17153 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
BUILDING PROJECT IDENTIFICATION PERMIT NUMBER „
BUILDING P APPLICATION & PERMIT 17153
a00RE55r9e/
- BUILDING — ELECTRICAL—PLUMBING—MECHANICALJ .�+%
OWNL S PLAN CHECK VALIDATION
r% Na _ QTY. ELECTRIC PERMITFEE
PRONE
CONTRACTOR S UTLETS-SWITCHES-RECEP 10.00/1 DO
22
vcg c �f Ic,NO. LIGHTING FIXTURES 10.00/1 00
CONTRACTORS - pPLIANCES-RESIDENTIAL 4 0 -
AOOREss �///7,• '
/ /� PXONP ,� PANELS 1000 DATE OF APPLICATION
AR HrtecTPANELS (OVER 200-AMP) 2000 PLAN CHECK FEE P.C.NO.
OR
ENGINEER LIC.NO, SIGNS TRANS. 3 0
ARCH.OR
ADDRESS ENG SPECIAL CIRCUIT 5 DO PERMIT VALIDATION ,
ZIP TEMP.METER OR POLE INS., - 20 00
APPLICANT'S
' MOTORS SEE FEES H
aooREss .
SERVICE CHANGE 2 O01,..•
w o 9 LICENSED CONTRACTORS DECLARATION --
a o I hereby affirm that I am licensed under provisions of Chapter 9 logoISSUANCE DATE
m w (commencing with Section 7000)of Division 3 of the Business and BLDG. ELECT. PLG. MECH.
F m i Professions de m�fL�ry�yY�SJreense is in full for
Z o m — LiceNumber - ❑ ❑ ❑
O w H w Date/ Contractor _
a y BUILDING PERMIT
¢ ¢w �
OWNER-BUILDER DECLARATION, - - INFORMATION
K
;LL H I herebyaffirm that I am exempt from the Contractor's License MISC.,— REFER T ORD
p VALUATION $/FT.
F a- '0 Law the following re ason f5ec.7031.5,Buxinessand Professions PERMIT ISSUANCE -
Code:Any city or county which requires a permit to construct,alter, '
rt ¢0 improve,demolish,or repair any structure,prior to its issuance,also ELED.CONTR. LIC.NO.' ELEC.
G u requires the applicant for such permit to file a signed statement that TOTAL PERMIT TO
Z
$ he is licensed pursuant to the provisions of the Contractor's License - JI
Fzi Law(Chapter 9(commencing with Section 7000)6fDivision 3ol the
a Business and Professions Code)or that he is exempt therefrom and OTY. PLUMBING PERMIT FEE
¢= the basis for the alleged exemption.Any violation of Section 7031.5 1 1 STORIES TYPE CONSTR.
i ; _ by any applicant for a peril subjects the applicant to a civil penalty ALTER-DRAIN&VENT-WATER (EA.) 5. 0
of not more than five hundred dollars($500).): '
❑ I,as owner of the property,or my employees with wages as BACK FLOW PROTECT. DEVICE 4. 0 DCC.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. 0
Code:The Contractor's License Law does not apply loan owner of '
property who builds or improves thereon,and who does such work FIXTURES-PER TRAP 5. 0 SQ FT.FLOOR AREA TOTAL ACREAGE
• himself or through his own employees.Provided that such improve-
merits are not intended or offered for sale,If,however,the building GAS-EA.SYSTEM-11NC.4 OUTLETS 6 O
or improvement is sold within one year of completion,the owner- GAS-EA.SYSTEM-OVER 4 (EA.) • 2 0 BUILDING USE
builder will have the burden of proving that he did not build or im- RES IND, CON PB Omar
prove for purpose of sale.). - INDUSTRIALWASTE INTER. 3000
❑ 1,as owner of the properly,um exclusively contracting with ❑ ❑ ❑ ❑ ❑
licensed contractors to construct the project(Sec. 7044,Business LAWN SPRINKLERS- 1 INC 5 V.B. 600 ASSESSORS PARCEL NO.
and Professions Code:The 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 0 r
contracts for such projects with a contractors)licensed pursuant to
the Contractor's License Law. SEWER-SANITARY-STORM EA.200ft/1 00 TRACT NO. PARCEL NO.
❑ lam exempt under Sec.—,BAP.C.for this WATER HEATER_W/VENT 6 0
reason
Owner Date WATER SYSTEM 5 O ACC.OATE ACL.FILE N0.
WORKERS'COMPENSATION DECLARATION WATER TREATING EQUIP. 5 0
I hereby affirm that 1 have a certificate of consent to self-insure, ZONING ENG.SITE NO.
or a certificate of Workers'Compensation Insurance,or a certified
copy thereof(Sec.3800,Lab C.). _
Policy No. Company
0 O Certified copy is hereby famished FIRE SPRINK ENERGY T-24
Z 2 Cerlifie ry is file ith the city inspection division.
P: p Arplicant • MISC.- REFER TO ORD. y ❑ N❑ Y ❑ N❑
rn PERMIT ISSUANCE 10.00 FLOOD ZONE A.L.U.C.
LU J ;RTIFICCCIiPE I ATIOTION PROM WORKERS'
1JJ COMPENSATION INSURANCE PLG.CONTR. LIC.NO. PLG. Y❑ N❑ v❑ N❑
IL O IThfs,section need nor be completed if the peril is far ane TOTAL
:D 2 hundred dollars IS 100)or less.)
U O I certify that in the performance of the work for which this per- QTY. MECHANICAL PERMIT FEE FEE SUMMARY
LL P mit is issued,1 shall not employ any person in any manner so as to ..
IJ
become subject to the Workers'Compensation Laws of California. - ' BUILDING
O 1
Dalc Applicant ALTER OR ADD TO MECH. 5. 0 IZ l07
} tan NOTICE TO APPLICANT: If,after making this Certificate of Ex-
(... ? emption,you should become subject to the Workers'Compensation APPLIANCE 5.00 PLAN CHECK' ,
provisions of the-Labor Code, you most forthwith comply with FEE
U such provisions or this permit shall be deemed revoked. AIR HANDLING UNIT(TO 10MC.F.M.) 4 DO
CONSTRUC'T'ION LENDING AGENCY AIR HANDLING UNIT(OVER I0,000C.F.M.) 600 SEISMIC FEE- t �
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. HEATING UNIT(TO 100,000 B.T.U.) 8. 0 MICROFILM
3097,Civ.C.).
Lender's No HEATING UNIT(OVER 100,0006.T.U.)9. 0 ELECTRIC '
Lender's Address
1 certify that I havo reud•rhis application and state that the above VENTILATION FAN (SINGLE) 4. 0 '
information is correct. I agree to comply with all city and county PLUMBING '
ordinances and state laws relating to building construction, and BOILER-OOMP(3 H.P.Or 100,000 B.T.U.) 6 0
hereby authorize representatives of this city to enter upon the BOILER-COMP IOver 100,000 BTUI SEE FEE$ H. MECHANICAL
above-mentioned properly liar inspection purposes.
(We) agree to save, indemnify and keep harmless the City of MISC.- -REFER TO'O D.
uperlino against liabilities,judgments, costs and expenses which CONST.TAX
1030
may in any way accrue against said City in conseq enc of the PERMIT ISSUANCE
ranting of this erm.1 - - MECH.CONT. LIC.NO. MECH.
t TOTAL I TOTAL lqV�>u
Signa pplicanl/Co act a
OFFICE COPY —
POST THIS CARD NEAR FRONT OF'BUILDING PERMIT NUMBER
CITY. OF CUPERTINO 17153
INSPECTION DIVISION
B INSPECTION RECORD' ;
V `ciL4tiL+J lO�$ 4
'a5 V44a 0 PERMIT EXPIRATION
JOB ADDRESS )O �.] UNIT# LOT
PERMIT EXPIRES IF WORK
[OWNER CONTRACTOR ' IS NOT 'STARTED WITHIN
INSPECTION DATE INSPECTOR INSPECTION RECORD 180 DAYS OF PERMIT ISSU- ..
FOUNDATION " - ANCE OR 180 DAYS-FROM
NOTE: LASTCALLED INSPECTION.."
UFER ALL GRADING AND DRAINAGE SHALL,BE,INSTALLED'
PREGUNITE TO COMPLY WITH THE APPROVED PLANS AND CITY.OF PERMIT VALIDATION
CUPERTINO STANDARDS,
GARAGE SLABS �; `
POUR NO CONCRETE UNTIL ABOVE HAS BEEN SIGNED "` V` 6� I
UNDERGROUND /SLAB
PLUMBING
ELECTRICAL - - ••� IssuANCE unrE
MECHANICAL eLDc ELECT. PLG, MecH
FEB' 819E9p . ❑ ❑ I ❑
DO NOT POUR FLOOR UNTIL ABOVE HAS BEEN SIGNED BUILDING PERMIT
WOOD FLOOR 09 Of CUOTH 10 INFORMATION
PLUMBING f VAiLunnoN_ M SIFT.
MECHANICAL /'• ' '� �.
ELECTRICALPERMrt ro
,7
FRAMING' - .%i -
INSULATION Sr DRIES 'TYPE CONSTR.
OCC GROUP RES UNITS
PLACE NO SUBFLOOR UNTIL ABOVE HAS BEEN SIGNED
• ,= ROOF NOTE:NO FINAL INSP.SHALL BE MADE BEFORE $OFT FLOOR AREA TOTAL ACREAGE
DIAPHRAGM THE CONSTRUCTION TAX IS PAID
BUILDING USE
ROOFS EATHING HE;S IND CON FIR O"_
APPLY NO ROOFING UNTIL ABOVE HAS BEEN SIGNED FINALS DATE INSP. ❑ El : ❑ ❑ ❑
ROUGH SAN.# ASSESSOHS PARCEL NO.
PLUMBING ELECT.ENERGY
TRACT NO. PARCEL NO
TUBS&SHOWER PAN PLUMBING ENERGY
MECHANICAL MECR ENERGY
.ELECTRICAL BUILDING ENERG77 ACC.DATE .ACC.PILE No
FRAMING ELECT.FINAL TEST
ZONING - ENG-SITE NO.
INSULATION PLUMBING
GAS TEST GAS
MECHANICAL E. 'FIRE SPRINK ENERGY T2A
COVER NO WORK UNTIL ABOVE HAS BEEN SIGNED HEATING 01 EJ NO
'
EXTERIOR SHEAR � ELECTRICAL RELEASE FLOOD ZONEA.L UCrC
INTERIOR SHEAR ' FIRE DEPT. v❑• NO . Y ❑ ' N❑;
SHEETROCK' GRADE, FEE SUMMARY
EXTERIOR LATH BUILDING"
INTERIOR LATH TEMPORARY APPROVALSAV BUILDING k r
SCRATCH COAT ELECTRIC PLAN CHECK
GAS FEE
NO TAPE OR PLASTER UNTIL ABOVE HAS BEEN SIGNED OCCUPANCY SEISMIC REE
OCCUPANCY OFBUILDING IS NOT PERMITTED UNTILBUILDING FINALISSIGNEDBY BUILDING INSPECTOR. MICROFILM
w ARRANGE FOR INSPECTION,BY PHONING 252-4505;
l•4� 'ELECTRIC
ONE WORKING DAY BEFORE REQUIRED INSPECTION. » ' PLUMBING
z PLEASE GIVE JOB ADDRESS WHEN PHONING.
— SEE PERMIT FOR EXPIRATION DATE -' :.a, MECHANICAL
CONST.TAX
IMPORTANT!
PLEASE READ REVERSE SIDE BEFORE '?.;.
CALLING FOR FINAL INSPECTION. 'TOTAL .
OFFICE'COPY .'