11562 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
r' '. #18 11 LDI NG PROJECT IDENTIFICATION PERMIT NUMBER
BUILDING- _ APPLICATION & PERMIT ^ ^ r n n
/CRSS I SAN"C� w Q BUILDING-ELECTRICAL-PLUMBING -MECHANICAL I I `562
OWNER'S PLAN CHECK VALIDATION
NAME C 1 OTV. ELECTRIC PERMIT FEE Sr
PHONE /5
CONTRACTORSZ2- UTLETS-SWITCHES-RECEP 10.00/1.00
(, NAME
T a/2p LU LIC.NO,?g2(,,4 Z- LIGHTING FIXTURES 10.00/1.00
r-ONTRAcroRs 'L PPLIANCES-RESIDENTIAL 4.00
AOOREas ^
-1.1 x..OA"Ifi PHONE 6-31a I PANELS 10.00 DATE OF APPLICATION
ARCHITECTPANELS (OVER 200 AMP) - 20.00 PLAN CHECK FEE P,C.NO.
OR
ENGINEER
Wt LIC.NO, SIGNS TRANS. 3.00
ARCH.OR END' SPECIAL CIRCUIT S.QQ PERMIT VALIDATION
ADDRESS
ZIP TEMP.METER OR POLE INS. .00 P
APPLIC MANTS MOTORS S SCH. OZ -'
ADDRESS - .^p
c SERVICE CHANGE
o o LICENSED CONTRACTORS DECLARATION
a v u I hereby affirm that I am licensed under provisions of Chapter 9 ISSU ,P
w w
(commemm�g with Section 7000)of Division 3 of the Business and BLDG. ELECT-7LG. MECH.
0 y i License Professions Code nil my license Is in full for -and e(f ct.
z o. License Class_ 2-Con Number"
umber Z-
O H Datc�r_). �¢.y_Contracto
x E - BUILDING PERMIT
m rt w a OWNER-BUILDER DECLARATION INFORMATION
DMISC.- REFER TO ORD
w e. I- I hereby affirm that I am exempt from the Contractor's License
a,o 4 Law for the following reason.(Sec.7031.5,Business and Professions PERMIT ISSUANCE 10.00 i VALUATION SIFT.
� w Code:Any city or county which requires a permit to construct,alter,
4
I[Q improve,demolish,or repair any structure,prior to its issuance,also ELEC.CONTR. LIC.N0. ELEC. / �j 0j U u V
ea u requires the applicant for such permit to file a signed statement that TOTAL V CJ PERMIT TO
whe is licensed pursuant to the provisions of the Contractor's License
rzi
Law(Clatter 9(commencingwith Section 7000)ofDivismn3ofthe s�J-,(6lTrOAs/ e[�a`0h
a Business and Professions Code)or that he is exempt therefrom and OTV. " PLUMBING PERMIT FEE
¢ _ $ the basis for the alleged exemption.Any violation of$ection 703 1.5 STORIES T/YP--E,,rrC/O�NSTR.
dg � by any applicant fora permit subjects 500).licant toacivil penalty ALTER-DRAIN&VENT-WATER (EA.) 5,00 / 0 /yA�
of not more than five rpermit)dollars the applicant
❑ 1,as owner of the property,or my employees with wages as BACK FLOW PROTECT.DEVICE 4.00 OCC.GROUP RES.UNITS
their sole compensation,will do the work,and the structure is not
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 does such work FIXTURES-PER TRAP 5.00 S SO.FT.FLOOR AREA TOTAL ACREAGE
himself or through his own employees,provided that such improve-
ments are not intended or offered for sale.If,however,the building GAS-EA.SYSTEM-1 INC.4 OUTLETS 6.00 W 163
L or improvement is sold within one year of completion,the owner- GAS-EA.SYSTEM-OVER 4 (EA.) 2.00
builder will have the burden of proving that Ise did not build or im- BUILDING USE
prove for purpose of sale.). INDUSTRIAL WASTE INTER. 30.00 RES IND CON PB omar
❑ 1,as owner of the property,am exclusively contracting with ❑ ❑ ❑ ❑
licensed contractors to construct the project(Sec. 7044,Business LAWN SPRINKLERS- .B. 6.00 ASSESSORS PARCEL N0.
and Professions Code:The Contractor's License Law does not apply
to an owner of property who builds or improves thereon,and who LAWN SPRINKLERS-OVER 5(EA 1.00
contracts for such projects with a contractors)licensed pursuant to BEWER-SANITARY E /1000
the Contractors License Law. . TRACT NO. PARCEL NO.
❑ I am exempt under Sec. .B.&P.C.for this I WATER HEATER Wi .00 -�
reason 4111
Owner Date WATER SYSTEM .00
ACC.GATE ACC.FILE NO,
WORKERS'COMPENSATION DECLARATION WATER TREATING EQUIP. 5.00
1 hereby affirm that 1 have a certificate of consent to self-insure. ZONING ENG.SITE N0.
or a certificate of Workers'Compentyti0n 3rasurance,or a certified
T` copy thereof(Sec.3800,Lab.C.I R t E.M F�
Policy No. Companyd�C'00"hP 0 ' c Pit
0ElCertified copy is hereby furnished. FIRE SPRINK ENERGY T 24
Z Z ❑ Certified coy Is filed with the city inspection division.
P -
o APPhcant"�" '�ylA _� MISC. REFER TO ORD. Y ❑ N❑ Y E] N[3
LU va PERMIT ISSUANCE 10
.00
CER7Fl
7CATIi OF EXEMPTION FROM WORKERS' FLOOD ZONE A.L.U.C.
W >_ COMPf:NSA1'ION INSURANCE PLG.CONTR. LIC.NO. PLG.
d 0 This section need not be completed if the permit is for one TOTAL S Y❑ N❑ Y ❑ N❑
Z hundred dollars(S 100)or less.)
U 0 1 certify that in the performance of the work for which this per- OTV. _ MECHANICAL PERMIT FEE FEE SUMMARY
LL P mit is issued. I shall not employ any Person in my mannerso as to
U become subject to the Workers'Com enation Laws Of California.
U y Datc Applicant p ALTER OR ADD TO MECH. 5.00 - BUILDING 3,2 e0o
} w NOTICE 'f0 APPLICANT: If,after making this Certificate of Ex-
f" ? emption,you should become subject to the Workers'Compensaliol APPLIANCE 5,00 PLAN CHECK
provisions of the Labor Code, you must forthwith comply with FEE
U such provisions or this permit shall be deemed revoked.- AIR HANDLING UNIT(TO 0 F.M.) 4.00 l-
CONSTRUCTION LENDING AGENCY AIR HANDLINGUNIT IO C.RM.16.00 SEISMIC FEE pJ
I hereby affirm that there is a construction lending agency for EXHAUST HOOD(WITH DU 5.00 S�
the performance of the work for which this permit is issued(Sec. MICROFILM
3097,Civ.C.). ( HEATING UNIT I 0, , ,U.) 8.00
Lender's Name Cfzl� 7/.Cb �/)•-'TL SAN/L
Leader's Addme« / ( 4`0p90'T No- HEATING UN IT( ER 100,WHOM9.50 ELECTRIC 63
1 certify that I have read this application and state that the above VENTILATION FA 4.00
information is correct.1 agree to comply with all city and county PLUMBING
s ordinances and state laws relating to building construction, and BOILER-COMP(3H.P.Or 100,000B.T.U.) 6.00
IheMbyuthorize representatives of this city to enter upon the BOILER-COMP(Over 100,000BTUISEE FEESCH. MECHANICAL
ntioned property for inspection purposesgree to save, indemnify and keep harmless' the City of MISC.- REFER TO ORD.
against liabilities,judgments,costs and expenses which PERMIT ISSUANCE 10.00 d- CONST.TAX
ny way accrue a sins 'ty in co quence of the
f[his permit ^Z a MECHCONT.' LIC.N0. TMECH
OTAL 3�r/U TOTALof A pplican ret r Date C
OFFICE COPY
POST THIS CARD NEAR FRONT OF BUILDING
PrRMIT NUMBER
CITY OF CUPERTINO 11562
INSPECTION DIVISION
JOB INSPECTION RECOD.
,PERMIT'EEXPI RATION
JOBADDRESS I�'J"� I L�1�V�--U I _LOT#
PERMIT EXPIRES IF WORK
OWNER CONTRACTOR IS NOT STARTED WITHIN
INSrECTION DATE INSPECTOR INSPECTION RECORD 180.DAYS OF�PERMIT ISSU-
ANCE OR 180 DAYS FROM
FOUNDATIO 7 LASTCALLED INSPECTION.
UFER
PREGUNITE PERMIT VALIDATION
POUR NO CONCRETE UNTIL ABOVE HAS BEEN SIGNED '
UNDERGROUND/SLAB ,
PLUMBING
ELECTRICAL ISSUANCE DATE
MECHANICAL BLDG. ELECT. 'PLG. MECH.
DO NOT POUR FLOOR UNTIL ABOVE HAS BEEN SIGNED 'x:BUILDING PERMIT
' INFORMATION
WOOD FLOOR
PLUMBING VALUATION SIFT.
9 ,. �r ,.J
MECHANICAL
ELECTRICAL /�T,� T- PERM ITT
FRAMING 7 �7'1/1/� I M"Y :EMO
STORIES TYPE CONSTR.
INSULATION
OCC GROUP RES.UNITS
Rt11' IP.L•ACE,NO SUBFLOOR UNTIL ABOVE HAS BEEN SIGNED D FT.FLDOR AREA TOTAL ALR SAGE
ROOF
-' ,DIAPHRAGM ' -
�aV - - PHLS INp ILBCON USE
PB Omer
J?AP,P.LCY NO ROOFING UNTIL ABOVE HAS BEEN SIGNED El 0 El E 0
ASSESSORS PARCEL NO.
ROUGH
PLUMBING 090A 71 t GAS TEST TRACT NO, PARCEL NO.
-
MECHANICAL
ACC.DATE ACC,FILE NO.
ELECTRICAL ,/3.. FINALS 0DATjEINSP,
FRAMING SAN # ING ENG.SITE NO.
-INSUCATION _ZD PLUMBINGGAS
MECHANICAL V.
FIRE SPRINK ENERGY T.24
COVER NO WORK UNTIL ABOVE HAS BEENSIGNED HEATINGLATH-INTERIOR - FN ELECTRICAL FLOODIONE A.L.U.C.:
LATH-EXTERIOR - FIRE DEPT. Y[] IN Y ❑ N❑,
SHEETROCK -,. ;!+ GRADE FEESUMMARY
SHEAR INTERIOR - BUILDING -/
SHEAR EXTERIOR -�� TEMPORARY APPROVALS// BUILDING
FIREWALLS - ELECTRIC PLAN CHECK
GAS FEE
LNO TAPE OR PLASTER UNTIL ABOVE HAS BEEN SIGNED OCCUPANCY SEISMIC FEE
OCCUPANCY OF BUILDING IS NOT PERMITTED UNTIL BUILDING FINAL IS SIGNED BY BUILDING INSPECTOR. MICROFILM
ARRANGE FOR INSPECTION BY PHONING 252.4505, ELECTRIC
IfW� ONE WORKING DAY BEFORE REQUIRED INSPECTION. PLUMBING
!o PLEASE GIVE JOB ADDRESS WHEN PHONING.
MECHANICAL
- SEE PERMIT FOR EXPIRATION DATE -
IMPORTANT!
CONST.TAX
PLEASE READ REVERSE SIDE BEFORE TOTAL
CALLING FOR FINAL INSPECTION.
OFFICE COPY