11176APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
BUILDING PROJECT I DENT FICATION
APPLICATION & PERMIT
BUILDING -ELECTRICAL -PLUMBING -MECHANICAL
PERMIT NUMBER
11176
OULLDING
pEBc '"
/",
IN R
NA
QTY. ELECTRIC PERMIT FEE
PLAN CHECK VALIDATION
C010MICTORsOUTLETS-SWITCHES-RECEP
NAME
10.00/1.00
ILiGHTING FIXTURES 10.00/1.00
LIC, NO.
CONTRACTOR'S
ADDRESS
APPLIANCES 4.00
PANELS 10.00
MONS
DATE OF APPLICATION
Rc11fTEcr
OR
O
ENGINEEN
uc, Nn.
PANELS (OVER 200 AMP) 20,00
PLAN CHECK FEE P.C. NO,
SIGNS TRANS. 3.00
ARC H.OR ENG,
ADDRESS
SPECIAL CIRCUIT 5.00
PERMIT VALIDATION
TEMP. METER OR POLE INS. 20.00
ZIP
%
APPLICANTS
ADDRESS
MOTORS SEE FEE SCH.
SERVICE CHANGE 20.00
LICENSED CON 'I'RACI'ORS I FC1.ARA'IION
I hereby u1'l iron thal I ale licensed under pnrvi,iuns or Chapter `)
(Cmmmmoeing with Section 7000) of Division 3 01 the 0uaimls wW
Professions Costa, and my license is in lull IUrcc and Or,"t
License Class Lie. Nosnbar
IS UANCE DATE
B
Rs m
.}I;L'yJjhJ
pa
MFC ,
Date Con haat.,
_
RUILDIN fLP.ERMIT
1Ir,"INFORMATION
OW'NRR-BUILD1'R DECLARATION
I hereby ulfinn Ihw I um exempt Iium the Contractor'] Licrm.•
Law our OIL• f011uwin'
s, rausun. lYec. 7U 1I.S, Isotecn amt trLrlFssiuns
impro e. d city Gr caunly which my ,Iu, Panuil,I its lct,aaeq
improve. he111UI1]11, „r lottlll' JIIY ]Idle 1. 11 p.1li 1,111, N]Ilan•'e, also
loll Mlle, toted inoa t 1 ]11e11 octant IN file a figmn atllellleltl t sal
III, is licrosvd Punuwu In the pwvi,iun, ul the C'ontracmv: Li¢nac
Law (ChapterY eommm�cing with Section 7000)w Divi,rcin 3 ofthe
Business and Prulcssiuns Code) or Thal he i, excmpl Ih,rei ono turd
MISC. - REFER TO ORD
VALUAT N
`Pq crtin
S/FT.
PERMIT ISSUANCE 10.00
ELEC. CONT 11, LIG, NO.
ELEC.
TOTAL
pEi TO
OTY. PLUMBING PERMIT FEE
5 ORIES
TYPE CONSTR.
the basis for the alleged Isenlptiun. Any si,d,tiun of S,,11.,, 7031.5
by any applicant for a permit objects Ole applicant ma 661penalny
of not mora than five hundred dollen (S500),I:
ALTER -DRAIN & VENT -WATER (EA.) 5.00
❑ 1, as owner of the pwperry, or my employee, wins wages as
their sole compensation, will du the work, :md the Mrucmle Is not
BACK FLOW PROTECT. DEVICE 4.00
OCC. GROUP
RES. UNITS
DRAINS -FLOOR, ROOF, AREA, COND. 5.00
intended or offered I'or sale (See. 7044, Business and I oh..inro
Code: The Contractor's License Law dues sol applyto an owner of
property who build, or improves thereon, and who doe] such work
himself Gr through in, own employee,, provided That wch improve
menu are not intended or offered for sale, 11, however, the building
F IXTURES - PER TRAP 5.00
SO, FT FLOOR AREA
TOTAL ACREAGE
GAS-EA.SYSTEM-1 INC.40UTLETS 6.00
or Imp rove mem i] sold within ane yea, of completion, the owner
builder will have tit, burden of proving that hn I huild or ins-
It, did o
pyfor purpose ofmle.).
1i 1, as owner of tire property, aln exclusively eon Rucbng will)[1
- . ..
GAS EASYSTEM -OVER 4 IEA) 200
BUILDING USE
5 Om
IND CON PB Oa,
0 0 13
INDUSTRIAL WASTE INTER. 30.00
LAWN SPRINKLERS- 1 INC 5 V.8. 6.00ASSESSORS
LAWN SPRINKLERS - OVER 5 (EA.) 1.00
licensed contractors to construct rhe project (See. 7044, Business
and Professions ( a: The Contractor's License Law Joel not apply
u an owner of pr ay who build, Io improve, B it,,i n, and who
PARCEL NO.
c mets for wch p 1 •en with a mnvano11,) lianxd pursuant in
he tractor's s L -c a• .aw,
SEW ER -SANITARY -STORM EA. 200ft/10.00
TRACT NO.
PARCEL N0.
I- cxennpr'• ,B.,4P.C. Gtr obi.
rea> _
Coo a _Dale
WATER HEATER W/VENT 6.00
WATER SYSTEM 5.00
ACC. DATE
AOC. FILE NO.
WATER TREATING EQUIP. 5.00
WORKIiRS'C 11PF-NSATIONI 'CLAIIAIION
I hereby affirm that I h - a cenificare oI L nsenl to cell -insure'
or a certificate n( WUrkelf tom Pen]at ion In,o .lie'. or a ernilll'd
ZONING
ENG. SITE NO.
copy IhaaOf (Set 3300,
Policy No. C'uln Pony
PIKE S'PRWK
Y 0 N ❑
ENERGY T IA
Y ❑ NE]
❑ Cenificd mPy is hereby IurnishcJ.
❑ Certified ropy i, tiled wish the city in]preliun Jivtoun,
Applicant
MISC. - REFER TO ORD.
CERTIFICATE OP EXEMPTION 17ROhl WORKERS'
PERMIT ISSUANCE 10.00
FLOOD ZONE
A.L.U.C.
COWWENSATION INSURANCE
section need not be completed if the Permit is Int one
PLG, CONTE. LIC. NO.
PLG,
TOTAL
Y N
Y N[](This
hundred dollars IS IOU) or less.)
I certify than in the perlonnan v of the work fur which this per-
mil is issued, I shall n.I eel ploy an, pen0n in any manner sa as m
QTY. MECHANICAL PERMIT FEE
FEE SUMMARY
BUILDING
betmnu subject to the Workers' Compensation Laws of C'altionda.
Dale Applicant
ALTER OR ADD TO MECH. 5.00
NO'T'ICE TO APPLIC'AN'T: 11, altar nwking this C1Rh,catc ul' Ek-
APPLIANCE 5.00
AIR HANDLING UNIT (TO 10=GF.M.) 4.00
PLAN CHECK
FEE
emption, you should become subject to the Workefs Compensation
provisions of Ole Labor Cute, you must I'011hwith comply with
such provisions or this permit shall be Jenne) revoked.
AIR HANDLING UNIT (OVER 10=C.F.M.) 6.00
SEISMIC FEE
CONSTRUCT ION LENDING AGENCY
1 hereby of inn that there is a construction )coding agency for
the performance of the work for which this pennit is issued tSec.
3U97, Civ.C.).
EXHAUST HOOD (WITH DUCT) 5.00
MICROFILM
HEATING UNIT (TO 100,000 B.T.U.) 8.00
Lender's Name
Lenders Address
IT UNIT (OV ER 100,000 B.T.U.)
ELECTRIC
l"Rify that l have read lhisapplicutwo and, late that the above
VENTILATION FAN (SINGLE) 4.00
information mlmct. agree to comply with all city and county
Ordinances m ,ole laws Terming no building construction, and
PLUMBING
BOILER -COMP (3 H.P. or 100,000 B.T.U.) 6.00
BOILER -COMP (Over 100,000 BTU) SEE FEE SCH.
MECHANICAL
hereby author I re Fresco moves OI' Ih i, city' to enter upon the
,bove-menlione 1perly for inspection purlmse,,
(We) agr a to n indemnity unJ k.•ep hannlcss the Ciq of
Hints ab trot I hl .ca, juilgnlvnts, nl,n unJ oxpenvz which
In any ' uc uc 'Igain,t sail Ciq in cunsauena• of (h
MISC. - REFER TO ORD.
CONST. TAX
PERMIT ISSUANCE 10.00hgMECH.
jy
CONT. LIC. NO.
MECH.
TOTAL
TOTALmre
of ApPlicans-0ntrInr Ualr
GrFr C__, COPY
POST THIS CARD NEAR FRONT OF BUILDING
CITY OF CUPERTINO
INSPECTION DIVISION -
JOB INSPECTION RECORD'
0
JOB ADDR E
a�(a�17- 901 lg(-) 2)/.
UNITL'OT#
f-
OWNERr,/SS 1� - _ # _
CONTRACTOR
INSPE ION DATE INSPECTOR INSPECTION RECO D
FOUNDATION
UFER
PREGUNITE
POUR NO CONCRETE UNTIL ABOVE HAS BEE SIGNED
UNDERGROUND/SLAB
PLUMBING
ELECTRICAL
_ MECHANICAL
00 NOT POUR FLOOR UNTIL ABOVE HAS BEEN SIGNED I-
MECHANICAL
ELECTRICAL
FRAMING
INSULATION
ROOF
DIAPHRAGM '
APPLY NO ROOFING UNTIL ABOVE HAS BEEN SIGNED
MECHANICAL ...
ENERGY T 24
Y ❑ N ❑
ELECTRICAL -
FINALS
FRAMING
SAN #
INSULATION
PLUMBING
GAS
MECHANICAL
COVER NO WORK UNTIL ABOVE HAS BEEN SIGNED
HEATING
LATH -INTERIOR,
ELECTRICAL
LATH -EXTERIOR
FIRE DEPT.
SHEETROCK '
GRADE
SHEAR INTERIOR -
BUILDING
ISHEAR EXTERIOR I TEMPORARY APPROVAL'z - I
NO
N
ELECTRIC
GAS
PLASTER UNTIL ABOVE HAS BEEN SIGNED JqCCUPANCY
OF BUILDING IS NOT PERMITTED UNTIL BUILDING FINAL IS SIGNED BY BUILDING I
ARRANGE FOR INSPECTION BY PHONING 252-450E
ONE WORKING DAY BEFORE REQUIRED INSPECTI
PLEASE GIVE JOB ADDRESS WHEN PHONING.
-SEE PERMIT FOR EXPIRATION DATE -
IMPORTANT!
PLEASE READ REVERSE SIDE BEFORE
CALLING FOR FINAL INSPECTION.
OFFICE COPY
PFRMIT NUMBER
11176
PERMIT EXPIRATION
PERMIT EXPIRES IF WORK
IS NOT STARTED WITHIN
180 DAYS OF PERMIT ISSU-
ANCE OR 180 DAYS FROM
LASTCALLED INSPECTION.
PERMIT VALIDATION
ISSUANCE DATE
B9.1BLY9.1 ELECT. PLG. MECH,
1 ❑ ❑ ❑
BUILDING PERMIT
INFORMATION
VVJALLLUAATTTIOONN S/FT7
7,✓✓V
FIRESPRINK
Y ❑ N ❑
ENERGY T 24
Y ❑ N ❑
FLOOD ZONE
Y[] NE]
A.L.0 C.
Yo No
FEE SUMMARY
BUILDING
5�
I1C
PLAN CHECK
FEE..
SEISMIC FEE
MICROFILM
ELECTRIC
PLUMBING
MECHANICAL
CONST. TAX
TOTAL
--=