11628 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
BUILDING PROJECT I ENTI IC TIO PERMIT NUMBER
BU1eD G APPLICATION & PERMIT
ADDRESS
'/ ' !�
IY/ o� fel. BUILDING - ELECTRICAL-PLUMBING-MECHANICAL 1162
t OWNER'S/�I/�`�Ly�rACA� 4j6 R PLAN CHECK VALIDATION
NAME OTY. ELECTRIC PERMIT FEE
coNTRACTORs UTLETS-SWITCHES-RECEP 10.00/1.00 J
AME Q
�- 1'�=-'ply 'D `u Llc.rvo.:J�3S�� LIGHTING FIXTURES 10.00/1.00
r:ONTRACTOR'S T 14u1 PPLIANCES-RESIDENTIAL 4.00
aoo �� pp.�(AtaDpgS JI CE� 1 �j
��W PANELS 10.00 DATE OF APPLICATION
ARCHITECT '/''/�y� PANELS (OVER 200 AMP) 20,00 PLAN CHECK FEE P.C.NO.
ENGINE,4V&U1M 0,$A/4 CdOco1
LIC.No. SIGNS TRANS. 3.00
ARCH.OR ENG. M n SPECIAL CIRCUIT 5,00 PERMIT VALIDATION
ADDRESSVic, Jv 9/o CA,
! EMP. METER OR POLE INS. 20.00
ADDRESS ATS MOTORS SEE FEE SCH.
SERVICE CHANGE 20.00 "
ro o LICENSED CONTRACTORS DECLARATION 1 /O
hx v I hereby affirm that I in.licensed under provisions of Chapter 9 •1 "t vISSUANCE DATE
w ¢w (eonnneneing will,Section 7000)of Division 3 of the Bit yp�sj BLDG. ELECT l nQPLG. MECH.
H m z Professions Code,an license is in full force m effec.
Z o rn - License Class_ Lie.Numb V �s ❑ ❑ ❑
2ZIg
F
+ Date Contractor
I= - BUILDING PERMIT
IS ¢ OWNER-BUILDER DECLARATION INFORMATION
D MISC- REFER TO ORD
wu y I hereby affirm that I am exempt from the Contractor's License VALUATION SIFT.
F LL o j Law for the following reason.(Sec.703 1.5,Business and Professions PERMIT ISSUANCE 10.00
UCodefl,
:Any city orcounly which requires a permit to construct,alter, ��<2O improve,demolish,or repair any structure,prior to its issuance,also ELEC.CONTR. LIC.NO. ELEC.
O Mrequires the applicant for such permit to file a Signed statement that TOTAL PERMIT TO�fhe is licensed pursuant to the provisions o(the Contractor's License 7x,, ✓-Law(Chapmr 9(commencingwilh Section 7000)ofDivision 3ofthe /�/'f
a Business and Professions Code)or that Be isexempt therefrom and OTY. PLUMBING PERMIT FEE
r $ the basis for the alleged exemption.Any violation of Section 7031.5 STORIES TYPE CONSTR.
d3 by any applicant for a permit subjects the applicant to a civil penalty ALTER-DRAIN&VENT-WATER (EA.) 5.00
of not more than five hundred dollars(S500).1:
❑ I,as owner of the property,or my employees with wages 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:The Contractor's License Law does not apply to an owner of
property who builds or improves thereon,and who does so ch work FIXTURES-PER TRAP 5.00 SO.FT.FLOOR AREA TOTAL ACREAGE
himself or through his own employees.Provided that such int building
Prones are not intended or offered for sale.If,however,the budding GAS-EA.SYSTEM-1 OVER
6.00
or improvement is sold within one year of completion,the owner- GAS-EA.SYSTEM-OVER 4 (EA.) 2.00 BUILDING USE
builder will have the burden of proving flat he did not build or im- RES IND CON PB Other
prove for purpose of sale.). INDUSTRIAL WASTE INTER. 30.00
❑ I,as owner of the property,all]exclusively contracting with ❑ ❑ ❑ ❑ ❑
licensed contractors to construct the project(Sec 7044,Business LAWN SPRINKLERS-1 INC 5 V.B. 6.00 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.) 1.00
contracts for such projects with a contraclor(s)licensed pursuant to SEWER-SANITARY-STORM EA.200ft/10.00 --TRACT NNO. PARCELNO.
the Contractor's License Law.
❑ lam exempt under Sec. ,B.&P.C.forthis WATER HEATER W/VENT 6.00
reason
Owner Date WATER SYSTEM 5.00 ACC.DATE ACC.FILE NO.
WORK E RS'COMPF-NSATION DECLARATION WATER TREATING EQUIP. 5.00
I hereby affirm that I have a certificate ofconsent fD self-insure, ZONING ENG.SITE NO.
or a certificate of Workers'Compensation Insurance,or a certifie
copy thereof(Sec.3800,Lab.C.).
Q
Policy No. Company�Td
❑ CeftENISA
ENSU2RANCE
FIRE SPR INK ENERGY T 24
Z Z, Ceinspection division. MISC.- REFER TO ORD. Y ❑ N❑ v ❑ N❑
Aun
Fy PERMIT ISSUANCE 10.00 T-YL
OOD20NE A.L.U.C.
- C ORKERS'
CCT PLG.CONTR. LIC.NO. PLG. ❑ No Y❑ N❑
CL O (This action need not be completed if the permit is for one TOTAL
Q Z hundred dollars(S 100)or less.)
U O 1 certify that in the performance of the work for which this,per- OTY. MECHANICAL PERMIT FEE FEE SUMMARY
LL P mit is issued,I shall not employ any person in any manner so as to
Q W become subject to the Workers''Compensation Laws of California. BUILDING .
Dale Applicant ALTER OR ADD TO MECH. 5.00 ✓
}
to NOTICE 'f0 APPLICANT: If,after making this Certificate of Ea-
F_ emption,you should become subject to the Workers'Compensation APPLIANCE 5.00 PLAN CHECK
provisions of the Labor Code, you must forthwith comply with FEE
CJ such provisions or this permit shall be deemed revoked. AIR HANDLING UNIT(TO 10=C.F.M.) 4.00
CONS'PRUCI'ION LENDING AGENCY AIR HANDLING UNIT(OVER 10MIC.F.M.) 6.00 SEISMIC FEE aZO
1 hereby affirm that there is a construction lending agency I'or 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 00.%.,e
Lender's Address HEATI NG UN IT(OV ER 100,000 B.T.U.)9.50 ELECTRIC
1 certify that 1 have read this application and slate that the above VENTILATION FAN (SINGLE) 4.00
information is correct I agree to comply with all city and county PLUMBING
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 upon the BOILER-COMP 10",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.
Caperlino against liabilities,judgments, costs and expenses which CONST.TAX
ay in any w rue against Said City in consequence of the PERMIT ISSUANCE 10.00
t' oft rm' CONT. LIC.NO. MECH.
q L
TOTAL TOTAL �� `�
Signatu o pbc t/Contac r Dale a
OFFICE COPY
POST THIS CARD NEAR FRONT OF BUILDING
PE OMIT NUMBER
CITY OF CUPERTINO 11628
INSPECTION DIVISION
JOB INSPECTION RECORD
- PERMIT EXPIRATION';-
JOB ADDRESS UNIT LOT#
PERMIT EXPIRES IF WORK
OWNER CONTRACTOR IS NOT STARTED WITHIN
N
INSPECTIODATE INSPECTOR INSPE ON RECORD 180 DAYS OF PERMIT ISSU-
ANCE OR 180 DAYS FROM
LASTCALLED INSPECTION.
UFER
PERN1IT VALIDATION
PREGUNITE
POUR NO CONCRETE UNTIL ABOVE HAS BEEN SIGNED t.
UNDERGROUND /SLAB
PLUMBING
ELECTRICAL IssuarvcE GAT
BLDG. ELECT PL MECH.
MECHANICAL ❑ ❑ ❑
DO NOT POUR FLOOR UNTIL ABOVE HAS BEEN SIGNED BUILDING PERMIT '
INFORMATION
WOOD FLOOR VALUATION SIFT,
PLUMBING
MECHANICAL PERM 0
ELECTRICAL
FRAMING
STORIES TYPE CONSTR.
INSULATION
OCC.GROUP RES.UNITS
PLACE NO SUBFLOOR UNTIL ABOVE HAS BEEN SIGNED
ROOF $O.IT
FLOOR AREA TOTAL ACREAGE
DIAPHRAGM BUILDING USE
HES IND CON PB Op",
APPLY NO ROOFING UNTIL ABOVE HAS BEEN SIGNED El E-1 11 El El
ASSESSORSPAHC EL NO.
ROUGH
PLUMBING
TRACT NO. PARCEL NO.
GAS TEST
MECHANICAL
ACC.DATE ACC.FILE NO,
ELECTRICAL IRLW FINALS MDATEINSP.FRAMING p SANZONING ENG.SITE NO.
INSULATION PLUMBING
GAS
FIRE SPRINK ENERGY T�2G
MECHANICAL Y [DN❑ Y [:] N❑
COVER NO WORK UNTIL ABOVE HAS BEEN SIGNED HEATINGPLooDzorvE a.L.u.cLATH—INTERIOR - ELECTRICAL
LATH—EXTERIOR FIRE DEPT. Y ❑ N❑ Y ❑ N❑
SHEETROCK GRADE FEE SUMMARY
SHEAR INTERIOR BUILDING WL B `l BUILDING '
SHEAR EXTERIOR TEMPORARY APPROVALS
FIREWALLS ELECTRIC PLAN CHECK
F
GAS EE
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
LU ONE WORKING DAY BEFORE REQUIRED INSPECTION. PLUMBING
0 PLEASE GIVE JOB ADDRESS WHEN PHONING.
Z I MECHANICAL
- SEE PERMIT FOR EXPIRATION DATE -
CONST.TAX
IMPORTANT!
PLEASE:READ REVERSE SIDE BEFORE TOTAL / J
CALLING FOR FINAL INSPECTION.
OFFICE COPY