844 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
' BIJILDING PROJECT IDENTIFICATION PERMITNUMBER
BDILDI G APPLICATION & PERMIT
AD
r r•7/�yy1 55 ejveI6 Cr�GI^ BUILDING-ELECTRICAL-PLUMBING -MECHANICAL 8844
e OWNER' GV•J'e� I� PLAN CHECK VALIDATION '
"AJ �y- ^� +t. ✓ I'� OTV. ELECTRIC PERMIT FEE 7 ,¢z/Z
• ( m T V� PRDNE 7 23Z-70
!/
NAME OUTLETS-SWITCHES-RECEP 10.00/1.00
T�LG Sows UC.NO. (-OZ LIGHTING FIXTURES 10.00/1.00
ADO TRACTORS APPLIANCES RESIDENTIAL 4,00
4�1/ HONE /I%5�O' PANELS 10.00 DATE OF APPLICATION
OR
i„(f p PANELS (OVER 200 AMP) 20.00 PLAN CHECK FEE P.C.NO.
ENGINEEfl
QP3`AI rm.NO. SIGNS TRANS. 3.00PAM
ARCH.OR ENG. PERMIT VALIDATION
A / SPECIALCIRCUIT 5.00
77 i�/O Q/. IP EMP.METER OR POLE INS. 20.00
ADDRESSTs MOTORS SEE FEE SCH.
5'50,0 0 ,IL 622 SERVICE CHANGE 20.00 'f,Copedino
.02 LICENSIiD CONTRACTORS DECLARATION TEMP.POLE 30.00
U 1 hereby affirm that I am licensed under provisions of Chapter 9 '
Z w SUANCE DATE
,commencing with Section 7000)of Ulvision 3 of the Business and
H w 2
Professions Code,a d my license is in full fort nn ff CL. BLDG ELECT. I.G.PMECH.
0 m License Class Lic.Number G
O Dale Contractor < 0 El 0 El
n ;/w
Q w a OWNER-BUILDER DECLARATION BUILDING PERMIT'
MISC.- REFER TO ORD INFORMATION
w ;LL y I hereby affirm Ih at I am exempt from the Contractor's License VALUATION $/FT.•
w O < Law far the following rcnson.(Sec.7031.5,Businessand Professions PERMIT ISSUANCE 10.00
fw0f Code:Any city or county which requires a permit to construct,alter, L✓-`
A O improve,demolish,or repair any structure,prior to its issuance,also ELEC.CONTR. - LIC.NO. ELEC.
D ¢ requires the applicant for such permit to file a signed statement that TOTAL
X$w he is licensed pursuant to the provisions of the Contractor's License PERMIT T
Hir
Law(Chapter 9(commencingwith Section 7000)of Division 3 oflhc
f i o Business and Professions Code)or that the is exempt therefrom and QTY. PLUMBING PERMIT FEE
H$ the basis for the alleged exemption.Any violation of Section 7031.5 ' STORIES TYPED STR.
i ; by any applicant for a permit subjects the applicant to a civil penally ALTER-DRAIN -WATER (EA.) 5.00
of not more than five hundred dollars($500).):
❑ 1,as owner 's the property,or my employees with wages as BACK F LOW PROTECT.DEV ICE 4.00 OCC.GROUP RES.UNITS
their sole compensation,will do the work,and the structure is not
Intended or offered for sale (Sec. 7044, Business and Professions DRAINS-FLOOR,ROOF,AREA,COND. 5.00
Code:The Contractor's License Law does not apply to an owner of
property who builds or improves thereon,and who does such work FIXTURES-PER TRAP 5.09 50.FT.FLOOR AREA TOTAL ACREAGE
himselfornot
tinte his own employees,provided ev such ibmdvu
mimprovment tended or offered for within
o I completion,
thebuildingov GAS-EA.SYSTEM-1INC.4OUTLETS 6.00
or improvement is sold within one year of completion,i it owner- GAS-EA.SYSTEM-OVER 4 (EA.) 2.00
builder will have the harden of proving that he Aid not build or im- BUILDING SE
prove 1,as owner
of sale.). INDUSTRIAL WASTE INTER. 30.00 RES IND PB one.
❑ L as owner of the property,he exclusively contracting with
licensed contractors to construct the project(Sec.7044, Business LAWN SPRINKLERS-1 INC 5 V.B. 6.00 ASSESSOR PARCEL NO.
and Professions Code:The Contractor's License Law does nut apply
to anowner of properly who builds or improves thereon, a who LAWN SPRINKLERS-OVER 5 IEA.) 1.00
contracts for such projects with a conlractor(sl licensed pursuant to
the Contractor's(aexempt
pt under
Sec. SEWER-SANITARY-STORM EA.200ft/10.00 TRACT NO. PARCEL NO.
❑ I am exempt under Sec. ,IL&P.C.for this
reason WATER HEATER W/VENT 6.00
Owner Date WATER SYSTEM 5.00 ACC.OATE ACC.FILE NO.
WORKERS'COMPENSATION DECLARA'r10N WATER TREATING EQUIP. 5.00
1 hereby alfrm that I have a certificate of consent to self-insure,
or a certificate of Workers'Compensation Insurance,or a certified ZONING ENG.SITE NO.
copy Ihereof(S�eg 3800,Lab.C.). / (� ,,,, ,(
Policy No.(�zn xo Company •SSB./3L`ed wr. ra4
O" ❑ Certified copy is hereby furnished. FIRE$PRINK ENERGYT24
Z 1� Certified c py is fig witIL the city inspection division.
p: Applicant ,�, MISC.- REFER TO ORD. v ry v NN[]rn
- CERTIFICATE F EXEMPTION FROM WORKERS' PERMIT ISSUANCE 10.00 FLOOD ZONE A.L.U.C. '
W a COMPENSATION INSURANCE PLG,CONTR. LIC.NO. PLC.
a. Z' (This section need not be completed if the permit is for one TOTAL v N v N
hundred'dollars IS 100)or less)
U O I certify that in the performanceofthe work for which this pEI
er- OTY. MECHANICAL PERMIT FEE FEE SUMMARY
LL I- mit is issued,I shall not employ any person in any manner so as to
U become subject to the Workers'Compensulion Laws of California.
y Datc ApplicantALTER OR ADD TO MECH. 5,00 BUILDING i
} m NOTICE TO APPLICANT: If,after making this Certificate of 6x-
F 2
unction,you should become subject to the Workers'Conhpensation 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 10.000 C.F.M.) 4.00
CONSTRUCTION LENDING AGENCY AIR HANDLING UNIT(OVER 10=C.F.M.) 6.00 SEISMIC FEE t�s
I hereby affirm that there is a construction lending agency for EXHAUST HOOD(WITH DUCT) 5.00
die performance of the work for which this permit is issued(See. MICROFILM
3097,Civ.C.). HEATING UNIT(TO 100,000 B.T.U.) 8.00
Lender's Name
Lender's Address HEATI NG UN IT(OVER 100,000 B.T.U.)9.50 ELECTRIC
I certify that 1 have read this application and ,are Mat the above VENTILATION FAN (SINGLE) 4.00
information is correct. 1 agree to comply with all city and comity PLUMBING
ordinances and slate laws relating to building construction, and BOILER-COMP(3 H.P.or 100,000 B.T.U.) 6.00
s.. hereby authorize representatives of this city to enter upon the BOILER-COMP (Over 100,000 BTU)SEE FEESCH. MECHANICAL
hereby
coauthored property for inspection purposes, h
(We) agree to save, indemnify and keep harmless the City of MISC.- REFER TO ORD. y
Cupertino against liabilities,judgnhenb, costs and expenses which PERMIT ISSUANCE 10.00 CONST.TAX
may in any way accrue against said City in consequence of the
granting Of this per Ail' MECH.CONT. LIC.NO. MECH.
[� TOTAL TOTAL
Signature A p heath[/Contractor ate
OFFICE COPY
POST THIS CARD NEAR FRONT OF BUILDING
. PERMIT NUMBER '
CITY OF CUPERTINO
8844 INSPECTION DIVISION
JOB INSPECTION RECORD "
A
PERMIT EXPIRATION.-
JOB
XPIRATION:JOB ADDR ESS ` UNIT# LOT#
PERMIT EXPIRES'IF WORK
OWNER CONTRACTOR ' -IS NOT STARTED WITHIN'
I P CTI O ' DATE INSPECTOR I PEC ION RECORD x.180 DAYS OF PERMIT ISS U- '
FOUN DAT ON 'ANCE OR 180 DAYS FROM
UFER' W-e,.GQ AST CALLED INSPECTION.
PREGUNITE ��,¢�• ct _ PtRNPl A IDN
MAY t 1980'
POUR NO CONCRETE UNTIL ABOVE HAS BEEN SIGNED S^ Q-'.- OK
UNDERGROUND /SLAB — !�
PLUMBING (li)I,OfCUpBfIIffO
-
ELECTRICAL "
ISSUANCE DATE
MECHANICAL RLD ELF T. v MECH. +
00 NOT POUR FLOOR UNTIL ABOVE HAS BEEN SIGNED I BUI DING ERMIT
WOOD FLOOR 1 FORM TION
• -$/FT.
PLUMBING VALUATION-
MECHANICAL '
• I
ELECTRICAL - r PERMIT TO
/
FRAMING
INSULATION STORIES— . TYPE C srR.
OCC.GROUP RES.UNITS
PLACE NO SUBFLOOR UNTIL ABOVE HAS BEEN SIGNED
ROOF SO,FT,FLOOR AREA . TOTAL ACREAGE
DIAPHRAGM'
BUILDING USE
HES IND CONJ. PB O,h.,
APPLY NO ROOFING UNTIL ABOVE HAS BEEN SIGNED ❑ ❑ i ❑ El
ROUGH
ASSESSORS ARCEL NO.
' PLUMBING -
GAS TEST TRACT NO. PARCEL N0.
- MECHANICAL
ACC.DATE ACC.FILE NO.
ELECTRICAL
-6-'—ol J– FINALS DATE INSP.
FRAMING - SAN #
INSULATIONPLUMBING ZONING ENG.SITE NO.
- � r,
GAS -
MECHANICAL FIRE SPRINK ENERGY T,24
COVER NO WORK UNTIL ABOVE HAS BEEN SIGNED HEATING - Y ❑ N❑ v ❑ N❑ .
LATH—INTERIOR ELECTRICAL FLOOD ZONE A.L.u.c.
LATH—EXTERIOR FIRE DEPT. , '- Y ❑ _ N❑ Y ❑ N❑ ,
SHEETROCK GRADE - FEESUMMARY
SHEAR INTERIOR BUILDING •
SHEAR EXTERIOR. - TEMPO RARV APPROVALS BUILDING
FIREWALLS " - ELECTRIC PLAN CHECK
GAS, FEE
NO TAPE OR PLASTER UNTIL ABOVE HAS BEEN SIGNED OCCUPANCY SEISMIC FEE` .
OCCUPANCYOF BUILDING IS NOT PERMITTED UNTILBUILDING FINAL IS SIGNED 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. "
- SEE.PERMIT FOR EXPIRATION DATE ' MECHANICAL
IMPORTANT! coNsr:TAx
PLEASE READ REVERSE SIDE BEFORE.' TOTAL
CALLING FOR FINAL-INSPECTION.
OFFICE COPY