C 9411 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
BUI LDI NG PROJECT 1 DENTI FICATI .- PERMIT NUMBER
th-uh- irG APPLICATION & PER 9 411
ADDRESS
BUILDING - ELECTRICAL-PLUMBING-MECHANICAL
OWNEfl' �.w -
NAME AN ECK VALIDATION
j su QTY. ELECTRIC PERMIT a FEE
4
CO
PHONE
CONTRA Tons UTLETS-SWITCHES-RECEP 10.00/1.00
NAME
GA`N LIC.NO, 3� 3 LIGHTING FIXTURES 10.00/1.00 }
CONTRACTORS APPLIANCES,RESIDENTIAL 4.00
ADD s ����t,
1001kl.q'Plll PHONE left
PANELS 10.00
DATE OF APPLICATION
OR
ARCHITECT PANELS (OVER 200 AMP) 20.00 PLAN CHECK FEE P.C.NO.
ENGINEEfl
Gi LEC.No.GG 22 SIGNS TRANS.- 3.00
A.....EEss ERG' / .'y SPECIAL CIRCUIT 5.00 PERMIT VALIDATION
6� O d/D�IV04 z I P
EMP.METER OR POLE INS. 20.00 /J
APPucANrs MOTORS SEE FEE SCH. //�`
ADDREss
�� �{^/g,S�4�✓ - , SERVICE CHANGE 20.00 ps-�+
woo LICENSED CONTRACTORS DECLARATION TEMP.POLE 30.00 L��l/7
a
to I hereby affirm that I am licensed under provisions of Chapter 9
H z iISSUANCE DATE
(commencing with Section 7000)of Division 3 of the Rosiness and ELECT. PLG. MECH.
r m z Pro fessions Co�de�,/�B�qqffI/Ippy license ie In full 4r<•' e q � ❑
z o m - License sso Lia Number
o z - Dote t Contractor
N
a rL ING PERMIT,
rz a w u OWNER-BUILDER DECLA RATION INFORMATION`S F
w ;n y I hereby affirm that I am exempt from the Contractor's License MISC.- REFER TO ORD p
r .. m ret to cons
j Law for the following mason.(Sec.7031.5,Business and Professions PERMIT ISSUANCE 1000 �I 0)N SIFT.
Code:Any city Or County which requires a permitruct,alter,
.
Q p Q Improve,demolish,or repair any structure,prior to Its issuance,also ELEC.CONTR. LIC.NO. ELEQ
- D LL H,goires the applicant for 50th permit to file a signed slalement that TOTAL /PERMIT TO
u w ce he is licensed pursuant to the provisions of the Contractor's License -
F z i Law(Chapter 9fcommencingwith Section 7000)OfDivision3ofthe TC'A/Q4N7 ��1J9f01/6' a
i o Business and Professions Code)or that he is exempt therefrom and OTY. PLUMBING PERMIT FEE
1- $ file basis for file alleged exemption.Any violation Df Bemion 7031.5 1 STORIES TYPE CONSTR.
w. by any applicant for a permit subjects the applicant to a civil penalty ALTER-DRAIN -WATER (EA.) 5,00
of not more than five hundred dollars(5500).):
❑ 1,as owner of the properly,or my employees will.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 (See. 7044, Business and Professions DRAINS-FLOOR,ROOF,AREA,COND. 5.00
Code:'file 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 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-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 hudd or um. GAS-EA.SYSTEM-OVER 4 (EA.) 2.00 BUILDING USE
PIT
1,aso nee of sale.). INDUSTRIAL WASTE INTER. 30.00 0 to c❑ON O Other
❑ d as owner of the property,he exclusively. 7044,ling with
licensed Professions
tars to construct the project(Sec. 7044,Business LAWN SPRINKLERS-1 INC 5 V.B. 6.00 ASSESSORS PARCEL NO.
and Professions Code:The hontmulor's improv Low does not apply
to as Owner of propertywithaildsor lrimprovesensed pursuant
and who LAWN SPRINKLERS-OV OVER 5(EA.) 1.00
contracts for such censeprojects with a conlracmrts)licensed pursuam to
the [am exempt
License Law. SEWER-SANITARY-STORM EA.200ft/10.00 TRACT NO, PARCEL NO.
❑ tum exempt under Sea ,B.&I'.C.for this
reason WATER HEATER W/VENT 6.00
Owner Date WATER SYSTEM 5.00 ACC.DATE ACC.FILE NO.
WORK FRS'COMPENSATION DECLARATION WATER TREATING EQUIP. 5.00
1 hereby affirm that I have a certificate of consent to seltBnsHm,
or a certificate of Workers'Compensation Insurance,or a certified ZONING ENG.SITE NO.
He,thv;4(See 800,Lab.C.I /,,,�T
Policy Nc(,LLW company_SCL w «�
Q ❑ Certified co is hereby furs'! d FIRE SPRINK ' ENERGY T2
Z
Z ❑ Cerli ti ' y is bled s i s he city Ins eaion,Aiv.,on.
nppr /Q,
MISC.- REFER TO ORD, v � N� v � N�
c - ERTII ATI:OF EXEMPTION FROM WORKERS'- PERMIT ISSUANCE 10.00 FLOOD ZONE A.L.U.C.
L COMP17NSATION INSURANCE PLG.CONTR. LIC.NO. PLG.
1 O (This section need not he completed if the permit is for one TOTAL v N� Y 0 NEl
LD Z hundred dollars IS I OD)or less.)
) 0 1 certify that in the performance of the work for which this per- CITY. MECHANICAL PERMIT FEE FEE SUMMARY
IL 1- mit is issued, I shall not employ any person in any manner so as to
O W become subject to the Workers'Compensation Laws of California.
d Datc Applicant ALTER OR ADD TO MECH. 500 BUILDING ��
} m NOTICE 1'O APPLICANT: IL after making this Certificate of Ex"
.
Z emption,you should become subject to the Workers'Compensation gppLIANCE 5.00 PLAN CHECK
provisions of the Labor Cade, you must forthwith comply with FEE
U such provisions or this permit shall be deemed revoked AIR HANDLING UNIT(TO 10,000C.F.M.) 4.00
CONSTRUCTION LENDING AGENCY AIR HANDLING UNIT(OVER IO,OODC.F.M.) 6.00 SEISMIC FEE p7N�
I 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. MICROFILM
3097,Civ.C.L HEATING UNIT(TO 100,000 B.T.U.) 8.00
Lender's Name
Lender's Address HEATING UNIT(OVER 100,000 B.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. I agree to comply with all city and county PLUMBING
ordinances and state laws relating to building construction, and BOILER-COMP(3 H.P.Or 100,000 B.T.U.) 6.00
hereby entiorid representatives forms of this city es enter upon the BOILER-COMP (Ove,100,000 BTU)SEE FEE SCH. MECHANICAL
above-mentioned property forinsp ofth i purposes.
(We) 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
nuxy in way accrue against '� City in consequence of the
"anti of lh 'permil' MECH.COAT. LIC.NO. MECH. �1
TOTAL TOTAL
' n fApphCant on utc '
OFFICE COPY
L
POST THIS CARD NEAR FRONT OF BUILDING
CITY®F CUPERTINO • Rml[NOmBER
INSPECTION DIVISION f 1 :9411
JOB INSPECTION RECORD
//nn//••�� PERMIT EXPIRATION '
JOBADDRESS '/I�(l/ lu� � •y��I Y��I ale. UNIT# LOT# '
—T �^ PERMIT EXPIRES IF WORK'
OWNER �. I CONTRACTORI tkf J) II • IS NOT STARTED WITHIN
INSPMTIOW DATE INSPECTOR INSPECTION RECORD 180 DAYS OF PERMIT ISSU- '
FOUNDATION - �('2i S(d. G(DfU1fG ANCE OR, 180 DAYS FROM
UFER
LAST CALED INSPECTION— �y
� � _ , .
PREGUNITE - G ,LLt�F•r O PERmlr vnuonnON
POUR NO CONCRETE UNTIL ABOVE HAS BEEN SIGNED '• _ ,,,4 �..+
UNDERGROUND SAB
PLUMBING
ELECTRICAL i • � (�a'
ISSUANC DATE
MECHANICAL BLDG.. -ELEr. LC mEC
DO NOT POUR FLOOR UNTIL ABOVE HAS BEEN SIGNED Bu o NG ER
WOOD FLOOR FOR ATION
PLUMBING - - VALUATION..
MECHANICAL - - - .
ELECTRICAL PERmrt ro c
FRAMING
INSULATION ' - STORIES TVP CONSTR. .
OCC.GROUP RES,UNITS
PLACE NO SUBFLOOR UNTIL ABOVE HAS BEEN SIGNED
i5 ROOF - SO,FT,FLOOR AREA TOTAL ACREAGE
DIAPHRAGM _IAW� v� ' BUILDING USE
'h 1• HES IND CON PB Other
APPLY NO ROOFING UNTIL ABOVE HAS BEEN SIGNED o ❑ o 0 ❑
ROUGH t d ASSESSORS PARCEL N O,
PLUMBING - - ,
GAS TEST / e TRACT NO. PARCEL NO.
MECHANICAL- _ . vp�i�/';14r
ACC.DATE ACC.FILE NO.
ELECTRICAL. - - FINALS DATE INSP.
• -FRAMING SAN #
ZONING ENG.SITE NO.
INSULATION � PLUMBING �O �
FIRE SPRINK ENERGY T-2E
MECHANICAL
COVER NO WORK UNTIL ABOVE HAS BEEN SIGNED HEATING Q "� "�
LATH-INTERIOR - ELECTRICAL
-a FLOOD ZONE- A.LUC.
LATH-EXTERIOR FIRE DEPT. - Y "❑ Y❑ N❑
SHEETROCK -( : GRADE FEE SUMMARY
SHEARINTERIOR _ BUILDING .. Q-�y' -
BUILDING
SHEAR EXTERIOR .T R PPROVALS
FIREWALLS ELECT - PLAN CHECK
LGA
TAPE OR PL ST R U TIL ABOVE BEN SIGNED OCCUPANCY SEISMIC FEE t
OCCUPANCY OF,BUILDING IS NOT PERMITTED UNTIL BUILDING FINAL IS SIGNED BY BUILDING INSPECTOR. MICROFILM
ARRANGE'FOR INSPECTION BY PHONING 252-4505, ELECTRIC
LU
ONE WORKING DAY BEFORE REQUIRED INSPECTION. : PLUMBING
PLEASE GIVE JOB ADDRESS WHEN PHONING.
- MECHANICAL
— SEE PERMIT FOR EXPIRATION DATE —
CONST.TAX
IMPORTANT.
PLEASE READ REVERSE SIDE BEFORE TOTAL
CALLING FOR FINAL INSPECTION.
. OFFICE COPY -