16953 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
_ - • �.
' BUILDING PROJECT IDENTIFICATION PERMIT x r NUMBER'
ADD DING APPLICATION & PERMIT q ��
/ ADDRESS
`�` •'�!/�[.X/ �]�i j/ENS[.�l•?"K BUILDING-.ELECTRICAL-PLUMBING-MECHANICAL �R¢
OWNER'S - - ). . PLAN CHECK VALIDATION
O7V. ELECTRIC PERMIT FEE
r
OilCONTRACTOR'S
NAME OUTLETS-SWITCHES-RECEP '10,00/1.00
_IC.NO LIGHTING FIXTURES 10.00/1.00
CONTRACTOR'S - PPLIANCES-RESIDENTIAL' -4.00
A DOREss
PHONE PANELS, 10.00 DATE OF APPLICATION r
ARCHITECT , PLAN CHECK FEE P.C.NO.
DR PANELS (OVER 200 AMP) -20.00
ENGINEER
• UC.NO. SIGNS TRANS. 3.00
NX ARCH.OR ENG. - SPECIAL CIRCUIT. ' 5.00 PERMIT,VALIDATION '
ZIP EMP.METER OR POLE INS. 20.00 / �.-2-Z-ri
ADDDREDRESS SN
Ars MOTORS SEE FEE SCH. 1 v'
SERVICE CHANGE "20.00 ,1
oo bIC-NSEI)•CONTRACTORS DECLARATION- n
a u u 1 hereby affirm that 1 am licensed under provisions of Chapter 9 ISSUANCE DATE
w� (commencing with Section 7000)of La%inion 3 of the Business and i a DG. ELECT. PLG. MECH.
r o Z DEC 221988
Professions Code,and my license is infull tome and effect ❑ ❑ ❑
2 oy- Date
Class CI.onNumber- ,�(
O ¢ H o' Datc Contractor - GtY VI glperfinp
ams -J+- BUILDING PERMIT
OWNER-BUILDER DECLARATION
E o a " 1 INFORMATION
w g:LL I hereby affirm that I am exempt front the Contmetor's Licenso MISC.- REFER TO ORD
FLLo J Law for the following reason.(See.703 I.S.Business and ProfessionspERM1T IS ,10.00 VALUATION $/FT.
Code:Any city orcounly which requiresa permit to construct,after,
a ¢ improve,dcrmlish;or repair any structure,prior to its issuance,also ELEC.CONTR. LIC.NO. - ELEC.
o ¢ requires the applicant for such permit to file a signed statement that TOTAL
n W•oNu PERMITTO,
he is licensed pursuant to the provisions of Ore Contractor's License
as
Law(Chapter 9(comnrencing with Section 700()of Division 3 oflheA/ �� .s L-
io Business and Professions Code)or that he is exempt therefrom and QTY. PLUMBING PERMIT FEE 4-0 C'' kc,* L
¢ r$ the basis for the alleged exemption.Any violation of Section 7031.5 _ STORIES TYPE CONSTR.
a ; by any applicant fore permit subjects(lie applicant toacivil penalty ALTER-DRAIN& VENT-WATER (EA.) 5.00 '
of not mora than five hundred dollars(5500).1: '
❑ I,as owner of the property,or nay employees wish wages as BACK F LOW PROTF,CT. DEVICE'. 4.00 Dec.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
Cade:The Contmctor's'License Law docs not apply to an owner of
property who builds onImprove%thereon,and who does srach work FIXTURES:PER TRAP - :5.00 1 SO.PT FLOOR AREA TOTAL ACREAGE
himself or through his own employees,provided that Such improve- _
mems are not intended or offered for sale.If,however,the building - GAS-EA.SYSTEM-1INC.4 OUTLETS 6.00
or improvmne rt is sold within one year of completion,tire owner-
GAS-EA.SYSTEM-OVER 4 (EA.) 2.00 r-. ..
builder will have the burden of proving that he AiJ not build or on. _ - •BUILDING USE
pr v fonpurpose of sale-L INDUSTRIAL WASTE INTER. 30.00 RES IN
-CON pit Omer
1,as owner of the property,am exclusively contracting with .❑ ❑ ❑ '❑ ❑
Ile ne contractors to construct'the project(Sec, 7044,Business r LAWN SPRINKLERS-1 INC 5 V.B. 6.00 ASSESSORS PARCEL NO.
- and Professions Code:The Contractor's License Law docs not apply -to an owner of properly who builds or improves thereon.and who LAWN SPRINKLERS-.OVER 5(EA.) . 1.00 '
contracts for such projects with a contractions)licensed pursuant to SEWER-SANITARY-STORM EA.200ft/10.00
the Contractors License Law, .TRACT NO. PARCEL NO.
❑ Iamexemptunder Sec. ,BL&P.C.for this WATER HEATER W/VENT" - 6.00 '
reason
.
Owner Dam WATER SYSTEM " 5.00
ACG DATE ACC.FILE NO,
WORK F.RS'COMPENSATION DECLARATION WATER TREATING EQUIP. 5.00 '
I hereby affirm that I have a certificate of consent nself-
or a certificate of Workers'Compensation Insurance,or' "il-I' d ZONING ENG.SITE NO.
copy thereof(Sec.3800,Lub.C.). "
Policy No.-Co •`
O ❑ Certitiedtopyis emby fit sheJ. . FIRE SPRINK ENERGY T-24
z Z� ❑ Cer copy fl th the city ins coon vision. MISC.- ' - REFER TO ORD.
O Applicant Y,[:]' 'N❑.' ' Y,❑ N❑
F- m PERMIT ISSUANCE ' 10.00
LU - CF:R'I'IF COOIPE EAEION INSURO WO KERS' FLOOD ZONE A.L.U.L.
W �_ COM11I'ENSATION INSURANCE PLG.CONTE. LIC.N0. PLG. i: '
D' o (This section nccd'not he completed if the permit 1s'for one .TOTAL Y❑ 'N❑ Y❑` .,N❑
Z) Z hundred dollars IS 100)or less.) - -
U O 1 certify that in Ore performmnce of the work for which this Per- OTY: MECHANICAL PERMIT FEE FEE SUMMARY
LL F mit is issued, 1 shall not employ any person in any munner so us m
O ED beconm subject to the Workers'Compensation Laws of Culfforma. r '
y Dam • ApplicantALTER OR ADD TO MECH. - 500 BUILDING" �/7
>_ m NOTICE.'10 API'LICAN'I': If,after making this Certificate of lix- . . _
Z eniption,You should become subject to the Workers'CuRpensation APPLIANCE ' 7 " 5.00 + PLAN,CHECK
provisions of the Labor Code, you must forlhwilh comply with FEE - va,b J
C„) such provisions or this permit shall be deemed revoked. AIR HANDLING UNIT,(TO 10=CF.M.)' -4.00
CONST RUCTION LEN DING AGI:NCY AIR HANDLING UNIT(OVER I0=C.F.M.).6.00 SEISMIC FE E' ,
• I hereby affirm that there is a construction lending agency for EXHAUST HOOD (WITH DUCT)- 5.00 ' 1.
Ore performance of the work for which this permit is issued(Sec. - MICROFILM
3097,Civ.C.). HEATING UNIT(TO 100,000 B.7:U.) 8.00
Lender's Name - HEATING UNIT 100,000 B.T.U.)9.50
Lender's Address ELECTRIC
Lea
I certify that l have read this application and state that the above VENTILATION FAN (SINGLE)' 4.00
Ordinaalisn n correct I agree to, to bl with all city st and county PLUMBING
ordinances and stun laws relating to building•construction, andmy BOILER-COMP,(3 H.P.Er 100,000 B.T.U.)'6.00
hereby authorize representatives of this city W enter upon the BOILER-_COMP(Over 100,000 BTU)SEE FEE SCH. 'MECHANICAL
above mentioned property for inspection purposes. -
(We) agree to save, indemnify and keep harmlesstlru City,of MISC.- REFER'TO ORD.
upertino ag inst liabilities,judgments, costs and expenses which - . CONST:TAX
ay in any seal roc against s City 'n conseyuen a of the PERMIT ISSUANCE 10.00 -
ranting of is r L' . - ECH.CONT. LIQ N0. MECH.. r
TOTAL TOTAL
Signat a of pplicant/Contras or I
OFFICE COPY
E` POST THIS CARD NEAR "FRONT'OF- BUILDING
PERMIT NUMBER
_ --. __CITY IOF CUPERTINO `- 1695
-- ,; INSPECTION DIVISION
JOB;INSPECTION'RECORD ti
• 'AR S - - j'7/�� PERMIT EXPIRATION
B '
JO BI
ESS .ZZ � �
I �DLIfJ1T# _LOT#
PERMIT. EXPIRES IF WORK
OWNER Q, CONTRACTOR IS NOT STARTED,WITHIN
•',+ , ' INSPECTION DATE INSPECTOR INSPECTION RECORD teo DkYS of PERMIT ISSU
FOUNDATION NOTE: _ ANCE OR 180'DAYS FROM",
LAST CALLED INSPECTION. '
UFER - ALL.,GRADING AND DRAINAGE SHALL BE INSTALLED
PR EGUNITE p - TO COMPLY WITH THE APPROVED PLANS AND CITY'OF PERMIT VALIDATION
CUPERTINO STANDARDS.
GARAGE SLABS . .•m �} ..�� 2
POUR NO CONCRETE UNTIL ABOVE HAS BEEN SIGNED
•`. UNDERGROUND /SLAB. EC• - .
•.
PLUMBING •
` ELECTRICAL r ' City of CU (�6
ISSUn NCE OAT
MECHANICAL > _ +' Dc. ELECT. ElPLGMecR,q
00 NOT POUR FLOOR UNTIL ABOVE HAS BEEN SIGNEDBUILDING PERMIT
.. INFORMATION
... _ WOOD ELOOR
PLUMBING - - - VALU TION S/FT.-
MECHANICAL r
PERMIT
ELECTRICAL .. -
FRAMING , L.
STORIES TYPE CONSTR.
* INSULATION,: -
. a., .,. , ,..• - OCC.GROUP , RES UNITS
PLACE NO SUBFLOOR UNTIL ABOVE HAS BEEN SIGNED r'
ROOF NOTE:NO FINAL INSP.SHALL BE MADE BEFORE sn. T,PLonR AREA TO TAO,ACREAGE
j. DIAPHRAGM - - THE CONSTRUCTION TAXIS PAID s -
BUILDING USE
ROOF.SHEATHING" 1 RCS IND CON PB u
—APPLY;NOROOFING,UNTIL'ABOVE HAS BEEN SIGNED,- ,'FINALS DATE INSP. �L L L L L_`.
ASSESSORS PARCEL NO,
ROUGH SAN.p
PLUMBING - - :1 ELECT..ENERGY nlncT NO r•ARce 1.No. '
TUBS&SHOWER PAN - PLUMBINGENERGY
MECHANICAL' MECH.ENERGY
ELECTRICAL' ' - BUIL'"DING ENERGY ACC,DATE ACC FILE NO
FRAMING; - ELECT.FINAL TEST TONING ENc,SITE No. .
INSULATION " PLUMBING -
GAS TEST GAS, -•'
FIRE SPRINK ENE WT,24
- - MECHANICAL - NQ Y Q;'w0
-COVER NO WORK UNTIL ABOVE HAS BEEN SIGNED, HEATING . '
• EXTERIOR SHEAR ' ELECTRICAL'RELEASE ., FLOOD ZONE: , A.L u.¢,��
:INTERIOR SHEAR FIRE DEPT, Y L , NL v L IN
SHEETROCK• - GRADE - - FEESUMMARY
EXTERIOR LATH ,. BUILDING { ( ,
.INTERIOR LATH • .TEMPORAR APPROVALS BUILDING O'O
SCRATCH COAT ELECTRIC FEE ELECTRIC CHECK
GAS
NO TAPE OR PLASTER UNTIL ABOVE,HAS BEEN SIGNED JOCCUPANCY SEISMIC FEE, "'1/F rD .
OCCUPANCY'0 F BUILDING IS NOT PERMITTED UNTIL BUILDING FINAL IS SIGNED BY BUI LDING INSPECTOR. MICROFILM • '
ARRANGE FOR INSPECTION BY PHONING 252-4505, ELECTRIC
F-
ONE WORKING DAY BEFORE REQUIRED INSPECTION: PLUMBING
OPLEASE GIVE JOB ADDRESS WHEN'.PHONING.
F ., z MECHANICAL
SEE-PERMIT FOR,EXPIRATION DATE
CONST.TAX
IMPORTANT!,
PLEASE READ REVERSE SIDE BEFORE ` 'TOTAL-
• CALLING FOR FINAL INSPECTION.
OFFICE COPY .