11555 APPLICANT TO FILL IN INFO MAT N WITRIM-LINES - USE BALL POINT PEN ONLY
e BUILDING PROJECT IDENTIFICATION - - PERMIT NUMBER '
BUIL01NG APPLICATION & PERMIT ,
ADDRESS �_ ' " 111555 .
BUILDING-ELECTRICAL-PLUMBING-MECHANICAL
r 0`//10
E 'S - PLAN CHECK VALIDATION
P . QTY. ELECTRIC PERMIT FEE '
PHONE
CONTRACTORS OUTLETS-SWITCHES-RECEP 10.00/1.00
NA
-LIGHTING FIXTURES 10.00/1,00 ,
-ONTRACTOH S APPLIANCES-RESIDENTIAL 4,00 '
A E $ ' (J//I/�j��
NE PANELS, 10.00 DATE OF APPLICATION
A CHI ECT PANELS (OVER 200 AMPI 20,00 PLAN CHECK FEE P.C.NO.
OR
ENGINEER
'LSC.NO. SIGNS TRANS. -I 3.00
ARCH.OR ENG. • ALIDATION
ADDRESS - SPECIALCIRCUIT - 5.00 ,
ziv EMP,METER OR POLE INS. 20.00 MAR
p ry 1
APPLICANTS MOTORS- SEE FEE SCH. MAR�,7 W"
(;/ jo
eo SERVICE'CHANGEv 20.00 i` It I d
• o o LICENSED CONTRACTORS DECLARATION �)`� QI �UQB"Ino
U u I hereby affirm that 1 am licensed under provisions of Chapter 9 ISSUANCE DATE
a, ¢H (commencing with Secy n 7000)of Division 3 of the Business and - - BLDG. ELECT. PLG. MECH.
r w z Professions n - liva c trim full f�d.o - Lice / < i . `�
wDat fj Comructor ,m - .BUILDING PERMIT
le ¢ OWNE:R-BUILDIER DIiCLA
a o o ° REFER TO ORD INFORMATION
se3 " r I hereby affirm that I am exempt from the Contractor's License MISC.- -
u D j Law for the following reason.(Sec.7031.5,Businessand Professions - PERMIT ISSUANCE 10.00 VALUATION $/FT.
r - Code:Any city or county which requires a permit to construct,alter,
Q Q Q O Improve,demolish,or repair any Structure,prior to Its issuance,also ELEG.CONTR. LIG,NQ ELEC.
O u requires the applicant for such permit to file n signed alafCmlCnf That TOTAL PERMIT TO
u_ $ he is licensed pursuant to the provisions of the Contractor's License , ,1
to Law(Chapter 9(commencingwith Section 7000)of Division 3 oflhe I`el
¢ Business and Professions Code)or that he is exempt therefrom and OTV. PLUMBING PERMIT +FEE
¢ r o the basis for the alleged exemption.Any violation of Section 7031.5 STORIES TYPE CONSTR.
by any applicant for a permit subjects the applicant to a civil penalty ALTER-DRAIN (EA.) 5.00
of not more than Ove handled dollars(S500)J: - ,
❑ 1,as owner of the property,or my employees with wages as
their sole compensation,will Jo the work,and the structure is not BACK FLOW PROTECT. DEVICE 4.00 DCC:GROUP. - RES.UNITS
intended Or offered for sale (Sec. 7044, Rosiness and Professions DRAINS-FLOOR,ROOF,AREA,COND. 5.00
Code:The Contractor's License Law does not apply to an owner of '
• properly 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-
mentsare nmintended oroffered for sale,Il',however'the building GAS-EA,SYSTEM-11 NC.4 OUTLETS,6.00
or improvement is soft] within one your of completion,the owner- GAS-EA.SYSTEM-OVER 4 (EA.) 2.00
builder will have the burden of proving that he did not build or im- BUILDING USE
prove for purpose at sale.). INDUSTRIAL WASTE INTER. 30.00 RES IND cory PB ower
❑ I,as owner of the property,and exclilslvely contracting with '❑ ❑ ❑ _ Q - ❑
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 Contractors License Law does not apply
to an owner of properly who builds or improves thereon,wW who LAWN SPRINKLERS-OVER 5(EA.) 1.00
contracts for Such projects with a eontractons)licensed Pursuont to
the Contractor's License Law. SEWER-SANITARY-STORM EA.200ft/10.00 - TRACT NO. PARCEL NO.
❑ I:unexemptunder Sec. ,B.&P.C.I'orthis WATER.HEATER W/VENT 6.00 -
reason
Owner Dare WATER SYSTEM 5.00
ACC.OATE ACC.FILE NO.
- .WWORKERS'COMPFNSA'I'1ON DIECLARA'I'ION' - WATER TREATING EQUIP. 5.00
I hereby affirm that I have a certificate of consent toscl4insurc, ZONING
or a certificate of Workers'Cnmpeyyyrya
clSojfnion;" nte r u certified' ENG.SITE NO.
copy lhRl)O.Lab.Cn„(/
P. 0lnp b lT�
O ❑ Certilicd copy is hereby famished. FIRE SPRINK ' ENERGY T.24
Z 2 �Certificd copy is filed with the city inspection division. MISC.- 'REFER TO ORD.
O. p tcanl Y ❑ N❑ Y ❑ N
~ rn PERMIT ISSUANCE 10.00
LU CERTIFICATE OF EXEMM ION FROMWORKF RS' FLOOD ZONE A.L.U.C.
'W � COMPISNSATION INSURANCE: PLG.CONTR. LIC.NO. PLG.
CL 0 (Thissectionneed not he completed if the permit is for one TOTAL Y❑ N❑ V ❑', N❑
Z llhndoed d.11m,1$100)or lass.)
V O 1 certify that in the performance of tale work for which this per- QTY. MECHANICAL PERMIT FEE FEE SUMMARY '
r
mit is issued,1 shall not employ any person in any manner so as to _
0ILL
U hewmesuh)ect to the Workers'Compmisatinn Laws of Cnlimrnim.
i Date Applicant ALTER OR ADD TO MECH. 5.00 �D BUILDING
} W NOTICE TO APPLICANT: If,after making this Coarfficuto af.Ex- .
H ? emption,You should bucoi a subject In 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 10=C.F.M.) 4.00
CONSTRUCTION LENDING AGENCY, AIR HANDLING UNIT(OVER IO,ODOC.F.M.) 6.00 SEISMIC FEE
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 issned(Sec. HEATING UNIT(TO 100,000 B.T.U.) 6.00 MICROFILM
3097,Civ.CJ. '_ '
Lender's Name HEATING UN IT(OVER 100,000 B.T.U.)9.50 ELECTRIC
'Lender's Address
lie
1 certify that I have read this application and stale that the above VENTILATION FAN (SINGLE) 4.00
information is correct. 1 agree to comply wilh,all city and,county PLUMBING
. ordiommes and,'late laws rotating to building'c...Unction, and BOILER.OOMP(3 H.P:or 100,000 B.T.U.1 6.00 f
hereby authorize representatives of,this city to enter, upon the
above-mentioned property for inspection purposes. BOILER-COMP (Over 100,000 BTU)SEE FEE SCH. MECHANICAL' '){f
,
(We) agree to save, indemnify and keel, I...nfl., the City of MISC.- REFER TO ORD.
Cupertino against liabilities,judgments, costs and expenses which �x CONST..TAX -
may in any ay accrue against said City io convert ace the PERMIT ISSUANCE, 10.00 V
gmnfingor v H.CONT. LIC.NO. MECH.
_ _� g/ '?)I-non TOTAL TOTAL i �-
Signature IAP man[/Contommr fi l[e H�/"1J4_(.. ) 5%
.OFFICE COPY
POST THIS CARD'NEAR FRONT OF BUILDING." - "
PEHNIITNUMBEN. .
CITY` OF CUPERTINO
`�`_ .'• " INSPECTION DIVISION � � ��� .•
JOB INSPECTION-RECORD
PERMIT EXPIRATION
20'1'95 STEVENS CREEK BLVD. 220
JOB ADDRESS UNIT# _LOT#' ' 1 PERMIT.EXPIRESJF WORK '
1 OWNER + W D ,T - CONTRACTOR THERMAL DESIGN SYSTEMIs NOT STARTED.WITHIN '
INSPECTION - ,DATE INSPECTOR - INSPECTION.RECORD '188UAYSOFPERMIT ISSU-11
FOUNDATION •+ - .r -NCE OR 168 DAYS-OOM'
'LIFER
MT`q LLED INSPECTION.
r - •-
PREGUNITE PERMIT VALIDATION
M
POUR NO CONCRETE UNTIL ABOVE HAS-BEEN SIGNED t��
UNDERGROUND /SLAB, Of Cpedlnd
' PLUMBING
ELECTRICAL,,'' - * ISSUANCE DATE
MECHANICAL , 'BLDG.., ELECT. PLG. ' MECH.
DO NOT POUR FLOOR UNTIL ABOVE HAS BEEN SIGNED BUILDING PERMIT
';' INFORMATION
WOOD FLOOR '.
VALUATION SF T.
PLUMBING -
MECHANICAL," ' -
{ ELECTRICAL
FRAMING
_ STORIES TYPE CONSTR,
INSULATION _ _ 1 o- - ,•,
• - O GROUP .`RE
CG 'UNITS 5
PLACE NO SUBFLOOR UNTIL ABOVE HAS DIAPHRAGM ,
ROOF. SD.R�FLOOBUILOAREA
TOTA
INC.USE
RES
BEEN SIGNED
z
HES IND.I CON PB GO-
El: ..
O-
b:•
APPLY NO ROOFING UNTIL ABOVE HAS'BEEN SIGNED r . - •� 13 - LN N
ASSESSORS PARCEL O.
ROUGH
n PLUMBINGrIRAc1 No. . PARCEL NO,.,
GAS TEST - • .
MECHANICAL. -dS %0- -
' ,ACC.DATE ACG FILE.NO;
ELECTRICAL'. FINALSDATE INSP: -
FRAMING - - SAN:*
'O ZONING ENG.SITE N@
INSU L'ATION.:. - - PLUMBING - - -
+, GAS P,
MECHANICAL' /` EIRE SPRINK ENERGY T 24 - -
COVER NO WORK UNTIL ABOVE HAS BEEN SIGNED HEATING ' . 7 r . 13 :N ❑ -"❑
LATH-,INTERIOR• ..; '„ ` -,^ 'ELECTRICAL L
_ FLOOD ZONE A UC,
NO
- LATH-EXTERIOR FIRE DEPT. YEJNEJ -Yo
SHEETROCK - - - GRADE'- I, - FEE SUMMARY
SHEAR.INTERIOR , BUILDING - -
SHEAR EXTERIOR _ .T.EMPO RARY APPROVALS BUILDING'
FIREWALLS ' : .r o ELECTRIC PLAN CHECK -
.. GAS
wry
NO TAPE OR PLASTER UNTIL ABOVE HAS BEEN SIGNED OCCUPANCY, SEISMIC FEE.
' UCCUPANCY,OF BUILDING IS NOT PERMITTED UNTIL BUILDING FINALISSIGNED BY BUILDING INSPECTOR. MICROFILM
ARRANGE FOR INSPECTION BY'PHONING 252-4505,' ELECTRIC
Iw— ONE WORKING DAY BEFORE REQUIRED INSPECTION PLunnsiNc
'•� PLEASE GIVE JOB ADDRESS WHEN PHONING.
.
'MECHANICAL "II% '
SEE PERMIT FOR EXPIRATION'DATE
n CONST.ITAX
:IMPORTANTC :r
PLEA§E.READ REVERSES DE BEFORE TOTAL`, Ifs
CALLING FORFINAL INSPECTION.
., "OFFICE COPY