8995 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES ,- USE BALL POINT PEN ONLY
BU I LDING PROJECT IDENTIFICATION PERMITNUMBER
moLD,NG APPLICATION & PERMIT n n
ADDRESS
101 � BUILDING -ELECTRICAL-PLUMBING-MECHANICAL `9' ``J
NAME
RS '�1 - !' ,� LAN CHECK VALIDATION
--may 0 Y. ELECTRIC PERMIT FEE
PHONE
,•i., NOMERAcioRs UTLETS-SWITCHES-RECEP 10.00/1.00 ,
LIGHTING FIXTURES 10.00/1.00
CONTRACTOR'S
A--R / PPLIANCES-RESIDENTIAL 4.00
/ 1; _/�V PRONE; VV PANELS 10.00 DATE OF APPLICATION
AllRRcci• PLAN CHECK FEE P.C.NO.
oR J -�.� 7 PANELS (OVER 200 AMP) 20.00
ENGINEER /� SIGNS TRANS. 3.00
LIC.N0.
r noon,orrEZZrvc� SPECIAL CIRCUIT 5.00 1 IDATION
v�. //4 M7 r 2 7Cl EMP.METER OR POLE INS. 20.00 t� e
MOTORS SEE FEE SCH. 'JUN 3 - 1986
SERVICE CHANGE' 20.00
0 0 i
0 o LICENSED CONTRACTORS DECLARATION TEMP.POLE 30.00 City of Cupertino
u u I hereby affirm that I am licensed under provisions of Chapter
w< "' (commencing with Section 7000)of Division 3 of the Business and IISSUANCE DATE
Professions Code,.W 14 license is in full force dD EC PLG. MECId.
G i u C License C Con r Number for
r Date Contractor
F - J
a w n, OWNER-BUILDER DECLARAT IOPM y B LDIN ERM
°LL U MISC.- REFER TO ORD " NFORMATIO ..
X ; N I hereby affirm that I am exempt from the Contractor's License
H u 0 j ou
Law for the following reason,(See.7031.5,Busu essand Professions VALUATION E/FT.
ve Code:Any city-,cnty whichrequires a permit to construct,alter, PERMIT ISSUANCE 10.00 10
m a o improve,demolish,or repair any structure,prior to its issuance,also EL CON LIC.NO. ELEC.
0 a, requires the applicant for such permit to file u signed statement that ,� � G� OTA / MIT TO
a w m he is licensed pursuant to the provisions of the Contractor's License
�zQLaw(Chapter 9(commencingwith Section 7000)of Division 3 ofthe
f 4 0 Ilusiness and Professions Code)or that he is exempt therefrom and OTY. PLUMBING PERMIT FEE
a I-w the basis for the alleged exemption.Any violation of Section 7031.5 5 TYPE STR.
i by may applicant fore permit sonars the applicant roacivil penalty ALTER-DRAIN -WATER (EA.) 5.00 O
of not more than fora hundred dollars the ap.li
❑ I,as owner of Inc properly,or my employees with wages as BACK FLOW PROTECT. DEVICE 4.00 OCC.GROUP RES,UNITS
intended
sole c-mpered ion,will(S the work,and the stnlct of is not
intended or offered for sale (Sec. 7044, Rosiness oto Professions DRAINS-FLOOR,ROOF,AREA,COND. 5.00
Code:The Contractor's License Law does not apply to un owner of
property who builds or improves thereon,and who does such work FIXTURES-PER TRAP 5.00
himself or through his own employees,provided that such Improve. 50.FT.FLOOR AREA TOTAL ACREAGE
ments are not intended or offered for sale.If,however,the building GAS-EA.SYSTEM-11NC.40UTLETS 6.00
or improvement is sold within one year of completion,the owner-
builder will have the burden of proving that he did not build or im- GAS-EA.SYSTEM-OVER 4(EA.) 2.00 BUILDING USE
prove for purpose of,eb.), INDUSTRIAL WASTE INTER3000 RE IND CON PB other
13 . .
I,as owner of the properly,am exclusively contracting with ❑ El ❑ 1:1licensed 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 does not apply
to an owner of properly who builds or improves thereon.and who LAWN SPRINKLERS-OVER 5(EA.) 1,00
contracts for such projects with a contractorfs)licensed pursuant to
the Contractor's License Law, SEWER-SANITARY-STORM EA.200ft/10.00TRACT NO. PARCEL NO.
❑ 1 um exempt under Sec. ,B.&P.C.for this
reason WATER HEATER W/VENT 6.00
Owner ate WATER SYSTEM 5.00 ACC.DATE ACC.FILE NO,
WORKERS'COMPENSATION DECLARATION WATER TREATING EQUIP. 5.00
I hereby affirm that I have a certificate of consent to scb&insure,
or a certificate of Workers'Compensation Insurance,or a certified ZONING
Pe ENG.SITE N0.
Copy thereof fSec.3800,Lab.C.).��/tir too
Policy No. � om any
Q ❑ Ceflifie yIs b furnished. FIRE SPR I NK ENERGY T.24
Z Z �Cerlif d cop is with the Ifs ee n llvaion.
F p ppbc:mt IRMSC.- REFER TO ORD. v❑ N❑ v ❑ N❑
CCN CER'I'll% Ii OFEXFMPTIONF OM/ ORKI:RS• PERMIT ISSUANCE 10.00 FLOOD ZONE A.L.UC.
LU >; COMPENSATION INSURANCE. PL N �C.N0. PI.G.
CL Cl (This section need not be completed if the ❑ ❑ ❑ N❑
I permit is fm one TOTAL Y N Y
0 Z I hundred dopers(S 100)pe less.)
U O� 1 certify that it the performance of the work for which this per- OTY. MECHANICAL PERMIT FEE FEE SUMMARY
LL F. 'mit is issued,I shall not employ any person in any manner so as to
Q W' become subject to the Workers''Compensation Laws of California.
C. Date-Applicant ALTER OR ADD TO MECH. 5.001BUILDING
to /} NOTICE TO APPLICANT: If,after making this Certificate of Ex-
r 2
eruption,you should become subject to the Workers'Compensation APPLIANCE 5.00 PLAN CHECK
provisions of the Labor Code, you most forthwith comply with
U such provisions or this permit shall he deemed revoked. AIR HANDLING UNIT(TO 10A000.F.M.1 4.00 FEE
CONSTRUCT ION LENDING AGENCY AIR HANDLING UNIT(OVER IOMC.F.M.) 6.00 SEISMIC FEE
I hereby affirm that !here is a construction lending agency for EXHAUST HOOD (WITH DUCT) 5.00
the performance Of the work fo whicI this permit is issued(Sec. MICROFILM
3097,Civ.C.). �' HEATING UNIT(TO 100,000 B.T.U.) 8.00
Lender's Name A i
Lenders Address HEATING UNIT(OVER 100,0008.T.U.)9.50 ELECTRIC
I Certify that I have read this application and state that the above VENTILATION FAN (SINGLE) 4.00
information is correct. 1 agree to comply with all city and county PLUMBING �-
ordinances and state laws relating to building construction, and
of this BOILER-COMP(3 H.P.or 100,000 B.T.U.) 6.00
hereby authorise representatives ths city to enter upon the
SIR, n ed properly for inspection purposes. BOILER-COMP(Over 000 BTU)SEE F E ESCH. MECHANICAL r'r
C
(We) agree to ve, indemnify and keep harmless the City of MISC.- 100, REFER TO 0
Cupertino . n f bilines,judgme s, costs and expenses which CONST.TAX
may i ey y Cerus ug st s City in rot:eque cc f the PERMI ISSUANCE 10.00
grant got it. MEC .CONT. LIC.NO. MOTAL
Sign fee pplicant/Contractor !yam 1) e �Jq/ TOTAL
OFFICE COPY
POST THIS CARD NEAR. FRONT OF BUILDING
PFR MIT NUMBER '
CITY OF CUPERTINO � ,
INSPECTION DIVISION
JOB IN PECTIO CORD
//J�Q/� PERMIT EXPIRATION
JOB ADD SS 1-' tlAIIT# ' LOT 7k
.•1 PERMIT EXPIRES IF WORK
OWNER C CTOR .IS NOT STARTED WITHIN '
INSPEC ION ATE INSPECTOR INSPECTION RECORD aBa onvS OF 'ERMIi Issu-
FOUNDATION - ANCE OR 160 DAYS FROM., .
LASTCALLED INSPECTION
UFER .i
` / 4 PERMIT VALIDATION
PREGUNITE 6 D .
C .¢ _/
'
POUR NO CONCRETE UNTIL ABOVE HAS BEWSMNED ///
UNDERGROUND /SLAB CJ'
PLUMBING [
ELECTRICAL '
ISSUANCE DATE
MECHANICAL OLDOA ELECT, I PLG. MEC .
00 NOT POUR FLOOR UNTIL ABOVE HAS BEEN SIGNED - , ' BUILDING-PERMIT
WOOD FLOOR ; INFORMATION
PLUMBING
VALUATION $/FT.
' � -. -" - , . -
MECHANICAL .-,'•�
ELECTRICAL MITT
FRAMING
INSULATION - • ST IES TYPE CONSTR.�
- OCC.GROUP
- S.UNITS
PLACE NO SUBFLOOR UNTIL ABOVE HAS BEEN SIGNED -
ROOF ` $O.fT.FLOORAREA iOTALACREAGE
DIAPHRAGM
BUILDING USE
RES IND CON PB GO,, '
APPLY NO ROOFING UNTIL ABOVE HAS BEEN SIGNED _❑ 0 1:1 11
ROUGH ASSESSO R S PARCEL NO.,
PLUMBING -
GAS TEST ' TRACTNO. PARCEL No.
MECHANICAL- '•
ELECTRICAL _� .,f�-b4941 FINALS DATE INSP. ACC.OATE ACC.FILE NO.
FRAMING SAN # '
INSULATION ZONING ENG.SITE NO.
PLUMBING'
' GAS -
MECHANICAL FIRE SPIRINK T-24
COVER NO WORK UNTIL ABOVE HAS BEEN SIGNED HEATING Y "� Y ❑ "C]
FLOOOZONE A.L.O.C. '
LATH-INTERIOR ELECTRICAL - -
T. ' LATH-EXTERIOR _ FIRE DEPT. Y_[D NO Y (� N❑
} SHEETROCK r GRADE FEE SUMMARY
�. SHEAR INTERIOR BUILDING p. ¢
• SHEAR EXTERIORT MPORARV OVALS BUILDING
FIREWALLS ELECTRIC PLAN CHECK
GAS. FEE
NO TAPE OR PLASTER UNTIL ABOVE HAS BEEN SIGNED OCCUPANCY' SEISMIC FEE t
OCCUPANCY OF BUILDING IS NOT PERMITTED UNTI L BUI LDING FINAL IS SIGNED By BUILDING INSPECTOR:
MICROFILM
ARRANGE FOR INSPECTION BY PHONING 252-4505, ELECTRIC
I� ONE WORKING DAY BEFORE REQUIRED INSPECTION. PLUMBING
z PLEASE GIVE-JOB ADDRESS WHEN PHONING.
— SEE PERMIT FOR EXPIRATION DATE — MECHANICAL
CONST.TAX
IMPORTANTI
PLEASE READ REVERSE-SIDE BEFORE TOTAL
CALLING FOR FINAL INSPECTION.
OFFICE COPY, -