C 8196 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
• BUILDING PROJECT I DENTI FICATIO PERMIT NUMBER
BUILDING
APPLICATION & PERMIT 8196
B
e BUILDING-ELECTRICAL-PLUMBING-MECHANICA
O R' AN CHECK VA�(CATION
J M QTY. ELECTRIC PERMIT FEE /�C�� 's S-J
I2�0 NONE Jj
NA RACTORS UTLETS-SWITCHES-RECEP 10.00/1.00
LIC.No. LIGHTING FIXTURES 10.00/1.00
p°N Ess 5�0� krAPPLIANCES-RESIDENTIAL 4.00
PHONE PANELS 10.00 DATE OF APPLICATION
OR ENGINEER
/ e / //`jam/ PANELS (OVER 200 AMP) 20,00 PLAN CHECK FEE P.C.NO.
ENGINEER (l/�liC� NO.
LIC NO. SIGNS TRANS. 3.00
AA CH OR
DDHES$ENG. �aR/O SPECIAL CIRCUIT 5.00 PERMIT VALIDATION
if
zIP Z EMP.METER OR POLE INS. 20.00
APPLICANT
ADDRESMOTORS SEE FEE SCH.
S i'
S SERVICE CHANGE 20.00
woo LICENSED CONTRACTORS DECLARATION TEMP.POLE 30.00 pR 131
< v w I hereby affirm that I am licensed under provisions of Chapter 9 ISSUANCE DATE
N a (commencing with Section erre)i of Division 3 of the Business and ^BLDG �I t OP� MEC
F N z Professions 1 y 'cense is in full forggq. N
i O m - License I ss Lia Number)-
0 w F Date Contractor -
a r s BUILDING PERMIT
¢ ¢ a OWNER-BUILDER DECLARATION
c o O INFORMATION
X y I hereby affirm that I am exempt from the Contractors License MISC.- REFER TO ORD
a_u VALUATION $/FT.
Fu Oj Law for the following reason. 703L5,Business Professions PERMIT ISSUANCE 10.00
vi Code:Anycily orcounty which requires a permit to construct,alter, zo� �C]
se Q Q improve,demolish,or repair any structure,prior to its issuance,also ELEC.CONTR. LIQ NO. ELEC.
- ¢ requires the applicant for such permit to file a signed statement that TOTAL PERMIT TO
A w m" he is licensed pursuant to the provisions of the Contractor's License
F i
Law(Chapter 9(commencingw6th Section 7000)of Division 3 ofthe /A_1 /r
io Business and Professions Code)or that he is exempt therefrom and QTY. PLUMBING PERMIT FEE �'
¢ the basis for the alleged exemption.Any violation of Section 7031.5 STORIES TYPE CONSTR.
by any applicant for a peomit subjects the applicant toacivil penally ALTER-DRAIN&VENT-WATER (EA.) 5.00
of not more than five hundred dollars(5500).):
❑ I,as owner of the property,or my employees with wages as BACKFLOW 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 docs such work FIXTURES-PER TRAP 5.00 50.FT,FLOOR AREA TOTAL ACREAGE
himself re through his own employees,provided that such iml!rove-
mentsarenotinghhis or employees,ffered for provided
that suhchmlding GAS-EA.SYSTEM-1INC.4OUTLETS 6.00
or improvement is sold within one year of completion,the owner- GAS EASYSTEM-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 OrM1ar
prove for purpose of sale.). INDUSTRIAL WASTE INTER. 30.00
❑ 1,as owner of the properly,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(EA.) 1.00
contracts for such projects with a contractors)licensed pursuant In
the Contractor's License Law. SEWER-SAN ITARV-STORM EA.200ft/10.00 TRACT NO. PARCEL NO.
❑ lam exempt under Sec. .B.&P.C.for this WATER HEATER W/VENT 6.00
reason
Owner Date WATER SYSTEM 5.00
ACC.DATE ACC,FILE N0,
WORK ERS'COMPF-NSATION DECLARATION WATER TREATING EQUIP, 5.00
1 hereby affirm that I have a certificate of cuasenl to self-insum. ZONING
or a certificate of Workers'Comp cation Insurance,or a certified ENG SITE NO.
copy(hereof(Sec.3800,Lab.C.
Policy No. Company_
O jI�Certif 'op s hereby f r ishedQ /Nl - RE SPRINK ENERGY T-24
❑ Cer[if d o is ih the city insp euro, I sI n' MISC.- REFER TO ORD.
Z p Applicant Y ❑ N❑ Y ❑ N❑
~ m PERMIT ISSUANCE 10.00 FLOOD ZONE A.L.uc.
� CIiRT'I I' TIi OP SAIL T NPR AI WORKERS'
ILS COd not be
INSURANCE PLG.CONTR. LIC.NO. PLG. y❑ N❑ Y❑ N❑
0 Z (This sellar^ aced not be completed if the permit is for one TOTAL
hundred dollars(n the pe lesO
performance
U O I comity that h the performance of the work for which this per- DTV. MECHANICAL PERMIT FEE FEE SUMMARY
0 F mit is issued,I shall not employ any person in any manner so is to
W become subject to the Workers'Compensation Laws of Calil ornia.
U i Date APPlicnm ALTER OR ADD TO MECH. 5.00 BUILDING (�C
} Go NO'f ICE TO APPLICANT': If,after making this Certificate of Ex-
♦- 2 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
U such provisions or this pernsit shall be deemed revoked. AIR HANDLING UNIT(TO 10000OF.M,) 4.00
CONSTRUCTION LENDING AGENCY AIR HANDLING UNIT(OVER I0,000C.EM.) 6.00 SEISMIC FEE
1 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,Civ.C.). HEATING UNIT TO 100,000 B.T.U.) 8.00
Lender's Name
Lender's Address HEATING UNIT(OVER 100,000 B.T.U.)9.50 ELECTRIC
1 certify that I have read this application and state that the above VENTILATION FAN (SINGLE) 4.00
information is correct.1 agree to comply with all city and county PLUMBING
ordinances and state laws relating to building construction, and BOILER-COMP(3H.P.Dr100,000B.T.U.) 6.00
hereby authorize representatives of this city to enter upon the BOILER-COMP (Over 100,000BTUI 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.
C ertino against liabilities,judgments, cost and expenses which CONST.TAX
in a way accrue against said City in consequence of the PERMIT ISSUANCE 10.00
g n go roper . MECH.CONT. LIC.NO. MECH.
TOTAL TOTAL
/\ Sign re oApplicantWItsfor Date
OFFICE COPY
r • POST THIS CARD NEAR FRONT•OF BUILDING PITHMITNUMBEII
CITY OF CUPERTINO �� 9
INSPECTION DIVISION
JOB INSPECTION RECORD .
3 .
IIODO /V . ( PERMIT EXPIRATION,
JOB ADDRESS UN LOT# r tl
-PERMIT EXPIRES IF WORK
OWNER O CID ACTOR IS NOT STARTED WITHIN
INSPECTION DATE INSPECTOR INSPECTION R CORD 180 DAYS OF PERMIT ISSU-
ANCE OR 180 DAYS FROM
FOUNDATION
UFER LASTCALLED INSPECTION.
� - L+L W"G�K•
PREGUNITE
PERMIT VALIDATION,
. '
• _ L
POUR NO CONCRETE UNTIL ABOVE HAS BEEN SIGNED
UNDERGROUND / LAB
PLUMBING Ole
ELECTRICAL �•_•✓E CE DATE
BLDG,
ELECT. PL MECN.
MECHANICAL �-� F� it ❑ ❑ ❑
00 NOT POUR FLOOR UNTIL ABOVE HAS BEEN SIGNED f 'BUILDING PERMIT .
INFORMATION
WOOD FLOOR VALUATION SIFT.
PLUMBING
MECHANICAL
ELECTRICAL RNnTr
FRAMING •^-•-
INSULATION STORIES TYPE CONSTR.
OCC.GROUP RES.UNITS
PLACE NO SUBFLOOR UNTIL ABOVE HAS BEEN SIGNED
5!],FT.FLOORPREP TOTAL ACREAGE
ROOF
DIAPHRAGM
ro
T RES IND ILDICON usEPB Omr,
APPLY NO ROOFING UNTIL ABOVE HAS BEEN SIGNED ❑ ❑ ❑ ❑ F-1
ASSESSORS PARCEL NO.
ROUGH
PLUMBING
TRACT No. PARCEL NO.
GAS TEST
MECHANICAL
ELECTRICAL FINALS DATE INSP. •A".DATE ACC.PB.E No.
FRAMING SAN #
ZONING ENG.SITE NO.
INSULATION PLUMBING
GAS
FIRE SPRINK ENERGY T24
MECHANICAL v ❑ N❑ r ❑ N❑
COVER NO WORK UNTIL ABOVE HAS BEEN SIGNED HEATING '
FLOOD ZONE A.L C.
LATH—INTERIOR ELECTRICAL
LATH—EXTERIOR FIRE DEPT. `'❑ NE] ❑ NE]
SHEETROCK GRADE FEE SUMMARY
SHEAR INTERIOR BUILDINGGO BUILDING
SHEAR EXTERIOR TEMPORARY APPROVALS
FIREWALLS ELECTRIC PLAN CHECK
GAS FEE
NO TAPE OR PLASTER UNTIL ABOVE HAS BEEN SIGNED OCCUPANCY' SEISMIC FEE
OCCUPANCY OF BUILDING IS NOTPERMITTED UNTIL BUILDING FINAL ISSIGNED BY BUILDING INSPECTOR. MICROFILM
ARRANGE FOR INSPECTION BY PHONING 252-4505, ELECTRIC
F ONE WORKING DAY BEFORE REQUIRED INSPECTION. PLUMBING
O� PLEASE GIVE JOB ADDRESS WHEN PHONING.
Z MECHANICAL
- SEE PERMIT FOR EXPIRATION DATE -
IMPORTANT! CONST.TAX
PLEASE READ REVERSE SIDE BEFORE TOTAL
CALLING FOR FINAL INSPECTION.
OFFICE COPY
I