11224APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
BU LD1 NG PROJECT IDENTIFICATION
APPLICATION & PERMIT
BUILDING -ELECTRICAL- PLUMBING - MECHANICAL
PERMIT NUMBER
11224
BUILDING
ADDRESS
OWNER'S
"AME��//
e'o/[i� /(,/fi // ` - PHONE
DTV. ELECTRIC PERMIT FEE
PLAN CHE VALIOATIpN
S ALI D !T I
y TT !/
�U G,p
DATE OF APPLICATION
CONTRACTOR'S
NAME //��
J -EA/ 00,VSy. uC. NO, /
OUTLETS -SWITCHES 10.0011.00
LIGHTING FIXTURES 10.00/1.00
ADDRESS TRAC Ons
COL/�' ��t,
e 1H '/
APPLIANCES - RESIDENTIAL 4.00
PANELS 10.00
R HITECT
OR %5L 00lP
ENGINEEP/ {s
` LIC.N., V
� �f�
PANELS (OVER 200 AMP) 20.00
PLAN CHECK FEE P.C. NO.
SIGNS TRANS, 3.00
ARCN. OP ExG.
AooREss '7• '�•,��
%QQ �IL$r �/ zIP
SPECIAL CIRCUIT 5.00
PERMIT VALIDATION
EMP. METER OR POLE INS. 20.00
APPLICANTS 04114165
DDRESS
IMOTORS SEE FEE SCH.
301IULSow M. :%yiRRu9
SERVICE CHANGE 20.00
LICENSED CONTRACTORS DECLARATION �Z 10
I hereby afOrm that 1 am licensed under provisions of Chapter 9
(commencing with Section 7000) of Division 3 of the Business and
Professions Code, and my license is in full farce and effect.
ISSUANCE DATE
License Class Lic. Number
Dale - Contractor
B NG PE
IAWT-
INFORMATION
OWNER -BUILDER DECLARATION
I hereby affirm that I am exempt from the Contractor'sMISC.
License
Law fornidi the following r ountywhichee. 703 requires a perminess t to construct, altos
Cade: Any dryer county r pair any structure p riot t o is issuance. also
prior to its issuance, also
improve, demolish, or repair h p structure, to
requires the applicant for such permit to file a signet) statement that
he is licensed pursuant to the provisions of the Contractor's License
REFER TO ORD
-PERMIT ISSUANCE 10.00
VALUATION
l
$/FT.
ELEC. CONTR. LIC. N0. ELEC.
TO
PERMIT TO
of Division 3 of the
Low (Chapter 9 (commencing with Section is exempt
Business and Professions Code) or that he is exempt therefrom and
DTV. PLUMBING PERMIT - FEE
S DRIES
TYPE CONSTR.
the basis for the alleged email subjects
Any violation of Section malty
by any applicant fora permit didlatsiheapplicunt loaeivilpenalty
of not more than five hundred dollaa (5500)J:
ALTER -DRAIN -WATER IEA.) 5.00
❑ 1, as owner of the property, or my employees with wages as
their sole compensation, will do tine work, and the structure is not
BACK FLOW PROTECT. DEVICE 4.00
OCC. GROUP
RES. UNITS
DRAINS LOO ROOF, AREA, GOND. 5.00
intended or offered for sale (Sec. 7044, Business and Professions
Code: The Contractor's License Law does not apply to an owner of
FIXTURES - PER TRAP 5.0
GAS - EA. SYSTEM - I INC. 4 OUTLETS 6.00
SO.FT.FLOORAREA
TOTALACREAGE
property who builds or improves thereon, and who does such work
himself or through his own employees, provided that such improve-
ments are not intended or offered for sale. If, however, the building
.,Improvement is sold within one year of completion, the owner-
builder will have the burden of proving that he did not build or int-
prove for purpose of sale.).
❑ 1, as owner of the property, am exclusively contracting with
GAS - EA. SYSTEM -OVER 4 (EA.) 2.00
BUILDING US
ES -IND CON B Omer
Q. 11
INDUSTRIAL WASTE INTER. - 30.00
licensed contractors to construct the project (Sec. 7044, Business
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 - 1 INC 5 V.B. 6.00
LAWN SPRINKLERS - OVER 5 (EA.) 1.00
ASSESSORS PAR L O.
_
contracts for such projects with a contractor(,) licensed pursuant to
(lie Contractor's License Law.
SEWER -SAN EA. 200ft/10.00
TRACT NO.
PARCEL NO.
O Ian. extmptrodm Sec. ,B.&P.C.for this
reason
WATER HEATER W/VENT 6.00
Owner Dale
WATER SYSTEM 5.00
ACC.DATE
ACC. FILE NO,
WATER TREATING EQUIP. 5.00
WORKERS'COMPENSA'PION DECLARATION
1 hereby affirm that I have a Certificate of consent to self -insure.
ate of Workers' Com ensat! pn�psuraic of gyr�IfieJ
p1.(/ r%rya
ZONING
ENG. SITE NO.
to there (Sec. 3800, Lah.G f'r a'O// 3 1.7
Policy N CompanyFl":�.FS-f=81L�2_
FIRE SPRINK
Y [:] N ❑
ENERGY T24
Y C] N�
entified copy is h 'rich, Noom ed. -
I Cup Ir file Witl h1!•-1'Ily inspection division.
Applita
MISC. - REFER TO ORD.
Ii RTI F I CATE OF 1: XP-Ml ION 17 ROM WO RK 1: RS'
PERMIT ISSUANCE 10.00
FLOOD ZONE
A. L. u.C.
COMPENSATION INSURANCE
(This section need not he completed if the permit is for one
Y ❑ NF]
Y ❑ N
PLG. CONTR. LIC. NO.
PLG.
TOTAL
hundred dollar, IS 100) or lass)
I certify that in the performance at (lie work for which this per-
mit is issued, 1 shall not employ any person in any mannerso as to
DTV. MECHANICAL PERMIT FEE
FEE SUMMARY
BUILDING
become subject to the Workers' Compensation Laws of California.
Date Applicant
NOTICE TO APPLICANT: If, after making this Certificate of Ex-
ALTER OR AD_ D TO MECH. 5.00
APPLIANCE 5.00
PLAN CHECK
FEE
emption, you should become subject to the Workers' Compensation
provisions of the Labor Code, you must forthwith comply with
such provisions or this permit shall be deemed revoked.
AIR HANDLING UNIT (TO 10MC.F.NL) 4.00
AIR HANDLING UNIT (OVER 10=C.F.M.) 6.0
SEISMIC FEE
CONSTRUCTION LENDING AGENCY
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.
3097, Civ.C.).
MICROFILM
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
VENTILATION FAN (SINGLE) 4.00
1 certify that I have read this application and state that the above
information is correct. I agree to comply with all city and county
ordinances and state laws relating to building construction, and
PLUMBING
BOILER -COMP (3 H.P. Or 100,000 B.T.U.) 6.00
BOI LER-COMP (Over 100,000 BTU) SEE FEE SCH.
MECHANICAL
--
hereby authorize representatives of this city to enter upon the
above-mentioned property for inspection purposes.
(We) agree t ve, derinlfy and keep harmless the City of
Cupertino agar t liabilit •s, judgments, costs and expenses which
may in any ay accru- against said City in consequence of the
graining of lhi permit
y)
MISC. - REFER TO ORD.
,pERMIT ISSUANCE 10.00
CONST. TAX
MECH. CONT. LIG NO.
TOTAL
IJAI
TOTAL
Signature on[ractor Radio
UFPICt GUPV
I 'w
POST THIS CARD NEAR FRONT OF BUILDING
CITY OF CUPERTINO „
PFR6 ITN NUMBER,
11.224
INSPECTION DIVISION.,
JOB INSPECTION RECORD
(/�/� ,q/'L}I �1^ oyj (/� e:
l Shiye `5 reek
a PERKMMEXPIRATION
� f I I
JOBA .QRESS `&1— • UNIT# _ _LOT#
J
PERMIT EXPIRES IF WORK
//��
OWcNER . 1 C1 Y115 CONTRACTOR
' IS NOT STARTED WITHIN
180 DAYS OF PERMIT ISSU-
ANCE OR 180 DAYS FROM
LASTCALLED INSPECTION.
INSPECTION DATE INSPECTOR
INSPECTION RECORD
FOUNDATION
_ -
UFER
PREGUNITE
PERMIT VALIDATION
ISSUANCE DATE
POUR NO CONCRETE UNTIL ABOVE HAS BEEN SIGNED
UNDERGROUND/SLAB
PLUMBING
ELECTRICAL
MECHANICAL
-
'Br
ELE
PLG M c
.
DO NOT POUR FLOOR UNTIL ABOVE HAS BEEN SIGNED
'
IS ILDING PE Myr
INFORMATION
WOOD.F FLOOR
VALUATION
$/FT. '-
PLUMBING
MECHANICAL
ELECTRICAL
PER TO -
FRAMING -
INSULATION -
s DRIES
TYPE CONSTR.
-
OCC,GROUP
RES. UNITS
PLACE NO SUBFLOOR UNTIL ABOVE HAS BEEN SIGNED
• ROOF -
C'
SO FL R.00R AREA
TOTAL ACREAGE
DIAPHRAGM
Ru DINr, usE,
_
dj p /
RES IND CON PB 4.ihpf,
'❑ -
APPLY NO ROOFING UNTIL ABOVE HAS BEEN SIGNED
nssessoas PAR/1c�L N,D.
"
ROUGH -
I
alz
PLUMBING /
GAS TEST
-
TRACT NO.
PARCEL NO.
MECHANICAL:
ELECTRICAL /p-/-
FINALS ___5ATE INSP.
ACC, DATE
ACC. FILE NO.
FRAMING
SAN #"
INSULATIONIt — A-6
PLUMBING
ZONING
,
ENG. SITE NO.
GAS
MECHANICAL
FIRE SPRINK
v ."�
ENERGY T"24
v Nl:l
COVER NO WORK UNTIL ABOVE HAS BEEN SIGNED
HEATING
LATH—INTERIOR
ELECTRICAL.
FLOOD ZONE
Y� N[:)
ALUC.
yo N❑
LATH—EXTERIOR
FIRE DEPT. _
SHEETROCK -
GRADE IIL7, [o-y-yb
FEESUMMARY
SHEAR INTERIOR
BUILDINGD 6
BUILDING
/
/ (µ
SHEAR EXTERIOR
TEMPORARY APPROVALS
FIREWALLS -
ELECTRIC -
PLAN CHECK
FEE
•
GAS
IND TAPE OR PLASTER UNTIL ABOVE HAS BEEN SIGNED JOCCUPANCY
SEISMIC FEE
ff
OCCUPANCY OF BUILDING ISNOTPERMITTED UNTIL BUILDING FINAL ISSIGNED BY BUILDING INSPECTOR.
MICROFILM
ARRANGE FOR INSPECTION BY PHONING 252-4505,
ELECTRIC
/
o�' ONE WORKING DAY BEFORE REQUIRED INSPECTION.
PLUMBING
PLEASE GIVE JOB ADDRESS WHEN PHONING.
MECHANICAL
z -SEE PERMIT FOR EXPIRATION DATE -
CONST. TAX '
IMPORTANT!
TOTAL
i r
PLEASE READ REVERSE SIDE BEFORE
CALLING FOR FINAL INSPECTION.
OFFICE COPY