13563 LICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
PERMIT NUMBER
UILDING PROJECT IDENTIFICATION
APPLICATION & PERMIT
a"UILD eD te;q!, O m,- 13563..
AREss BUILDING-ELECTRICAL-PLUMBING-MECHANICAL
!L4 !
OWNEITS B 4„Axr PLAN CHECK VALIDATION
�IIL "nme OTV. ELECTRIC PERMIT FEE /)
•' C PHONE61Y JC
CONTRACTOR'S UTLETS-SWITCHES-RECEP 10.00/1.00
NAME
LS 6cC+C ~5 LIC.NO. O LIGHTING FIXTURES 10.00/1.00
C TRACTOR'S 40.0 ,q ' PPLIANCES-RESIDENTIAL 4.00
AOOeRESS
p^S7 O
PHONE /y ,.y PANELS 10.00 GATE OF APPLICATION
/RCHITECT PANELS (OVER 200 AMP) 20.00 PLAN CNECK FEE P.C.NO.
OR ❑
ENGINEER - 'J,QO Ag
IC.No. SIGNS TRANS.
ARCH.OR ENG. 5.00 PERMIT VALIDATION
ADDRESS ,0 SPECIAL CIRCUIT
r s
ZIP 7d EMP.METER OR POLE INS. 20.00 `-
APPLICANT'S MOTORS SEE FEE SCH.
ADDRESS /t YP,):-.:�
p SERVICE CHANGE 20.00 i1l' OIE �V3
O p 7
.09 LICENSED CONTRACTORS DECLARATION /O// a /
H ISSUAN E DATE
a u I hereby off..Thal 1 am licensed under provisions of Chapter 9
w< N (commencing with Section 7000)of Division 3 of the Business and BLDG. ELECT. PLG. MECH.
r o z Professions Codea rld my license is in full force ad e 1'e
Z o N - License ass��Lir.Number ICI .
O - D
Date C Contractor
a x j BUILDING PE MIT
¢ ¢ m
OWNER-BUILDER DE ARAT10 INFORMATION
k ; 1 hereby affirm that I am exempt from the Contractor's License MISC.- REFER TO ORD
a g PERMIT ISSUANCE 10.00 VALUATION $/FT.
n o¢ Law for the affirm
t reason.(Sec.7031.5,Business end Professions /
L m rn I Cade:Any city or county which requires permit to construct.alter, 0-Il
k�.,,,
re ea Q O improve,demolish,or repair any structure,prior to its Issuance,also ELEC.CONTE. LIC.NO. ELEC. V�� V I s�
D u requires the applicant for such permit to file a signed statement that TOTAL PERMIT T
m$w he is licensed pursuant to the provisions of the Contractors License
Fz > Law(Chapter 9(commencingwithSection 7000)ofDivision3ofthe ANT o4
Z ¢c Business and Professions Code)or that he o exempt therefrom and OTV. PLUMBING PERMIT FEE STORIES TYPE CONSTR.
the basis for the alleged exemption.Any violation of Section 7031.5
d ; _ by any applicant for a permit subjects the applicant toa civil penalty ALTER-DRAIN&VENT-WATER (EA.) 5.00
of no(more than five hundred dollars($500).)
❑ 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 AR EA,GOND. 5.00
intended or offered for sale (Sec. 7044, Business and Professions DRAINS-FLOOR,ROOF,
Code:The Contractor's License Law does not apply to an owner of
who docs such work FIXTURES ES-PER TRAP 5.00 �`- SD.FT.FLOOR AREA TOTAL ACREAGE
property who builds or improves thereon,and
himself or through his own employees,provided that such improve. GAS-EA.SYSTEM-1 INC.4 OUTLETS 6.00
meats are not intended or offered for sale.II',however,the budding
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 that he did not build or im. RES IND CON PB Omer
prove for purpose of sale.). INDUSTRIAL WASTE INTER. 30.00 0 El 13
O Las owner of the property,am 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 IEA.) 1.00
contracts for such projects with a contractors)licensed pursuant to SEWER-SANITARY-STPFIM EA.200ft/10.00iRACTNO. PARCEL NO.
the Contractor's License Law.
❑ 1a exempt under Sec. .B.&P.C.for this WATER HEATER W/VENT 6.00
reason
Owner Date - WATER SYSTEM 41 •-� ' 5.00 -ACC.DATE ACD.FILE NO.
WORKERS'COMPENSATION DECLARATION WATER TREATING'EQUIP.
1 hereby affirm that I have a certificate of consent to sell'-insure, Cihl Ot LVnt1 tss ZONING ENG.SITE NO.
or a certificate of Workers'Compen tion Insurance,or a certified _
copy thereof(Sec.3800,Lab.C.)./ -
Policy No. C.ti reb y-ZL/'Z SL7
❑ Certified Copy is hereby fur ushed.W-7 06'��� FIRE SPRINK ENERGY T�29
Z� Pr Certifie opy/is fjlfit Hh the city inspectmn division. MISC.- REFER TO ORD. y 0 IN Y [] NC]
O Applicant
cc CE IFICATE OF EXEMPTION FROM WORKERS' PERMIT ISSUANCE 10.00 Q FLOOD ZONE A.L.U.C.
w > COMPENSATION INSURANCE PLG.CONTE. LIC.NO. PLG. nn O7 Y� N� Y ❑ N[]LU O TOTAL I[aK-
CL. (This sectidn need not be completed it the permit is for one
7Z hundred dollars($100)or less.) FEE SUMMARY
0 O 1 certify that in the performance of Ole work for which this per, CITY. MECHANICAL PERMIT FEE
H mit is issued,I shall not employ any person in any manner so as to
L-LO W become subject to the Workers'compensation Laws of California. IFEE
G
Date Applicant ALTER OR ADD TO MECH. 5.00
} N NOTICE TO APPLICANT: If,atter making this Certificate of Ex. 5.00 ECK
? emption,you should become subject to the Workers'Compensation APPLIANCE
provisions of the Labor Code, you must forthwith comply with
V such provisions or this permit shall be deemed revoked. AIR HANDLING UNIT ITO 10,000 C.F.M.) 4.00
CONSTRUCTION LENDING AGENCY AIR HANDLING UNIT IOPMC.EM.) 6.00 FEE 'S'«
I hereby affirm that there is a construction lending agency for EXHAUST HOOD (WITH DUCT) 5.00 LM
the performance of the work for which this permit is issued(Sec. HEATING UNIT(TO 100,000 B.T.U.) 8.00
3097,Ci¢CJ. o�
Lender's Name HEATING UN IT(OV ER 100,000 B.T.U.)9.50 ICLender's Address( certify that l havereadlhisepplicmion and slate that the above VENTILATION FAN (SINGLE) 4.00 NG
information is correct.1 agree to comply with all'city and county ordinances and stale laws relating to building construction, and BOILER-COMPI3 H.P.Di100,000B.TU.) 6.0hereby authorize representatives of this city to enter upon the BOILER-COMP IDwrr 100.000.TUI SEE FEE 11. NICAL
above-mentioned property for inspection purposes.
(We) agree to Save, indemnify and keep harmless the City of MISC.- REFER TO ORD. TAX
Cupertino against liabilities,judgments, costs and expenses which PERMIT ISSUANCE 10.00
may in any way accrue,against said City in consequence of the
gronY gof is MECH.CONT. LIQ NO. MECH.
TOTAL TOTAL t3S�=j0
r
etore 6f Apiorcanticonvactor D e
OFFICE COPY
POST THIS CARD NEAR FRONT OF BUILDING
PFRMIT NUMBER
CITY- OF CUPERTINO 13563
.'INSPECTION-DIVISION
JOB INSPECTION RECORD
PERMIT EXPIRATION
JOB ADDRESS 1,0.123 -N.- WOLFE ROADUNIT# lOT# Y.- -
LANE BRYANT PERMIT EXPIRES'IF WORK
OWNER CONTRACTOR SPRINGER CONSTRUC IS NOT STARTED WITHIN
. _ INSPECTION DATE INSPECTOR INSPECTION RECORD 180 DAYS OF PERMIT ISSU-,:
FOUNDATION fp' NCE OR 180 DAYS FROM'
UFER LAST CALLE D,I NSPECTI ON.
PR EGUNITE - - - PERMlr VALIDATION ,
POUR NO CONCRETE UNTIL ABOVE HAS BEEN SIGNED ' i<
UNDERGROUND /SLAB m qL f d
PLUMBING
ELECTRICAL ISSUANCE DATE
MECHANICAL - BLDG. ELEAeTy PLO. MECH.
,y t,pr0fa El
DO NOT POUR FLOOR UNTIL ABOVE HAS BEEN SIGNED BUILDING PERMIT ;
WOOD FLOOR
INFORMATION
- - VALVA I?N $/FT.
PLUMBING
MECHANICAL
ELECTRICAL - PERMIT TO
FRAMING - - '� E:
I
INSULATION
STORIES TYPE CONSTR. `
� � -
- OCC GROUP RES,UNITS
PLACE NO SUBFLOOR UNTIL ABOVE HAS BEEN SIGNED - -
ROOF SO.FT.FLOOR AREA TOTAL ACREAGE
DIAPHRAGM - -
BUILDING USE
RES 'IND CON PB ONer
APPLY NO ROOFING UNTIL ABOVE HAS BEEN SIGNED E] E] E] F] ❑
ASSESSORS PARCEL NO.
ROUGH
PLUMBING Q_ 5'— i
GAS TEST - - - TRACT No. PARCEL NO.
MECHANICAL
ELECTRICAL ACC.DATE ACC.FILE NO.
FINALS DATE INSP.
FRAMING G e c- �'� SAN #
/ "_/f- ow 7 ZONING ENG.SITE NO.
INSULATION PLUMBING -
r'• GAS
MECHANICAL FIRE SPRINK 'ENERGY T-24
'
COVER NO WORK UNTIL ABOVE HAS BEEN SIGNED HEATING YE] No Y ❑ NEI
LATH-INTERIOR ELECTRICAL FLOOD ZONE A.L.U.C. -
LATH-EXTERIOR 'i - FIRE DEPT. ' YE] N❑ Yo N❑
'• SHEETROCK GRADE FEE SUMMARY
SHEAR INTERIOR - BUILDING -
SHEAR EXTERIOR, TEMPORARY APPROVALS BUILDING-
FIREWALLS ELECTRIC PLAN CHECK
GAS - FEE
NO TAPE OR PLASTER UNTIL ABOVE HAS BEEN SIGNED IOCCUPANCY 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
F� ONEWORKING DAY BEFORE REQUIRED INSPECTION. PLUMBING J
z PLEASE GIVE JOB ADDRESS WHEN.PHONING.
- SEE PERMIT FOR EXPIRATION DATE - MECHANICAL
IMPORTANT!
CONST.TAX
PLEASE READ REVERSE SIDE BEFORE TOTAL
CALLING FOR FINAL INSPECTION.
;OFFICE COPY