18080 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
BUILDING PROJECT IDENTIFICATION PERMIT NUMBER
gYILDING APPLICATION & PERMIT 1 8 O H O
A0ORESS
BUILDING -ELECTRICAL-PLUMBING -MECHANICAL
OWNER'S PLAN CHECK VALIDATION
NAME [�` CITY. ELECTRIC PERMIT FEE
VHONE J,J' Q tI
C CONTERACTOR'S UTLETS-SWITCHES-RECEP 10.00/1.00 , 00
E rr
uc.nds6p fI
LIGHTING FIXTURES 10.00/1.00 (t OQ
TRACTOR'S PPLIANCES-RESIDENTIAL 4.00
A
RE
55
,�Q nHONE�s 5 - PANELS 10.00 DATE OF APPLICATION
ARCHITECT PLAN CHECK FEE PC.NO.
on PANELS (OVER 200 AMPI 20.00
ENGINEER
LIC.NO. SIGNS TRANS. - 3.00
AARCH.OR DDRESS ENG. SPECIAL CIRCUIT 5.00 PERMIT VALIDATION
IIP TEMP.METER OR POLE INS. 20.00 -,
ARESMOTORS SEE FEE SCH. � 6 V
ADDDDRESSS Z
I
b SERVICE CHANGE PAM 20.00 1O
o o LICENSED CONTRACTORS DECL. ATION \P #A " `vc ��
¢ u'w I hereby affirm that 1 am licensed under provisions of Chapter 9 ISSUANCE GATE
,HA Z Irnmmencin with Section 7000)01'Division 3 of Om Business and
Q y g
H w z Professions Cod --ad my license BLDG. ELECT. PLG. MECH.
is in full to a If � � ❑ ❑
z Licenje Class Lic Numher_ }�/_
m Dale a --Qf_ Contractar Y pct
Q �(6. Of
¢ < OWNER-BUILD DEARATIo rCupertino BUILDING PERMIT r
¢ ¢o A o - INFORMATION
wz,¢ N 1 herchy affirm thal.l an exempt from the Contractor's License MISC.- REFER TO ORD
LL o.a: Law forthe(ollowing reason. 7031.5,Husinessand Professions pERMIT ISSUANCE 10.00. �Q VALUATION $/FT.
� - Code:Any city.,,.but,which requiresa permit to construct,alter, rq'DO
ac ¢¢ p improve,demolish,or repair any structure,prior 10 its issuance,also ELEC.CONTE. _ LIC.NO. - ELEC. (•� V
u W Int u requires the applicant for such permil to filen signed statement that TOTAL/ �0 PERMIT TO
he is licensed pursuant to the provisions of the Contractor's License /„( `�-/
rzi Law
(Claptcr9(commencingwithSection7000)ofDivision3ofthe I�e�ode� P
RusinaW and P,.hawons Code)or that he is excu,n therefrom and CITY. PLUMBING PERMIT FEE
¢ r the basis for the al learn exemption.Any vin IS t ion of Sect ion 703 1.5 STORIES TYPE CONSTR.
a ;$ by any applicant for a permit subjects the applicant toa civil penally ALTER-DRAIN -WATER IEA.) 5.00
Of not more than five hundred dollars($5001.1:
❑'• I,as owner Of the property,nr my th
with wage as r. �
� their sole compensation,will do the work,,and the structure is not BACK FLOW PROTECT.DEVICE 4.00 OCC.GROUP RES.UNITS
intended or offered for Sale(Sec. 7044, Business and ProfessionsDRAINS-FLOOR,ROOF,AREA,COND. 5.00
Code:The Contractor's License Law does not apply to an owner of '
Property who builds.r 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. 4
punts arcIn.t intended or offered for sale.If,however,the building GAS-EA.SYSTEM-1 INC.4 OUTLETS 6.00
or improvement is 'sold within one year of completion, the owner- GAS-EA.SYSTEM-OVER 4(EA.) 2.00
builderwIll have the burden of proving that Ire did not build or im- BUILDING USE,
prove for purpose of sale). INDUSTRIAL WASTEINTER. 30.00 RES IND CON P8 Omar
(21,as owner of the property,ant exclusively contracting with ❑ ❑ ❑ ❑ ❑
licensed contractors to construct Ile 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 property who builds or improves thereon.and who LAWN SPRINKLERS-OVER 5(EA.) 1.00 '
contracts for such projects with it contractons)llcena:d pursuant to SEWER-SANITARY-STORM EA.200ft/10.00
the Contractor',License Law. TRACT NO. PARCEL NO. {
❑ I am exempt under Sec. ,BAP.C.]or this
WATER HEATER W/VENT - 6.00 r�i
reason
Owner Dale WATER SYSTEM 5.00 ACC.DATE ACC.FILE NO.
WORKERS'COMPENSAT10N DECLARATION WATER TREATING EQUIP. 5.00
I hereby affirm that 1 have a certificate of consent to self-insure, ZONING ENG.SITE NO.-
or a certificutu of Workers'Compensation Insurance,or a certifier _
Policy NocPl�t e' �-By�}�i�'ID'7
❑ Cert/lifted cop,,is herchy funtiabed. FIRE SPRINK ENERGY T-24
Z Z ❑ CeT ' d copy is N wiQt the city inspection division. MISC.- REFER TO ORD.
O Applicant Y❑ N❑ Y ❑ N❑
~ w PERMIT ISSUANCE 10,00
� - CIiR'I"ICA'rL OI'IiXEMP'1.1 I'ItOM WOItKF.R$' FLoOO ZONE A.L.U.C.
LU > COMPENSATION INSURANCE. PLG.CONTR. LIC.NO. PLG.
0 ('I[Its section Toed not be completed if the action is for one TOTAL Y❑ N❑ Y ❑ N❑
hundred dullors(S 100)or Icss)
U O I certify that in the performance of the work for which this per- CITY. MECHANICAL PERMIT FEE FEE SUMMARY
LL I- mit is issued,I shall not employ any pars....in any manner so as to
U become subject to the Workers'Compensation Laws of California.
0. Date A li ant BUILDING
>_ 0 NOTICE TO APPLICANT:If,after making this Certificate of Ex- 'ALTER OR ADD TO MECH. 5.00 Dip
F Z emotion,you should become subject to the Workers'Compensation APPLIANCE 5.00 PLAN CHECK
provisions of the Labor Code, you most barthwith comply with FEE 3.2' `v
O
V ' such provisions or this permil shall be deemed revoked. AIR HANDLING UNIT(TO 10,00DC.F.M.) 4,00
` CONSTRUCTION LENDING AGENCY AIR HANDLING UNIT(OVER 10=CF.M.) 6.00 SEISMIC FEE 1 V V
I hereby affirm that there is a construction Icuding'ugency for EXHAUST HOOD(WITH DUCT) 5.00
the performance of the work for which this permit is issued(Sec. MICROFILM
3097,Civ.C). HEATING UNIT(TO 100,000 B.T.U.) 8.00
Lender's Name HEATING UNIT(OVER 100,000 B.T.U.) y�
j_.. Lenders Address ELECTRIC
1 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 conshuction, and BOILER-DUMP(3 H.P.or 100,000 B.T.U.) 6.00
�T hereby authorize representatives of this city to enter upon the BOILER-COMP (Over t00,0000TU1 SEE FEE$CM. MECHANICAL
atiove-mentioned property for inspection purposes.
..(We)agree in save, indemnity and keep handcar the City of MISC.- REFER TO ORD.
Cupertino against liabilities,judgments, costs and expenses which CONST.TAX
PERMIT ISSUANCE 10.00
Try.in any way accrue against said City in consequence of the
ting.(this perm', - - / MECH.CONT. 'LIC.NO. MECH. /
W t'JA � TOTAL TOTAL !
Si azure o Applicant/ ontrador late
OFFICE COPY
POST THIS CARD NEAR FRONT OF'BUILDI'NG
PERMIT NUMBER
CITY OF CUPERTINOgpgp
r INSPECTION DIVISION
JOB INSPECTION RECORD
r ♦ PERMIT EXPIRATION
"JOB ADDRESS 2- _LOT# � PERMIT.EXPIRES IF WORK
OWNER V` 4e. CI h� CONTRACTOR 44 S o IS NOT STARTED WITHIN
I SPECTION DATE INSPECTOR INSPECTION RECORD 180 DAYS OF PERMIT ISSU .
ANCE OR 180 DAYS FROM,
FOUNDATION NOTE: ` LASTCALLED INSPECTION.
UFER - ALL GRADING AND DRAINAGE SHALL BE'INSTALLED
PREGUNITE TO COMPLY',WITH.THE APPROVED PLANS ANDCITY OF w'ERrv+n VALO
IDATIN
CUPERTINO STANDARDS.
GARAGE,SLARS - -_, 0 .s•
POUR NO CONCRETE UNTIL ABOVE HAS BEEN SIGNED
UNDERGROUND./SLAB �`�-
PLUMBING �. ' V< )°v L+L., (•.t;.
ELECTRICAL - ISSUANCE DATE
- MECHANICAL - .Dc E .ecT. PLG. MECH
FMALE D I El ❑ .
DO NOT.POUR FLOOR UNTIL ABOVE HAS BEEN SIGNED 01 BUILDING PERMIT ;
INFORMATION
WOOD FLOOR VALLATION SIFT.
PLUMBING J9
MECHANICAL. S?
.ELECTRICAL (I
FRAMING
IL[
INSULATION - - ii STORIES TYPE coNsrR.
- � OCC GROUP RES UNITS
-PLACE NO SUBFLOOR UNTIL ABOVE HAS BEEN SIGNED
Sp.FT rLOOR AREA TOTAL ACREAGE
ROOF - NOTE.NO FINAL INSP.SHALL BE MADE BEFORE
i ,DIAPHRAGM THE CONSTRUCTION TAX IS PAID
9uILOI u5E
.
'ROOF SHEATHING _ I+es IND CON PIa um1" .
APPLY NO ROOFING UNTIL ABOVE HAS BEEN SIGNED FINALS DATE INSP. - ❑ El ❑ ❑
n SS ESSOR SPnRCF.L NO
ROUGH SAN.a .
PLUMBING , ELECT. ENERGY
THACT NO. PARCEL NO
TUBS 8 SHOWER PAN PLUMBING ENERGY
. MECHANICAL - MECH.ENERGY
ELECTRICAL BUILDING ENERGY ACC DATE - ACC,FILE NO
FRAMING r ELECT.FINAL TEST ZONING ENG.SITE NO.
INSULATION Al lsq - PLUMBING
GAS TEST GAS
• MECHANICAL FIRE SPRINK ENERGY TN
COVER NO WORK UNTIL ABOVE HAS BEEN SIGNED HEATING v ❑ ru❑ ` E]
FLOOD ZONE A,I.U.C.
_ EXTERIOR SHEAR - ELECTRICAL RELEASE
INTERIOR SHEAR - FIRE DEPT. •. V❑ N❑ v ❑ No
SHEETROCK = GRADEFEE SUMMARY
EXTERIOR LATH BUILDING - -
.INTERIOR LATH TEMPORARY APPROVALS BUILDING , 015
SCRATCH COAT ` ELECTRIC PLAN CHECK f/!n
FEE
GAS T�
NO TAPE OR PLASTER UNTIL ABOVE HAS BEEN SIGNED OCCUPANCY SEISMIC FEE I(
OCCUPANCY OF BU I LDI NO IS NOT PERM ITTE DUNTILBUILDI NG F I NA L IS SIGNED BY B U I LDI NG INSPECTOR. MICROFILM
ARRANGE FOR INSPECTION BY•PHONING 252-4505, ELECTRIC d
Ill ONE WORKING DAY BEFORE REQUIRED INSPECTION.
O•� PLUMBING-
PLEASE GIVE JOB ADDRESS WHEN PHONING.
i
- SEE PERMIT FOR EXPIRATION DATE - MECHANICAL
IMPORTANT!
CONST.TAX
PLEASE READ,REVERSE SIDE BEFORE TOTAL
CALLING FOR FINAL INSPECTION. D
OFFICE COPY