17293 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES -'USE BALL POINT PEN ONLY
BUILDING PROJECT IDENTIFICATION PERMIT NUMBER
APPLICATION & PERMIT r
noun ss �' - - 1.7, 93_.
ztri
BUILDING -ELECTRICAL-PLUMBING-MECHANICAL ti7•
NAME , /'- ♦ - - - PLAN CHECK VALIDATION,
Sj y72 TV. 4 ELECTRIC PERMIT. r,:; ,'FEE
CONT14ACTUR'S f
NAME Azelry UTLETS-SWITCHES-RECEP 10.00/100lcw� ' ''
io.-. < uc.iso.. LIGHTING FIXTURES 10.00/1.00, ,
-- ADDREAcroR's PPLIANCES-RESIDENTIAL' � � 4.00 • '
�,j2.q....h PHONE .�.P+'---L 'PANELS 10.00 DATE OF APPLICATION' `
AARRCHITECr ., s . PANELS (OVER 400'AMPI ' .^ 20.001 PLAN CHECK FEE P.C.NO.
n
LIC.NO, '" SIGNSTRANS. '13.00 r"
ARCH.OR ENG. - - PERMIT VALIDATION
At'IpREGG__ ` ' SPECIAL CIRCUIT `' - .5.00 ,
•
ZIP TEMP.METER OR POLE-INS. 20.00
APPLICANT - - MOTORS SEE FEE SCH.
ADDRESS
,
SERVICE CHANGE' 20.00IrZiI1
F o o LICENSED CONTRACTORS DECLARATION
< i w 1 hereby affirm that I am licensed,under provisions of Chapter 9 xi. ISSUANCE DATE
(commencing with Section 7000)"of Division 3 oFthe Business and -"
BLDG. ELECT. PLG. MECH.
G w i Professions Code, b d my)icensc is in full forcyjmtl efRSy�� ❑ ❑ ❑
Zo 0 rn o License Cldss 'Li,.Number 7`1 N/ �. �O
Dane �
Contractor ti
¢ Y f BUILDING PERMIT
Ic ¢ w OWNT:R-U UILDER DIeCLARAT'[ON - INFORMATION
w ;e-y 1 hereby affirm that I am exempt from the Contractor's License MISC.- - REFER TO ORD
at u o J Law for the following reason.(Sec.7031,.5,BmsmCSSand Professions - PERMIT ISSUANCE 10.00 VALD ATION - S/FT.-
y0 Code:Any city or county whlCllrequlre9apernllttocnnstplCLalteq - ` M
pe: 0 Improve,de1110IIsh.Of repair any SVlle[Ilfe:prlOr IO IIS ISs11JOC2,Sir, ELEC.CONTR. LIC.NO. '. ELEC.' '�� CDD '
D Ie requires Iho applicant for such permit to file a signvd L,mIcnHmt that TOTAL'
d w m LL he is licensed pursuant to the provisions of the Contractor's License PERMIT TO
Fz >
Law(Chapter 9(commencing with Section 7000)ofDivision 3 ofthe , 1
4 o Business and Professions Code)or that he is exempt therefrom and QTY. PLUMBING PERMIT FEE "m N
M f$ the basis for the alleged exemption.Any violation of Sect ion 7031.5 " STORIES TYPE CONSTR.
iby any applicant fora permit suhlect,the applicant to u civil penult, ALTER-DRAIN&VENT-WATER IEA.) 5.00
of not mom than five hundred dollars(5500).):
❑ 1.his owner of the property,or my employees with voges 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:*file Contramor's License Law does not apply to an owner of - `
property who builds or improves thereon,and who does such work FIXTURES-PER TRAP - 5.00 so.Fr.FLOOR AREA TOTAL ACREAGE
himself or through his own employees,provided lint such improve-
menta are not intended or offered for sale:If,however,the building GAS-EA.SYSTEM-I INC;4 OUTLETS 6.00
or improvement is sold within one year of completion,thCLownerr. I.GAS-EA.SYSTEM-OVER 4 (EA.) 2.00
builder will have the burden of proving that he did not build or im- BUILDING USE
RES. IND CON PB Other
prove U as owner
of the
I . INDUSTRIAL WASTE INTER. 30.00
❑ 4,as owner of the construct file exclusively contracting with - ❑ ❑ ❑ ❑ ❑
licensed contractors : construct the project(Sec. 7044,Business LAWN SPRINKLERS- 1 INC 5 V:B. 6.00 AssEg5oR5 PARCEL N0.
and Pro Cessions Code:The Contractor's o License Law does not who - - -to tr owner of property who builds tr improves thereon.and who LAWN SPRINKLERS-OVER 5 IEA.) 1.00
contracts,ctor'ssuch
cenProjects Lwith ucontraclor(s)licensed Pursuant to SEWER-SANITARY-STORM EA.200ft/10.00
the Contractor's License Law. � TRACT N0. PARCEL N0.
❑ I am exempt under Sec. ,Is.&P.C.for this WATER HEATER W/VENT - 6.00
reason
Owner Date WATER SYSTEM _ 5.00 ACC.DATE ACC.FILE No.
WORK 17 RS`COMPENSA'I ION DECLARATION WATER TREATING EQUIP. ' .5.00 -
I thereby affirm 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 thereof(Sec.3800,Lab,C.).:
Policy Nn. Company
` ❑ Cetilied copy is herebni
y furshed. - ..FIRE SPR INK ENERGV,T-29
Z 2 ❑ Certified 'copy.is filed with the city inspection division.
F p Applicant , REFER.TO ORD.
Y ❑ N❑ V'❑ N❑
CC m CERTIFICAI'F.015 EXEMPTION FROM WORKERS' PERMIT ISSUANCE 10.00 FLOOD ZONE A.L U.C.
W > COMPHNSA'1'ION INSURANCE PLG.CONTR. - uC.N0. PLG.'.
_ CIL -
(This section need not be completed if the permit is.Car one TL
L' V❑ N❑ y Y❑ N❑
V O hundred 011mrs($100)or ICS,.)
I certify that in the performance of the work for which this per- QTY MECHANICAL PERMIT FEE• FEE SUMMARY
W F-` . hilt Is issued,I shall not employ any person many_Illnlme so as to ,
Q W; becmne subject to the Workeri Compensation Laws of California. -C. DateApplicant - - BUILDING J� �p
} N NOT'ICE'TO APPLICANT': If,after making this Certificate of Ex- ALTER OR ADD TO MECH. - 5.00 l'JCs..�7
Z emption,you should,become subject to the Workers'Compensation APPLIANCE5.00 PLAN CHECK
provisions of the Labor Code, you must forthwith comply with -V FEE 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 I0,000C.RM.) 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.), _ HEATING UNIT(TO 100,000 B.T.U.) '8.00 -
-^- -- Lender's Name
Lender's Addresx HEATINGUNIT(OVER100,000B'.T.U.)9.50 ELECTRIC
I certify do,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 unit county PLUMBING
ordinances and stale laws relating to building construction, and BOILER-COMP I3 H.P.Or 100.,000 B.T.U.) 6.00
hereby anientharine ropertyfor ins alethia city es enter upon,the BOILER-COMP 100,000 BTU)SEE FEE SCH. MECHANICAL
above-mentioned property for inspection purposes. ,
._..^._ -(We) agree to save, indemnify and keep harmless the City of misc.- - REFER TO ORD. '
Cupertino against liabilities,judgments, costs and expenses which' PERMIT ISSUANCE 10.00 CONST.TAX
may in any way accrue against said City in consaq ounce of the
rza ting Of this permit. MECH.CONT. LIC.NO. MECN.. '
/L�d2�� / TDTAL 1 .. TOTAL
_. SignaNrc oC Ep icant/Contractor Dnle
OFFICE COPY
'• y -'POST THIS CARD NEAR.FRONT OF BUILDING . .
,.. PERMIT NUMBER'
; . -CITY .OF' CUPERTINO 17293:'
INSPECTION DIVISION
JOB;INSPECTION RECORD ,
/ P,ERMIT EXPIRATION e1
66 S�P�/= �� R(VNI LOT" J,
JOB ADDRESS :
PERMIT EXPIRES IF WORK,j
OWNER P U`� .�S V L�QO CONTRACTOR "S( I✓c - IS NOT STARTED WITHIN
INSPECTION 'DATE INSPECTOR INSPECTION RECORD' - 180 DAYS OF PERMIT,ISSU-
FOUNDATION - ANCEOR 180 DAYS FROM
NOTE: - LASTCALLED INSPECTION. '
UFER - ALL GRADING AND ORAINAGE-SHALL BE INSTALLED
TO COMPLY,WITH THE APPROVED PLANS AND CITY OFPERMn A
VLIDATION
PREGUNITE' •. - ., .,
i
CUPERTINO STANDARDS"
GARAGE SLABS -
POUR NO CONCRETE UNTIL ABOVE HAS BEEN SIGNED p
UNDERGROUND /SLAB B2wo;,' �ef_tL'RjAtcc.j
PLUMBING - p ->< .. , -
ELECTRICAL 'CI I OP VOpW Ww .,ISSUANCE DATE
" MECHANICAL - 'BLDG -EL[CL PLG. MECR.
p El I -o o '
DO NOT POUR FLOOR UNTIL ABOVE HAS BEEN SIGNED BUILDING PERMIT
. . • ' 'INFORMATION
WOOD FLOOR It VALUATION $IFT.
PLUMBING -
MECHANICAL - - - _ !T} v'C�•D�
ELECTRICAL - - _ PERMIT To
FRAMING r � �•
INSULATION ' - sm es TvrE,coNsnl.
- orc.r,Raur BEs.UNITS
PLACE NO SUBFLOOR UNTIL ABOVE HAS BEEN SIGNED
ROOF - '^ NOTE:NO FINAL INSP.'SHALL BE MADE BEFORE so.rT AFI_ooP APFA roTAL ncRt:Ace
DIAPHRAGM ,THE CONSTRUCTIONTAX IS PAID
RUIL.OI US[
' ROOF.SHEATHING �.. � .. hr _ ' ''i- � ruts "'INDNu CON Pd <,no,d'{
-' -APPLY NO ROOFING UNTIL ABOVE HAS BEEN'SIGNED " FINALS DATE JNSP: 11 0 ❑ E
• ASSESSURS PARCEL NO
- ROUGH' SANA
PLUMBING ELECT.ENERGY
TRACT NO, PARCEL NO..
TUBS&SHOWER PAN - PLUMBINGENERGY -
MECHANICAL MECH.ENERGY - _
ELECTRICALBUILDING ENERGY L ACC,DATF. . ACC.FILE NO
'FRAMING ELECT.FINAL TEST
INSULATION PLUMBING
20NING . ENG.SITE NO
`
' GAS TEST GAS '
FIRESPRINK - ENERGY T-24
MECHANICAL v Q . Nc v, NO
COVER NO WORK UNTIL ABOVE HAS BEEN SIGNED HEATING
EXTERIOR SHEAR ELECTRICACRELEASE FLooOzoNE A.L,U.C.
INTERIOR'SHEAR - FIRE DEPT.' ' Y'Q No YO 'N❑
_ SHEETROCK GRADE ' FEE SUMMARY
EXTERIOR LATH BUILDING / `/�' —"Al' BUILDING r�.Q•O'
.INTERIOR LATH TEMP RARY APPROVALS:
SCRATCH COAT ELECTRIC - ' PLAN CHECK
, GAS,. L FEE
NO TAPE OR PLASTER UNTIL ABOVE HAS BEEN SIGNED OCCUPANCY• SEISMIC FEE.
cv
OCCUPANCY OF BUILDING IS NOT•PERMITTED UNTIL BUILDING FINAL ISSIGNED 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.=
MECHANICAL t-
- SEE PERMIT FOR 'EXP.IRATION DATE
Y
' IMPORTANT! CONST.TAX
PLEASE READ REVERSE SIDE BEFORE J TOTALZ�
CALLING FOR FINAL INSPECTION.
OFFICE COPY