C 9181 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
BUILDING PROJECT IDENTIFICATION PERMIT NUMBER
BUILDING APPLICATION & PERMIT
?RAO 5MMM
ADDRESS
UILDING-ELECTRICAL-PLUMBING-MECHANICA�
9181
pJ. wPIAN CHECK VALIDATION
QbdCti
TY.' ELECTRICPERMIT `FEE
coNr acroRs TG.' - UTLETS-SWITCHES-RECEP 10.00/1.00
HRrr(.S� uc.rvD.�� LIGHTING FIXTURES 10.00/1.00
"ONA.D AA�cro��'s - PPLIANCES-RESIDENTIAL 4.00
An t W( U 52'
PANELS10.00 DATE OF APPLICATION
ARCmiECT - , PANELS (OVER ZOO AMPI 20.00 PLAN CHECK FEE P.C.NO. r
Gn.
ENGINEER �jr -
L¢.No. �3 SIGNS TRANS. 3.00
AARCH,09 DDRESS ENG. SPECIAL CIRCUIT 5.00 ,PERMIT VALIDATION
zIP EMP. METER OR POLE INS. 20.00 l
APPLICANT'S s MOTORS SEE FEE SCH. �D �-(�!I"F�-�7Y•/
appRES
lot
-„ SERVICE CHANGE 20.00
0 0 o
LICENSED CONTRACTORS DECLARATION TEMP.POLE 30.00
a u I hereby affirm that 1 am licensed under provi,mmx.fChapter 9 DANCE DATE
Z.w (commencing with Section 7000)of Division 3 of the Business and -
ri. a a CT. PLG. MECH.
Hw i Professions Cod,,,a0�I my license is in full for e ❑ ❑ ❑
o i g W License lalav d12.==Con Number .
Date " Contractor
~ N~ J
ams < - - BUILDING PERMIT
¢ a OWNI:R-BUILDER DECLARATION
a a i U - INFORMATION
LL I hereby ulflrm that I am exempt from the Contractor's License MISC.-.` . PREFER TO ORD
r1_i VALUATION $/FT..-
¢ 2Ix0 ¢ LawfO the cycitllOTCOonlng upn.(SrequirLpeorn5.Business and Professions PERMIT ISSUANCE '10.00
�o Code:Any city or county which reyuiresa permit mconsNucLalteq /!f(/ ODOI
¢ Improve,demolish,or Rpalr any structure,prior to Its IsSUUBCe,aI50 ELEC.CONTR.' LIG,N0� ELEC.
u W'm, requires the applicant for such permit to file a signed statement that TOTAL - PERMIT
he is licensed pursuant In the provisions of 000)ofDivision License
rza Law(Chand Professions
Code)th Section is exempt Division ofthe (//N✓•/
Nosiness and Professions Code)or that he is exempt therefrom andOTV. PLUMBING PERMIT FEE
¢H o the basis for the alleged exemption.Any violation of Section 7031.5 STORIES TYPE CONSTR.
A ; by any applicant for a permit subjects the applicant toe civil penalty -
ofnot more Until five]Hundred dollars(5500).1: ALTER-DRAIN &VENT-WATER (EA.) 5.00 _
❑ 1;as owner of the property;or my employees with wages as BACKFLOW 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 does not applyto an owner of
property who builds or improves Uhercon,and who does such work FIXTURES-PER TRAP '5.00 Sp.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.SVSTEM-11NC.40UTLETS 6.00
or improvement is sold within one year of completion, - . .1 2.
the owner- GAS EASYSTEM-OVER 4 IEA00 BUILDING USE
,builder will have the burden of proving that he did not build or im- ` RES IND CON PB Omer
prove 1, purposeas owner of sole.). INDUSTRIAL WASTE INTER. 30.00 - ❑ ❑ ❑ ❑
❑ I,as owner of the property,am exclusively contracting with
licensed contractors to construct the project(Sea 7044,Business LAWN SPRINKLERS-1 INC 5 V.B. 6.00 ASSESSO RCELNO.
and Professions Code:'[lie Contractor's License Law does not apply
to an owner of property who builds or improves thereon,and who LAWN SPRINKLERS-OVER 5(EA.) 1.00 _
contracts for such projects with t contractor(,)licensed pursuunt Her SEWER-SANITARY-STORM EA.200f1/10.00
the Contractor's License Law. TRACT NO. PARCEL NO.
❑ I am 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'WMPrNSATION DECLARATION WATER TREATING EQUIP.' 5.00
I hereby affirm that I have a certificate of consent to self-insure,'
or certificate of Workers'Compensation Insurance,or a certified ZONING ENG,SITE NO.
ttrpy thereof lSec.3g00;Lah.C.
policy No. Cmnpan
0 ❑ Cetlilicdc yis her ni cd. FIRESPRINK ENERGY T 24
Z Z ❑ Cert' y is a He inspection division.
O Applicant MISC.- REFER TO ORD. Y ❑- N❑ Y ❑ No
~ m PERMIT ISSUANCE - . 10.00
cc - CERI'IFICATIi 01'EXEMPT N PROM WORKCItS' FLOOD ZONE, A.L.U.C.
LU - - COMPENSATIONNSURANCE PLG.CONTR. LiC,ND. PLG. Y❑ N❑ r Y❑ NE]Z (This section need not be completed if the permit is for one 'TOTAL
handled dollars IS 100)or less.)
U-O 1 cettlfy that ln the performance of the work Do which this per- QTY. MECHANICAL PERMIT' FEE FEE SUMMARY
LL H- mil is issued,1 shall not employ any person in any manner so as to
0w become subject to the Workers'Compensation Laws of California.
Date Applicant BUILDING �Q Q
a pp ALTER OR ADD TO MECH, 5.00 u
} rn NOTICE TO APPLICANT: If,after making this Certificate of Ex-
�.... Z cltnption,you should thcoome subject to the Workers'Compensation APPLIANCE 5.00 PLAN CHECK
provisions of the Labor Code, you must forthwith comply Willi FEE
U such provisions or this permit shall be deemed revoked. AIR HANDLING UNIT(TO 1Of100C.F.M.) 4.00 G '
CONSTRUCTION LENDING AGENCY AIR HANDLING UNIT(OVER 10=C.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 issued(Sec. MICROFILM
3097,Civ.C.L HEATING UNIT(TO 100,000 B.T.U.) 8.00
Lender's Name HEATING UNIT 100,000 B.T.U.)9.50
- Lender's Address - ELECTRIC '
I certify that I have read this application and state that the above - VENTILATION FAN (SINGLE) 4.00
V information is correct. I agree to comply.with ell city and county PLUMBING
'ordinances and state laws relating to building construction, and BOILER-COMP(3 H.P.or 100,000 B.T.U.) 6.00
hereby authorize representatives of this cityto enter upon tile
shove-mentioned property for inspection purposesBOILER-COMP (Over 100,000 BTU)SEE FEE SCM. MECHANICAL
.,
. (We) agree to save,%indemnify and•keep harmless the City of MISC.- REFER TO ORD.
Cupertino against Iia6"es,jud enls, costs and expenses which - CONST.TAX
may in any way rue gai said Hy in can equene of the PERMIT ISSUANCE - 10.00
grantinf4 this p it. MECH.CONT. ,LIQ NO. MECH.
92 Aq f� TOTAL
TOTAL 6/ 7/0
Siature fA pli n Contr or I Dale
-OFFICE COPY ,
POST THIS CARD NEAR'FRONT OF BUILDING
PFRMIT NUMBER `
;. CITY OF" CUPERTINO #
911 INSPECTION DIVISION
JOB INSPECTION RECORD
�- ~PERMIT EXPIRATION
'�[R :5 ? e/s-
JOB ADDRESS
UNIT,# LOT# '
! /P� `` �-J, „y PERMIT,EXPIRES IF WORK- •'
OWNER $ pen k, JI coNTdncroR P,I? IS NOT STARTED WITHIN
INSPECTION DATE INSPECTOR INSPECTION RECORD - .?ieo,oav'soFvERMirlssu
ANCE OR 180 DAYS FROM
FOUNDATION -
.. LIFER ;; if>; LASTCALLED INSPECTION:: .
PREGUNITE - -GasPERM ITOALIDATION
” r
POUR NO CONCRETE UNTIL ABOVE HAS BEENSIGNED
UNDERGROUNDLSLAB ' . . . .
PLUMBING .„«r. �..✓./ .I-. '. `F. .
ELECTRICAL 1 iy - .. ISSUANCE'DATE
MECHANICAL - '- BLOG. ELECT. 'PLG” MECH.
DO NOT POUR FLOOR UNTIL ABOVE HAS BEEN SIGNED f., BUILDING PERMIT
INFORMATION
. . . WOOD FLOOR . VALUATION S/FT. ,
PLUMBINGt.
MECHANICAL • ,r' ,I 1'' =' ^� `
ET TO
ELECTRICAL
. • FRAMING. - ., .' • s. .t !. RMI
INSULATION ' <' - _STORIES , -,TYPE'CONSTR. F
.. �"
_ -OCC.GROUP RES,UNITS
`PLACE NO SUBFLOOR'UNTIL ABOVE HAS BEEN SIGNED « '
ROOF SO,FUFLOOR AREA TOTAL ACREAGE
r , `
DIAPHRAGM -
RIS IN BUILDING USE
D CON PB( Otn
APPLY NO ROOFING UNTIL ABOVE HAS BEEN SIGNED Q : El 0, ❑
ASSESSORS A.RCEL NO.
ROUGH (�
. ' PLUMBING
GAS TEST , TRACT NO, -PARCEL NO.
MECHANICAL Acc.DATE Acc.FILE No..
,ELECTRICAL - FINALS - ' DATE INSP• '
- FRAMING — SAN"#
ZONING ENG.SITE NO.
• INSULATION - PLUMBING -
�.. GAS-
_ FIRE SPRINK "ENERGY T.24: 1
MECHANICAL E "
COVER NO WORK UNTIL ABOVE HAS BEEN SIGNED HEATING NE] E] N[] q
LATH—INTERIOR ELECTRICAL' -FLOODZONE - A.L.u,c. -
LATH-EXTERIOR FIRE DEPT. '. 6-�, k ❑, NQ, 4 v �] N❑ `
SHEETROCK GRADE FEE SUMMARY
`r- SHEAR INTERIOR BUILDING :'�• .
BUILDING '
SHEAR EXTERIOR', TEMPORARY APPROVALS , "-;
FIREWALLS ELECTRIC 'PLAN CHECK.'. '
GAS .. FEE , ..-
NO TAPE OR PLASTER UNTIL ABOVE HAS BEEN SIGNED JOCCUPANCY I SEiSMICIFEE
OCCUPANCY OF BUILDING IS NOT PERMITTED UNTILBUILDING FINAL IS SIGNED BY BUILDING INSPECTOR. .MICROFILM
4 ,
` �•.."�. �f ELECTRIC • 4
I
ARRANGE'FOR'INSPECTION BY PHONING 2524505;,-4—
\ F ONE WORKING DAY BEFORE REQUIRED INSPECTION PLUMBING
O PLEASE GIVE JOB ADDRESS WHEN PHONING.Z —'SEE PERMIT FOR EXPIRATION DATE — MECHANICAL
CONST.TAX '
IMPORTANTI "
PLEASE READ REVERSE SIDE BEFORE
CALLING FOR FINAL INSPECTION. TOTAL , 7:
'V,':
°, L OFFICE COP.V