 100,000 B.T.U.) 5.00Lender's Addr HEATING UNIT(OVER 100,000 B.T.U.)9.50Lender's Address
I certify that I have Rad this application mulState Ihm to above VENTILATION FAN (SINGLE) 4.00
information is correct. I agree to comply with all city and county PLUMBING
r• ordinances and state laws'relating to building construction, and BOILER-CUMP(3 H.P.or100,000B.T.U.) 6.00
hereby authorize representatives of this Cily 10 Crater upon the gQILER-COMP (Over 100,000 BTU) FEE SCH. MECHANICAL
above-mentioned property for inspection purposes.
(WC) agree to Save, indemnify and keep harmless the City of MISC.- REFER TO ORD.
Cupertino against liabilities,judgments, costs and expenses which PERMIT ISSUANCE 10.00 CONST.TAX
may in any way accrue against said City in consequence of the
ranting of this permit. MECH.CONT. LIC.NO. MECH.
OXAC/ACT A� t�i�t J 2so-BFc TOTAL TOTAL IS
-S'D
Signal eof Applicant/Confrac or Date
OFFICE COPY
POST'THIS CARD NEAR FRONT OF BUILDING PERMITNUMBER
CITY OF CUPERTINO 16998
INSPECTION DIVISION
JOB INSPECTION RECORD
PERMIT EXPIRATION
JOBB ADDRESS—t �3( D. ��1T��-.h Jq-p— UNIT# _LOT#
1.Y A �/1 ,,/ PERMIT EXPIRES IF WORK
OWNER CSL` \der CONTRACTOR V c)�ft 0 u IS NOT STARTED WITHIN
I SPECTIO DATE INSPECTOR INSPECTION RECORD 180 DAYS OF PERMIT ISSU-
FOUNDATION ANCE OR 180 DAYS FROM
NOTE: LAST CALLED INSPECTION. .
UFER - ALL GRADING AND DRAINAGE SHALL BE INSTALLED
PREGUNITE TO COMPLY WITH THE APPROVED PLANS AND CITY OF PER NUT VALIDATION
GARAGE SLABS �
CUPERTINO STANDARDS.
_
POUR NO CONCRETE UNTIL ABOVE HAS BEEN SIGNED q 1
UNDERGROUND /SLAB - DEC 2 7 1988"
PLUMBING
ELECTRICAL City Of CUpBIt10O ISSUANCE DATE
MECHANICAL BLDG ELECT PLG MECH
❑ ❑ ❑
DO NOT POUR FLOOR UNTIL ABOVE HAS BEEN SIGNED /-✓' A fzgl;V 41Z /T/ BUILDING PERMIT
O
INFORMATION
WOOD FLOOR i W Gk G.. VALUATION SIFT.
PLUMBING
MECHANICAL
ELECTRICAL PERMIT TO 't
FRAMING J'�1�w
INSULATION sroR es P CONSTR
OCC GROUP RES UNITS I
PLACE NO SUBFLOOR UNTIL ABOVE HAS BEEN SIGNED
' . '
ROOF NOTE:NO FINAL INSP.SHALL BE MADE BEFORE ,SOFT FLOUR ARCA TOTALACREAGE
DIAPHRAGM THE CONSTRUCTION TAX IS PAID
ROOF SHEATHING RES "BUILDING USE
D CON PB OI-
---- APPLY NO ROOFING UNTIL ABOVE HAS BEEN SIGNED FINALS . DATE INSP. ❑
ASSESSORS PARCEL NO,
ROUGH SAN.N
PLUMBING ELECT.ENERGY
TUBS B SHOWER PAN PLUMBING ENERGY rHACT NO PARCEL NO
MECHANICAL MECH.ENERGY
ACC DATE ACC FILE NO.
ELECTRICAL BUILDING ENERGY
FRAMING ELECT.FINAL TEST
INSULATION PLUMBING ZONING - ENG.SITE NO.
•
• GAS TEST GAS
' MECHANICAL EIRE SPRINK ENERGY T.24
COVER NO WORK UNTIL ABOVE HAS BEEN SIGNED HEATING Y ❑ N� IN
EXTERIOR SHEAR ELECTRICAL RELEASE `LDOD ZONE A,L U.0
INTERIOR SHEAR FIRE DEPT. Y❑ NE] Y L, N❑
SHEETROCK GRADE FEE SUMMARY
EXTERIOR LATH BUILDING VVI
INTERIOR LATH TEMPORARYAPPROVAL BUILDING
• SCRATCH COAT ELECTRIC PLAN CHECK
GAS FEE
NO TAPE OR PLASTER UNTIL ABOVE HAS BEEN SIGNED OCCUPANCY SEISMIC FEE
OCCUPANCY OF BUILDING IS NOT PERMITTED UNTIL BUILDING FINAL IS SIGNED BY BUI LDING INSPECTOR, MICROFILM
ARRANGE FOR INSPECTION BY PHONING 252-4505, ELECTRIC
F, ONE WORKING DAY BEFORE REQUIRED INSPECTION. PLUMBING'
o PLEASE GIVE JOB ADDRESS WHEN PHONING.
SEE PERMIT FOR EXPIRATION DATE - MECHANICAL
IMPORTANT! CONST. TAX
PLEASE READ REVERSE SIDE BEFORE TOTAL ��rd
CALLING FOR FINAL INSPECTION.
OFFICE COPY