C 9180 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
BU LDI NG PROJECT I DENTI FIG ON PERMIT NUMBER
BUILDINGAPPLICATION & PIhnMIT 9180
ADDRESS BUILDING - ELECTRICAL-PLUMBING-MECHANICAL
OWNER'S PLAN CHECK VALIDATION
NAME yN� f , • ••yY}y'�rp a.
OTY. ELECTRIC PERMIT PA,D
PHONE
CMRACrlbtVS AME UTLETS-SWITCHES-RECEP 10.00/1.00
S N
(.QI see.NO. LIGHTING FIXTURES 10.00/1.00 e1v[- I •�• j(��5
0H. TOHs PPLIANCES-RESIDENTIAL 4.00 ox
,
'( PHONE PANELS 10.00 oxApt ION
ARCHITECT PANELS (OVER 200 AMP) 20.00 P PLAN CHECK FEE P.C.N0.
OR
ENGINEER
LIC.NO. : 6 5 SIGNS TRANS. 3.00
nooeess ENaI SPECIAL CIRCUIT S.QQ PERMIT VALIDATION
2 •` zIP EMP. METER OR POLE INS. 20.00
APPLICANT 5 MOTORS
ADDRESS SEE FEE SCH.
SERVICE CHANGE 20.00
-,02
0o LICENSED CONTRACTORS DECLARATION TEMP.POLE 30.00 /
<v u I hereby affirm that I am licensed under provisions of Chapter 9 ISSUANCE DATE
H a w (Commencing With Section 7000)of Division 3 of the Business and -97J-G7-ELECT. PLG. MECH.
H H w/ Professions Co d my license is in full f t
0 m`V- Licens lass Lic.Number ❑ ❑ ❑
5 m io G Dale y �..�_Contractor
r - s_tBUILDING PERMIT.., ,:y
c w ¢ OWNER-BUILDER DECLARATION •-- n
o itr.-..INFORMATION
. oA MISC.- REFER TO ORD
u ; 4 I hereby affirm ing 1 am exempt from the Contractor's License VALUATION S/FT.
LLoJ Law Code:
ony city
Whihec.703LS.ermit to
Professions PERMIT ISSUANCE 10.00
Code:Any city or county which requiresa permit to mnsuanc alter.
2 ¢ 0 improve,demolish,or repair any structure,prior to its issuance,also ELEC.CONTR. LIC,NO. W O
ELEC.
F. C LL requires the applicant for such permit to file a signed statement that TOTAL PERMIT TO
' aa B he is licensed pursuant to the provisions of the )ofDivision License
Hzi Law(Chapter 9(<Ommencingwith Section 700010fDivision3of[he
¢ Business and Professions Code)or that he is exempt therefrom and QTY:'. - PLUMBING PERMIL.
¢ Do the basis for the alleged exemption.Any violation of Section 7031.5 - STORIES TYPE CONSTR.
d ; m by any applicant fora permit subjects the applicant to a civil penalty ALTER-DRAIN&VENT-WATER (EA.) 5.00
of not more than five hundred dollars(S500).):
❑ 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 don not apply to an owner of
property who builds or improves thereon,and who does such work FIXTURES-PER TRAP 5.00 50.FT,FLOOR AREA TOTAL ACREAGE
himself or through his own employees,provided that such improve- GA$-EA.SVSTEM-11NC.40UTLETS 6.00
mems are not intended or offered for sale.If,however,the building
or improvement is sold within one year of completion,the owner- GAS-EA.SYSTEM-OVER 4 (EA.) 2.00 BUILDING USE
builder will have the burden of proving that he did not build or im-
prove for purpose of sale.). INDUSTRIAL WASTE INTER. 30.00 R s IND CON PB Other
prove
I,as owner of the property,am exclusively contracting with ❑ ❑ ❑ ❑
licensed 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
t0 an owner of property who builds or improves thereon.and who LAWN SPRINKLERS-OV ER 5 IEA.) 1.00
contracts for such projects with a contractoAs)licensed pursuant to
the Contractor's License Law. SEWER-SANITARY-STORM EA.200ft/10.00 TRACT NO. PARCEL NO.
❑ lam exempt under Sec.-,B&P,C.for this WATER HEATER W/VENT 6.00
reason
Owner Date WATER SYSTEM 5.00
ACC.DATE ACC.FILE NO.
WORKERS'COMPENSATION DECLARATION WATER TREATING EQUIP. 5.DO
I hereby affirm that I have a certificate of consent to self-insure. ZONING ENG.SITE N0.
or a"rtificate of Workers'Compensation Insurance
t or a citified
opy thereof(Sec.3800,Lab.CA. s�ti �LD
'Policy No. Company r
Q ❑ Certiliedcop sls, I on I. FIRE SPRINK ENERGY T 24
Z Z ❑� s f: th city inspection division. MISC.- REFER TO ORD.
IO ¢
ant
Y ❑ N❑ Y ❑ N❑
CC rn .RTIFICATE OF EXEMPTION FRO WORKERS' PERMIT ISSUANCE 10.00 FLOOD ZONE A.L.U,C.
LU COMPENSATION INSURANCE PLG.CONTR. UC.NO. PIG.
1 O -iThis section need not be completed if the permit is for One TOTAL Y❑ N❑ Y [:] N❑
Z hundred dollars(5100)or lers.l
IJ Q 1 certify that in the performance of the work for which this per, y r FEE SUMMARY
IL H mit is issued. I shall not employ any person in any manner so as to DTV' .• , MECHANICAL,PERMIT',;-f') '.-, FEE,;
U become subject to the Workers'Compensation Laws of California. p jL
LU Date Applicant ALTER OR ADD TO MECH. 5.00 BUILDING Q
} 0 NOTICE TO APPLICANT: If.after making this Certificate of Ex.
F ? emplion.you should become subject to the Workers'Compensation 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 10p00C.F.M.) 4.00
CONSTRUCTION LENDING AGENCY AIR HANDLING UNIT(OVER 10=C.F.M.) 6.00 SEISMIC FEE ZQ
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,CN.C.). HEATING UNIT(TO 100,000 B.T.U.) 6.00
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•tx1NNP 13 H,P.of 100000 B.T.U.) 6.00
hereby authorize representatives of this city to enter upon the BOI LER-COMP to.,100,000 BTU)SEE FEE SCH. MECHANICAL
above-mentioned properly ftnspeclidn purpose.
(We) ag ve de 'ify and keen harmless the City of MISC.- REFER TO ORD.
tin ainst Iia dgments, c is and expenses which pERMIT ISSUANCE 10.00 CONST.TAX
ma m y y a i sl said Cit in consequence of the
nti M H.CONT. LIC.NO. MECH. isl
��l TO TAIL TOTAL !j[
of Applicant ontractor Dare
OFFICE COPY
POST THIf ^ARD NEAR FRONT OF BUILDING
PF RM1:IT NUMBER
Ch f OF CUPERTINO ^
INSPECTION DIVISION
JOB INSPECTION RECORD
aQ0ys sfeuerts Creek ' I PERMIT EXPIRATION
JOB ADDRESS UNIT# _LOT# PERMIT EXPIRES IF WORK
DwNER r Q I/ Fe, CONTRACTOR o - -7-a t, I Pr IS NOT STARTED WITHIN
INSPECTION DATE I INSPECTOR INSPECTION RECORD 180 DAYS OF PERMIT ISSU-
ANCE OR 180 DAYS FROM
FOUNDATION LASTCALLED INSPECTION.
UFER
PREGUNITE
VALIDATION
POUR NO CONCRETE UNTIL ABOVE HAS BEEN SIGNED �u`" 1 I tis
UNDERGROUND /SLAB C1tN of SlipeTWIC)
PLUMBING
ELECTRICAL - ISSUANCE DATE
MECHANICAL BLDG, ELECT. PLG I NECK
❑ ❑ ❑
DO NOT POUR FLOOR UNTIL ABOVE HAS BEEN SIGNED BUILDING PERMIT
INFORMATION
WOOD FLOOR VALUATION SIFT.
,P,LUMBLNG+
MECHANIC(f "
"PER IT TO
ELECTRICAL.'
FRAMING
STORIES TYPE CONSTR.
INSULATION (
OCC.GROUP RES,UNITS
PLACE NO SUBFLOOR UNTIL ABOVE HAS BEEN SIGNED
Sp fT FLOOR AREA TOTAL ACREAGE
ROOF
• DIAPHRAGM
BUILDING USE
RE IND CDN PB Other
APPLY NO ROOFING UNTIL ABOVE HAS BEEN SIGNED ❑ Cl ❑ ❑
A55E4SORSPARCELNO.
ROUGH
PLUMBING
TRACT NO. PARCEL NO
GAS TEST .
MECHANICAL
ACC.DATE ACL.FILE NO.
ELECTRICAL FINALS DATE INSP.
FRAMING SAN ft ZONING ENG.sIrE No.
INSULATION PLUMBING
GAS
FIRE SPRINK ENERGY L24
MECHANICAL v ❑ N❑ v ❑ N❑
COVER NO WORK UNTIL ABOVE HAS BEEN SIGNED HEATING
FLOOD ZONE 4L0.C.
LATH—INTERIOR ELECTRICAL i
J Y❑ N❑ Y N❑
LATH—EXTERIOR FIRE DEPT.
SHEETROCK GRADE FEESUMMARY
SHEAR INTERIOR BUILDING •
SHEAR EXTERIOR TEMPORARY A#PROVALS BUILDING
FIREWALLS ELECTRIC PLAN CHECK
GAS ak' FEE
NO TAPE PLASTER UNTIL ABOVE HAS BEEN SIGNED OCCUPANCY SEISMIC FEE
OCCUPANCYOF BUILDING IS NOT PERMITTED UNTIL BUILDING FINAL ISSIGNED BYBUILDING INSPECTOR. MICROFILM
ARRANGE FOR INSPECTION BY PHONING 252-4505, ELECTRIC
F ONE WORKING DAY BEFORE REQUIRED INSPECTION. PLUMBING
z� PLEASE GIVE JOB ADDRESS WHEN PHONING.
— SEE PERMIT FOR EXPIRATION DATE — MECHANICAL
IMPORTANT! CONST.TAX _
PLEASE READ REVERSE SIDE BEFORE TOTAL
CALLING FOR FINAL INSPECTION.
OFFICE COPY
I POST THI A'RD NEAR FRONT OF BUILDING
PERMITNO YEN 31
,OF GUPERTlNO;
CI
INSPECTION DIV,ISION: . $ ,
' JOB INSPECTION RECORD
z
,,goo y5-: .s- e erg {�r2e(� r ". .PERMIT�EXP.IRATION
JOB ADDRESS - UNIT# LOT - r
PERMIT EXPIRES'IF WORK `
OWNER 1-1 Q 'I f -,cONrRAcroRl )g- ISS,NOT STARTED WITHIN
INSPECTION DATE INSPECTOR - INSPECTION RECORD 180 DAYSOFPERmaisSU`:!
FOUNDATION - ,p t, .. ANCE OR'180 DAYS FROM',
LIFER . • � S r. "LAST CALLED INSPECTION'
PREGUNITE; " - vALmnnON l '
• � ' • . � . � 1985 : •
' -POUR NO CONCRETE UNTIL ABOVE HAS BEEN SIGNED
,UNDERGROUND /SLAB
y^Of�Upe100 •' `
PLUMBING
ELECTRICAL-' r- "'` ISSUANCE DATE. f +
_} MECHANICAL -
BLDG. ELECT .PLG.:. "ECM
DO NOT POUR FLOOR UNTIL ABOVE HAS BEEN SIGNED u " BUILDING PERMIT
INFORMATION
-WOOD FLOOR vaLunnoN SIEr
PLUMBING) - - - . , r
' S
!MECHANICAL - •`r i. t` -,zP`T
LECzRIbA'L gin./•'•'PERMITTo A •;�
ARAMING
INSULATION' .. '�''Y 'j.._STCRBS - TYPE CONSTR t. tti
• OCC.GROUP— RE.S:UNITS. .
PLACE NO SUBFLOOR UNTIL ABOVE HAS BEEN SIGNED.
ROOF • SO Pr FLOOR AREA TOTAL ACREAGE
DIAPHRAGM' _ UILDING USE_
RL .. INU CON PB OtR
APPLY NO ROOFING UNTIL ABOVE HAS BEEN SIGNED 0 ❑ 0 0
ASSESSORS PARCEL NO. -
ROUGH. j.
PLUMBING - +:- , , ! • d
GAS TEST a TRACT NO. I PARCELING.
MECHANICAL .j'.. "
ACC.OATE •'-ACC.FILE NO,,
ELECTRICAL '. FINALS DATE INSP.
`
FRAMING SAN
+
INSULATIONr ZONING - ENG.SITE NO.
•. _ PLUMBING - - � -
GAS '
,•,p MECHANICAL' FIRE S4FE
'.ENE GY T 24 '
{, COVER.NO WORK UNTIL ABOVE HAS BEEN SIGNED HEATING - 'Y � , v0
LATH-INTERIOR - ELECTRICAL �' FLOO9 •A.L.Uc.'. '
CATH-EXTERIOR •' FIRE DEPT. - °:maSHEETROCK ' ' GRADE MARY
SHEAR'INTERIOR. ' - - BUILDINGSHEAR EXTERIOR 'TEMPO RARY• PROVALS :giBUILDf�
FIREWALLS ELECTRIC,. `t t : PLAN CHECK
GAS . dK, 'FEE ' .t
'NO TAPE OR PLASTER UNTIL ABOVLHAS BEEN SIGNED OCCUPANCY '• S'is ' - .gEISMIC FEE
OCCUPANCY OF BUILDING IS NOTPERMITTED UNTIL BUILDING FINAL ISSIGNEOBY BUILDING INSPECTOR. •MICROFILM
.. .,
ARRANGE FOR INSPECTION BY PHONING 252-4505, ELECTRIC ;
ONE,WORKING DAY,BEFORE REQUIRED INSPECTION.. PLUMBING
O PLEASE GIVE JOB ADDRESS WHEN PHONING
i Z MECHANICAL
SEE PERMIT FOR EXPIRATION DATE
IMPORTANT,
CONST.TAX
PLEASE READ:REVERSESIDE'BEFORE � '
CAL'LING'FOR FINAL'INSPECTION. : TOTAL
OFFICE,COPY'
- a i- '•A