11457 / APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY \
SOI LDING PROJECT I DENTI FICATION PERMIT NUMBER
APPLICATION & PERMIT
ALNliss O L'
VRLLCU F PL/47-11BUILDING-ELECTRICAL-PLUMBING-MECHANICAL
o -0,4plE, 11 far o r 11457
OWNER'S 9 pt PLAN CHECK VALIDATION
"AME womANs WOkL.-D QTY. ELECTRIC PERMIT FEE
PHDNE I 9 17,1 (00
rRAcrors OUTLETS-SWITCHES-RECEP 10.00/1.00
NOMEs'7 2-t1
NA
T LIC.NO. 3y6 LIGHTING FIXTURES 10.00/1.00
' CONTRACTOR'S PPLIANCES-RESIDENTIAL 4.00
v, ADDRESS
l� O � (, PHON PANELS 10.00 DATE OF APPLICATION
IAPCHITECip /� rk/.11-'�11L PANELS (OVER 200 AMP) • 20.00 PLAN CHECK FEE P.C.NO.
OR / /N mr'!c GNG L.
ENmNEER K C� s (p SIGNS TRANS. 3.00
C.NO. n
ARCH.OR ENG. pC�I G-E QJOAJS OR \ SPECIAL CIRCUIT 5.00 PERMIT VALIDATION
ADDRESS OO JJ OO�e JJ Cu
Y ZIP TEMP.METER OR POLE INS. 20.00
APPLICANTS MOTORS SEE FEE SCH. 31
tc"-
ADDRESS
SERVICE CHANGE 20.00 01 +./4
w O o LICENSED CONTRACTORS DECLARATION \ �'[�
< v w I hereby affirm that 1 am licensed under provisions of Chapter 9 IS DATE
N a w (commencing with Section 7000)of Division 3 of the Business an BLO PLG. MECH.
al z Professions Codyxand my license is in full to ❑
00. - License Class Lia Number 76 ❑ ❑
o F Date ^10 (f 7 Contractor
a x BUILDING PERMIT
rt w OWNER-BUILDER DECLARATION INFORMATION
X 3 LL N 1 hereby affnm that I am exempt from the Contractor's License MISC.- REFER TO ORD
g Business and Professions VALUATION $/FT.
F LL O a Law for the following reason.(Sec.7031,5, PERMIT ISSUANCE 10.00 7� ��
oa Code:Any city or county which requires a permit In construct,alter, /
Q Q Q 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 flat TOTAL PERMIT TO
wm he is licensed pursuant to the provisions of the Contractors License _
F; i Law(Chapter 9(corimeneing with Section 7000)of Division 3 of the /�R R
a Business and Professions Code)or that be is exempt therefrom and 51BA`CK
PLUMBING PERMIT FEE v ����'
F
. 10. the basis for file alleged exemption.Any violation of Section 7031.5 STORIES TYPE CONSTR.
a �' � of not moPelthm,leivchundtit md subjects the
lS:i00)�yCmv toueivll penaltyTER-DRAIN&VENT-WATER (EA.) 5.00
❑ I,as owner of 0,e property,ser my employees with wages as FLOW PROTECT. DEVICE 4.00 OCC.GROUP RES.UNITS
their sole compensation,will do lire work,and the structure is not
intended or offered for sale (Sec. 7044, Business and ProcessionsAINS-FLOOR,ROOF,AREA,COND. 5.00
Code:The Contrdetor's License Law dons not apply In an owner of
property who builds or improves thereon,and Whn dOCs sUe11 WorkTURES-PER TRAP 5.00 S0.FT.FLOOR AREA TOTALACREAGE
himself or through his own employees,provided that such improve-
marts are not intended or offered for sale.It,however,the buildingS-EA.SYSTEM-11NC.4 OUTLETS 6.00
or improvement is sold within one year of comletion, the ownerS-EA.SYSTEM-OVER 4 IEA.) 2.00 BUILDING USE
builder will have the burden of proving that he did not build or inI- RES IND CON PB Omar
prove for purpose of sale.). DUSTRIAL WASTE INTER. 30.00 ❑ ❑ ❑ ❑❑ L as owner of the property,am exclusively Contracting withlicensed mmmctors to construe the project(Sec 7044,BusinessWN 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 property who builds or improves thereon,and whoWN SPRINKLERS-OVER 5(EA) 1:00
contmctsforsuch projects with a contrucmr(s)licensed lrursuaut toSEWER-SANITARY-STORM EA.200ft/10.00 TRACT NO. PARCEL NO.
the Contractor's License Law.
❑ lam exempt under Sec. ,B.&P.C.for this WATER HEATER W/VENT 6.00
reason
Owner nate WATER SYSTEM 5.00 ACC.DATE ACC.FILE NO,
WORKS RS'COMPENSATION DECLARATION WATER TREATING EQUIP. 5.00
1 hereby affirm that I have a certificate of consent to self-insure ZONING ENG.SITE NO,
or a Certificate of Workers'Compensation Insurance.or a certified
copy thereof(Sce.3800,Lab.C.). /-
Policy No. Company_G
O ❑ Certilicd copy is hereby furnished. FIRE SPRINK ENERGY T Z4
'z� Conor copy f d with the ci epeclion division. MISC.- REFER TO ORD. y N❑ Y ❑ N❑
O App icant
CC Cli l'IFICATEOF EXP'NIMION'FROMWORKERS' PERMIT ISSUANCE 10.00 FLOOD ZONEA.L.U.C.
UJ > COMPENSATION INSURANC17 PLG.CONTR. LIC.NO. PLO. Y❑ N❑ Y❑ N❑
CL 0 (This section need not be completed if the permit is for one TOTAL
0 2 hundred dollars(SI00)or less)
U O 1 certify ilial in the performance of the work for which this per- QTY MECHANICAL PERMIT FEE FEE SUMMARY
LL F mit is issued,1 shall not employ any person in any manner so as to
Ow become subject to the Workers Compensation Laws of California. BUILDING `�
Date Applicant ALTER OR ADD TO MECH. 5.00 �-
} ED NOTICE TO APPLICANT: If,ufill making this Certificate of L'x-
H 2 emption,you should become subject to the Worken.'Compensation 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=11F.ML) 4.00
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,CP.CJ. HEATING UNIT(TO 100,000 B.T.U.) 6.00
Lender's Name HEATING ON IT(OVER 100,000 B.T.U.)9.50 ELECTRIC
Lender's Address
I Certify that I h.cC,cad this application and stale that the above VENTILATION FAN (SINGLE) 4.00
information is correct. 1 agree to comply with all city and countyPLUMBING
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 City to enter "pun the BOILER-COMP (Over 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,�k�mta,and oxpenacs which PERMIT ISSUANCE .10.00 CONST.TAX
may in any way accrue against said :U4 in Cray equC^Ce of the
granting of this pemliL 77- MECH.CONT. LIC.NO. MECH.
\Jk/1 Q,' TOTAL TOTAL 3
Siglure 1 plicant/Contra' Datc��-
OFFICE COPY 2 S
3 r�Z
POST THIS CARD NEAR FRONT OF BUILDING
rrlvnvr Nun+BEH
CITY OF CUPERTINO 11457
\ INSPECTION DIVISION
JOB INSPECTION RECORD �
;2a&// /^
i!5 PERMIT EXPIRATION
JOBADDRESS lo�a� UNIT# LOT#
PERMIT EXPIRES IF WORK
OWNER CONTRACTOR "S IS NOT STARTED WITHIN
INSPECTION DATE 1WSPECTOR I INSPECTION RECORD 180 DAYS OF PERMIT ISSU-
ANCE OR 180 DAYS FROM
FOUNDATION LASTCALLED INSPECTION.
UFER
PERMIT VALIDATION
PREGUNITE
POUR NO CONCRETE UNTIL ABOVE HAS BEEN SIGNED -,
UNDERGROUND /SLAB
L
PLUMBING - C y
ELECTRICAL ISSUANCE DATE
BLD ELECT. PLG. rMECH,
MECHANICAL ❑ 1 ❑ 1 El
DO NOT POUR FLOOR UNTIL ABOVE HAS BEEN SIGNED BUILDING PERMIT
INFORMATION
WOOD FLOOR VALUATION s/FT.
PLUMBING I
MECHANICAL PERMIT TO
ELECTRICAL /.4/rER/OR-1 Kryi
FRAMING STORIES TYPE CONSTR.
INSULATION
OCC.GROUP RES,UNITS
PLACE NO SUBFLOOR UNTIL ABOVE HAS BJSIGNED $OFTFLUOR AREA TOTAL ACREAGEROOF
DIAPHRAGM BUILDING USE
RES IND CON PIT 00—
APPLY NO ROOFING UNTIL ABOVE HAS BESP
ASSESSORS PARCEL NO
ROUGH
PLUMBING TRACT NO. PARCEL NO.
GAS TEST
MECHANICAL
'ACC.GATE ACC.FILE NO.
ELECTRICAL FINALS DATE INSP.
FRAMING SAN # zoNiNc ENG.SITE NO.
INSULATION PLUMBING
GAS
FIRE SPRINK ENERGY 124
MECHANICAL Y [] NE] Y 0 NE3
COVER NO WORK UNTIL ABOVE HAS BEEN SIGNED HEATING
FLOOD ZONE a,LU.C.
LATH-INTERIOR ELECTRICAL
LATH-EXTERIOR FIRE DEPT. v N� v �] N❑
SHEETROCK GRADE FEE SUMMARY
SHEAR INTERIOR BUILDING BUILDING
SHEAR EXTERIOR TEMPORARY APPROVALS
FIREWALLS ELECTRIC PLAN CHECK
FEE
GAS ,
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
I" ONE WORKING DAY BEFORE REQUIRED INSPECTION.
- PLUMBING
PLEASE GIVE JOB ADDRESS WHEN PHONING.
— MECHANICAL
SEE PERMIT FOR EXPIRATION DATE —
CONST.TAX
IMPORTANT!
PLEASE READ REVERSE SIDE BEFORE TOTAL
CALLING FOR FINAL INSPECTION.
OFFICE COPY _ - -