C 8516 APPLeI ANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
91UI LDING PROJECT IDENTIFICATION PERMIT NUMBER
ADDIRENG /I�.ME' bEv Go APPLICATION & PERMIT
a03oO STEveNs CR��1� � 8516
BUILDING — ELECTRICAL—PLUMBING—MECHANICAL
OW
NEN'
],JAIn LT2 ' F&sL$bT-1105 PLAN CHECK VALIDATION
U DTV. ELECTRIC PERMIT FEE
s PHONE 'r V1&\4 zj I �D
CONTRACTORS uM — 2y UTLETS-SWITCHES-RECEP 10.00/1.00
CA-LO ,U M I I NC_ LIC.NO.. 3�1J ll� LIGHTING FIXTURES 10.00/1.00
CONTRACTOR'S nn IL
aOGREss APPLIANCES-RESIDENTIAL 4.00 ,,1){
P-03JU STFV'LNS 0WEC PHONE qA4G 019'7 PANELS 10,00 DAT ON
ARCHITECT OR PANELS (OVER 200 AMP) 20.00 PL H KP.C.NO.
a ENGINEER K
/"f4 o ` LIC.NO. SIGNS TRANS. 3.00
ADDRESS ENG' SPECIAL CIRCUIT 5.00 PERMIT VALIDATION
ITEMP.METER OR POLE INS. 20.00
APPLICANTS
'
ADDRESS MOTORS SEE FEE SCH.
`10300 S7t'VE4xfS 4-/605"IG SERVICE CHANGE 20,00
w O o LICENSED CONTRACTORS DECLARATION TEMP.POLE 30.00
a,0 U I hereby affirm That I am licensed under provisions of Chapter 9
H<y (commencing with Section 7000)of Division 3 of the Businessand ISSUANCE DATE
BLD ELECT. PLG. MECH.
v- 7 z Professions Code,a 1 my license is in full fort• n e gel 1:1
❑o i o License CI s Lic.Number 11
r w r j Dale �_b Contmclor
it ¢ a OWNER-BUILDER DECLARATION
BU ILD(NG`PERMIT;�'
w- 0 w uINFORMATION
g LL N I hereby affirm that I am exempt from the Contractor's License MISC.- REFER TO ORD
u O ¢ Law for the following reason.(Sec.7031.5,Businessand Profusions VALUATION $/FT.
Code:An til or count PERMIT ISSUANCE 10.00
Any y y which requires a permit to construct,alter,
Q ¢ Q �
improve, or repair any structure,prior bits issuance,also ELEC.CONTE. LIC.NO. ELEC. JA
o ¢ requires the applicant for such permit m I Re a signed statement that TOTAL
n
15:
m w he is licensed pursuant to the provisions of the Contractor's License PERM T
s- 2a Law(Chapter 9(commencing with Section 7000)ofDivision 3 ofthe
Fi 0 Business'and Professions Code)or that he is exempt therefrom and QTY. PLUMBING PERMIT ' FEE '
Ce H $ the basis for the alleged exemption.Any violation of Section 7031.5 SZWRIhs IYPECOPSTR.
a ; by any applicant fora pennitsubjects the applicant to a civil penalty gLTER-DRAIN&VENT-WATER (EA.) 5.00
of not more than fill hundred d.11ms($500).):
❑ 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 stnmturt,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
properly who builds or improves thereon,and who docs such work FIXTURES-PER TRAP 5.00 SO.FT.FLOOR AREA TOTAL ACREAGE
• himself or through his own employees,provided that such improve-
ments are not intended or offered for sale.If,however,the building GAS-EA.SYSTEM-1 tNC.40UTLETS 6,00
or improvement is sold within one year of completion,the owner- GAS EASYSTEM-OVER 4 IEA.) 2.00
builder will have the burden of proving that h - .e did not build or im- BUILDING USE
prove for purpose ofsale.). INDUSTRIAL WASTE INTER. 30.00 IN❑D C❑ON ED OOr
❑ 1,as owner of the property,am exclusively contracting with
licensed contractors to construct the project(Sec. 7044,Business LAWN SPRINKLERS- 1 INC 5 00 ASSESSORS PARCEL NO.
and Professions Code:The Contractor's License Law does not apply V.S.. .
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 contractor(s)licensed pursuant to
the Contractor's License Law. SEWER-SANITARY-STORM EA.200ft/10.00 TRACT NO. PARCEL NO.
❑ Ism exempt under Sec. ,B.&P.C,for this
reason WATER HEATER W/VENT 6.00
Owner Date WATER SYSTEM 5.00 ACC.DATE ACC.FILE NO,
WORKERS'COMPENSATION DECLARATION I WATER TREATING EQUIP. 5.00
I hereby affirm that I have a certificate of Consent tr self-insure,
or a certificate of Workers'Compensation Insurance,or a certified ZONING ENG.S1TE NO.
copy thereof(Sec.3800,Lah.C.).
Policy No. Company
O ❑ Certified copy is hereby furnished. FIRE SPRINK ENERGY T-24
ZZ Certified cop is filed with th inspection division.
� �'O Applicant % . MISC.- REFER TO ORD. y N V N[—]
Ky CERTIFICA'I'Ii O FEXEMPTIO FROM WORKERS' PERMIT ISSUANCE 10.00 FLOOD ZONE A.L.U.C.
-W > COMPENSATION INSURANCE PLO.CONTR. LIC.NO. PLG.
CL 0 (This section need not be Completed if the permit is for one TOTAL Y N� Y [:] N�
::) Z hundred dollars(5100)or less.)
W O 1 certify that in the performance of the work for which this per QTY. MECHANICAL PERMIT FEE FEE'SUMMARV
(L H mit is issued.I shall not employ any person in any manner so as to
U become subject to the Workers'Compensation Laws of California.
0 i
Date—Applicant BUILDING ( r
} 0 NOTICE TO APPLICANT: If,alter making this Certificate of Ex. ALTER OR ADD TO MECH. 5.00
I— ? emption,you should become subject to the Workers'Compensation APPLIANCE 5.00 PLAN CHECK
h— provisions of the Labor Cade, you must forthwith comply with FEE
U such provisions or this permit shall be deemed revoked. AIR HANDLING UNIT(TO IOMCF.M.) 4.00
CONSTRUCTION LENDING AGENCY AIR HANDLING UNIT(OVER 10=C.F.M.) 6.00 SEISMIC FEE ;�?(p,
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 N issued(Sec. MICROFILM
3097,0,C.). HEATING UNIT(TO 100,000 B.T.U.) 8.00
Lender's Name—
Lender's
E
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.1 agree to comply with all city and countyPLUMBING
Ordinances and state laws refuting to building construction, and BOILER-COMP(3H.P.or100,000B.T.U.) 6.00
hereby authorize representatives of This city es enter upon the 801 LER-COMP IOVS,100,000 BTU)SEE FEE SCH. MECHANICAL
herebymentioned property representatives
rvesp of
ection purposes to,
(We) agree to save, indemnify and keep harmless the City of .MISC.- REFER TO ORD
Cupertino against liabilities,judgments, costs slid expenses which PERMIT ISSUANCE ORD CONST.TAX
may in any way accrue against said City in consequence of the10.00
granting of is permit MECH,CONT. LIC.NO, MECH.
ti- 0 gs TOTAL TOTAL
Signatureo abut/Coarsen to
OFFICE COPY
y � POST THIS CARD NEAR FRONT OF BUILDING
' PFRMIL NUMNEH
CITY OF .CUPERTINO
INSPECTION DIVISION k.._--"'" 8516
r JOB INSPECTION RECORD
•. yam// /p/� - PERMIT EXPIRATION
JOB ADDRESS - �w(��C ✓1`1�� UNIT# LOT# - PERMIT EXPIRES IFWORK
OWNER I'! ✓ CONTRACTORftegQ M &r IS NOT STARTED'WITHIN
INSPECTION DATE INSPECTOR INSPECTION RECORD ISO DAYS OF PERMIT ISSU-
FOUNDATION - Cele' ANC E OR,180 DAYS FROM
SQJ -
UFER LASTCALLEDINSPECTIO N.
• r
PR'EGUNITE -
PERMIT VALIDATION
POUR NO CONCRETE UNTIL ABOVE HAS BEEN SIGNED
UNDERGROUND /SLAB /
PLUMBING •
ELECTRICAL
• � ISSUANCE DATE
MECHANICAL -. 8L ELECT.I "PLG. MECH.
/ 0 El . .❑ .
DO NOT POUR FLOOR UNTIL ABOVE HAS BEEN SIGNED N13UILDING PERMIT
WOOD FLOOR INFORMATION
PLUMBING
.VALUATION $/FT.
� �
MECHANICAL
ELECTRICAL, - - PERM
�, /
FRAMINGf
P
'INSULATION - - I •. STO IESi1 r�YPE CONSTR.
OCC.GROUP RES.UNITS
PLACE NO SUBFLOOR UNTIL ABOVE HAS BEEN SIGNED '
• ROOF SO.FT FI,OOR AREA TOTAL ACFWGE
DIAPHRAGM Ii
BUILDING USE
NES� IND 'CON PB Olney
APPLY NO ROOFING UNTIL ABOVE HAS BEEN SIGNED El 0 El El
ASSESSORS PARCEL NO.
ROUGH ,
PLUMBING T GAS TEST - _ TRACT NO. PARCEL,NO.
MECHANICAL - by
ELECTRICAL FINALS DATE INSP. AOc.once Acc.F EEp,_ND.
FRAMING SAN #•- - - - ?�'I
ZONING ENG;SITENO.
INSULATION � PLUMBING � -
GAS _
MECHANICAL
FIRE SPRINK' ENERGY T24 '
' - -
COVER NO WORK UNTIL ABOVE HAS BEEN SIGNED 1HEATING ' YF] No Y 11 . N
YJ •*' . .
LATH-INTERIOR - � ELECTRICAL FLOOD ZON�,E". ALuC.
LATH-EXTERIOR - FIRE DEPT. Y E - N[:] Y I] No
SHEETROCK GRADE FEE SUMMARY
SHEAR INTERIOR - BUILDING ' -
SHEAR EXTERIOR - TEMPORARY!APPROVALS BUILDING
FIREWALLS ELECTRIC 1PLAN CHECK
GAS FEE
NO TAPE OR PLASTER UNTIL ABOVE HAS BEEN SIGNED OCCUPANCY SEISMIC FEE
UCCUPANCY OF BUILDING IS NOT PERMITTED UNTI L BUILDING FINAL,IS SIGNED BY BUILDING INSPECTOR. MICROFILM
ARRANGE FOR INSPECTION BY PHONING 252'4505, ELECTRIC
o� ONE WORKING DAY BEFORE REQUIRED INSPECTION. PLUMBING
Z PLEASE GIVE JOB ADDRESS WHEN PHONING.
-,SEE PERMIT FOR EXPIRATION DATE = MECHANICAL
IMPORTANTI CONST.TAX. .
PLEASE READ REVERSE SIDE BEFORE
CALLING FOR FINAL INSPECTION. TOTAL ,,
OFFICE COPY` - •' I