17074 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
BUI LDINc PROJECT IDENTIFICATION -PERMIT NUMIBER
aUII ING �.3 APPLICATION & PERMIT
an7 �paESs� /yx^^'^ I `f
I'Iw W1 BUILDING -ELECTRICAL-PLUMBING -MECHANICAL 7
OWNER'5 p .L� T c� C I'
NAME T❑Iv11Lp W� sL ONr-� f�dOg'�lV+-19'1 PLAN CHECK VALIDATION
�� HD$_L(.x�3 I QTY. ELECTRIC PERMIT FEE �D
PNo E
4115
NTnACTDfl's •-�/�
Na OUTLETS-SWITCHES-RECEP 10.00/1.00 rYJ ��-/
• �y LiC No, LIGHTING FIXTURES 10.00/1.00
Co RACTOR'Sl S �-t i 0 PPLIANCES-RESIDENTIAL 4.00
aooRess
C' PNO TSO^" I 1 PANELS 10.00 DATE OF APPLICATION
ARCRfTECi PLAN CHECK FEE P.C.NO.
OR a.21I OI-Y Aft VD•
ENGINEER tK PANELS (OVER 200 AMP) 20.00 _..
LIC.NO. CI•I SIGNS TRANS, 3.00
mo ss SPECIAL CIRCUIT PERMIT VALIDATION
oE
ZIP EMP.METER OR POLE INS. 20.00 t),D
ADDRESS
APPLICANT s MOTORS SEE FEE SCH.
DRESSE55
C U SERVICE CHANGE 20,00 -///�1.�,,1''
.02 LICENSED CONTRACTORS DECLARATION
< is W I hereby affirm that I am licensed under provisions of Chapter 9 ' ISSUa NCE DATE
(commencing with Section 7000)of Division 3 of the Business and
m¢ a Q B G. ELECT. PLG. MECH.
r 0 z Professions Code,and my license is in full force and effect. f. Q
z 0 T License Class Li,.Number
z 0 Date Contractor
m f cit oil ---m; BUILDING PERMIT
Ic o re 4re U OWNER-BUILDER DECLARATION INFORMATION
X 0 H 1 hereby affirm that I am exempt from the Contractors License MISC.- REFER TO ORD
VALUATION SIFT.
Fu0 Law for the following reason.(Sec.7031.5.Businessand Professions PERMIT ISSUANCE 10.00 ) aO71
mj Code:Any city or county which requiresa permit toconstruct,alleq eyJ ? oO/v
IF ¢ ¢ p improve,demolish,or repair any structure,prior to its issuance,also ELEC.CONTR. LIC.NO. ELEC.
o u requires the applicant for such permit to file a signed statement that TOTAL d3a / PERMIT TO
e w m he is licensed pursuant to the provisions of the Contractor's License
zi Law(Chapter 9(commencing with Section 7000)ofDivision3ofthe SFOwLD
E i c Business and Professions Code)or that he is exempt therefrom and QTY. PLUMBING PERMIT FEE v-_
R I-$ the basis for the alleged exemption.Any violation of Section 7031.5 STORIES TYPE CONSTR.
by any applicant for a permit subjects the applicant to a civil penalty ALTER-DRAIN -WATER (EA.) 5.00
of not more than five hundred dollars(S500)J:
❑ I,as owner of the property.or my employees with wages as BACK FLOW PROTECT.DEVICE 4.00 DLC.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 apply to an owner of
property who builds or improves thereon,and who does such work FIXTURES-PER TRAP 5.00 Sa FT.FLOOR AREA TOTAL ACREAGE
himself or through his own employees,provided that such improve-
: merits are or intended or offered for Sale.If,however,the building GAS-EA.SYSTEM-11NC.40UTLETS 6.00 �^2r`T i-6
or improvement is sold within one year of completion,the owner- GAS-EA.SYSTEM-OVER 4 (EA.) 2A0 BUILDING USE
builder will have the burden of proving that he did not build or im- ,R Es IN❑O CON PB Other
prove for purpose of sale.). INDUSTRIAL WASTE INTER. 30.00 1�dYS
❑ d as owner of the progeny,he exclusively contracting with
licensed contractors to construct the project(See,7044,Business LAWN SPRINKLERS-1 INC 5 V.B. 6.00 ASSESSORS PARC
and Professions Code:The Contractor's improv Law does not apply'
to an owner of property who builds tr improves thereon,and who LAWN SPRINKLERS-OVER 5 (EA.) 1.00 �j�j� x -JYD-
contracts for such projects with a comnetol(sl license)pursuant to v RAC -O. L.+V9
the Contractor's License Law. SEWER-SANITARY-STORM EA.200ft/10.00 TRACT NO. PARCEL NO.
❑ lam rx mdn Se . .. ,B.&I'.C.for tlds
lesson WATER HEATER W/VENT 6.00
Owner Date WATER SYSTEM 5.00
ALL.GATE ACC.FILE NO.
WORK ERS'COMPENSATION DECLARATION WATER TREATING EQUIP. 5.00
1 hereby affirm that I have a certificate ofcoment 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
O ❑ Certified copy is hereby famished. FIRE SPRINK ENERGY T]4
Z Z ❑ Certified copy is Died with lite city inspection division. ❑ ❑
F O Applicant MISC.- REFER TO ORD. v❑ ❑N v N
Lo CERTIFICATE OF EXEMPTION FROM WORKERS' PERMIT ISSUANCE 10.00 FLOOD ZONE A.L.U.C.
LU > COMPENSATION INSURANCE PLG.CONTR. LIC.NO. PLG. ,
d ❑ ❑
D (This section need not he completed if tile Permit e peit is for one TOTAL I Y❑ ❑N Y N
Z hundred dollars IS 100)or less.)
C.1 O 1 certify that in the performance of the work for which this per, QTY. MECHANICAL PERMIT FEE FEE SUMMARY
LL U mit is issued,1 shall not employ a pe on in a y manner so as to
O L) hero sobjey the Worke C ofC lifornia. BUILDING oe(�
o- Daur��_I=i _Applicam ALTER OR ADD TO MECH. 5.00
>_ Z NOTIC TO APPLICANT: If,after making thus s Cer cute of lix-
f- - emption,you should become subject to the" ompensr F,`o APPLIANCE 5.00 PLAN CHECK
Provisions of the Labor Code, you must forthwith comply with FEE
U such provisions or this permit shall be deemed revoked. AIR HANDLING UNIT(TO 10=C.F.M.) 4,00
CONSTRUCTION LENDING AGENCY AIR HANDLING UNIT(OVER 10A00GEM.) 6.00 SEISMIC FEE e2A
I hereby affirm that there is a construction lending agency for EXHAUST HOOD (WITH DUCT) 5.00
the performanc f the work fur hich this per it is issued ISec. MICROFILM
3097.r's Na....
HEATING UNIT(TO 100,000 B.T.U.) 8.00 �q /
Lenders Name X' HEATING UNIT(0V E R 100,000 B.T.U.)9.50 V al
Lender's Address ELECTRIC
I certify that I have read this applicltl ion and state that the.lbo,' VENTILATION FAN (SINGLE) 4.00 n
information is correct. 1 agree to comply with all city and county PLUMBING 1
ordinances and state laws relating to building construction, and BOILER-COMPI3H.P.or 100,000B.T.U.) 6.00
• hereby authorize property for
on this to enter upon the BOILER-COMP(Over 100,00 B 1 SEE FE SCH. MECHANICAL
hereby entioned ro ml torins of th purposes.
(We) dgree to save, indemnify and keep harmless the Cityof MISC.njNkA1. ER TO RD. -
Cupertino against liabilities,judgments, costs and expenses which PERMIT ISSUANCE 10.00 Q CONST.TAX
may ap way ac ue against sail City in consequence of the
gr g o this er I /11 MECH.CONT. LIC.NO. MECH.
TOTAL TOTAL (�
SI nature of Appllca t/Con apttor (Date D /
OFFICE COPY
Y•► POST THIS CARD NEA P BUILDI,�1G PERMIT NUMBER
' '" ' CITY 01 ` E TING -� 170?
INSPECTION DIVISION
JOB INSPECTION RECORD 3
` DT . TION
-'11:
MA ADDRESS7PR-MTE7UR
. d /. LO,(
PERMIT EXPIRES IF WORK
OWNER- —e v- .41 v?'o-1N !A CONTRACTOR I .Q III- T IS NOT STARTED WITHIN
INSPECTION f DATE INSPECTOR I INSPE TION 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
UPERTIN STANDARDS.
GARAGE SLABS _
d
POUR NO CONCRETE UNTIL HAS BEEN SIGNED 3 4.t G.ptL
ABOVE 1 ; f
UNDERGROUND /SLAB Okq K �]' ��/a�' '"
PLUMBING '* $Y. - t"►� V'CF .,
/ "G. "` YU.�C,,�
ELECTRICAL `BIZ Lp puxz as ISSUANCE DATE
MECHANICAL � S c ELECT PLG. MECR
u"ZZ2 i .
00 NOT POUR FLOOR UNTIL ABOVE HAS BEEN SIGNED - u - ERMIT
WOOD FLOOR, vn wnnTIONnN siFr.
PLUMBING- _
I
MECHANICAL
ELECTRICAL FfPERMIT TU
FRAMING �-
INSULATION f+Ao I®Q STORIES TYPE CONSTR,
OCC GROUP RES UNITS
OBJ T
PLACE NO SUBFLOOR UNTIL ABOVE HAS BEEN SIGNED
50,'FT,FLOUH AREA TOTAL ACREAGE
_ ROOF NOTE:NO FINAL INSP.SHALL BE THE CONSTRUCTION TAX IS PAID ADE BEFORE . p
DIAPHRAGM aU
BUILDING USE
ROOF SHEATHING 2f- q u!5 R IND Com PR. on... :
APPLY NO ROOFING UNTIL ABOVE HAS BEEN SIGNED FINALS DATE INSP. ❑ ❑ ❑ ❑
ROUGH SAN.N ) AssessnORS PAR EG- pTT
PLUMBING @� ELECT.ENERGY � L�'Q JO
TRACT NO. PARCEL NO
TUBS&SHOWER PAN 7(r dec PLUMBING ENERGY
MECHANICAL MECH.ENERGY
ACC DATE ACC.FILE NO
ELECTRICAL BUILDING ENERGY
FRAMING 'Z ELECT.FINAL TEST
INSULATION PLUMBING ZONING ENC.slrE No.
GAS TEST GAS
If
MECHANICAL -
HRE SPRINK ENERGY T 2e
COVER NO WORK UNTIL ABOVE HAS BEEN SIGNED HEATING ❑ N❑ . Y ❑ N❑
On .
_
EXTERIORSHEARELECTRICAL RELEASE FLn,ZONE I ALUC.
INTERIOR SHEAR FIRE DEPT. Y❑ N❑ Y N❑'
SHEETROCK (Z GRADE FEE SUMMARY
EXTERIOR LATH BUILDING'
INTERIOR LATH TEMPORARY APPROVALS BUILDING
SCRATCH COAT - ELECTRIC PLAN CHECK .r
GAS FEE'
NO TAPE OR PLASTER UNTIL ABOVE HAS BEEN SIGNED OCCUPANCY SEISMIC FEE
OCCUPANCY OF BUILDING IS NOT PERMITTED UNTIL BUILDING FINAL IS SIGNED BY BUILDING INSPECTOR. MICROFILM -
ARRANGE FOR INSPECTION BY PHONING 252-4505, ELECTRIC /4/ ell/
I- �ONE WORKING DAY BEFORE REQUIRED INSPECTION. PLUMBING t
z° PLEASE GIVE JOB ADDRESS WHEN PHONING.
— SEE PERMIT FOR EXPIRATION DATE — MECHANICAL _
IMPORTANT! CONST.TAX r1
PLEASE READ REVERSE SIDE BEFORE TOTAL
CALLING FOR FINAL INSPECTION. ��
OFFICE COPY.