12089 (2) V APPLICANT TO FILL IN INFO TION WITHIN RED LINES - USE BAAL POINT PEN ONLY
BUILDING PROJECT IDENTIFICATION PERMIT NUMBER
BDILDINqIII APPLICATION & PER 12089
�, DD as
BUILDING-ELECTRICAL-PLUMBING-MECHANICAL
OWNE PLAN CHECK VALIDATION
• NA (y ((��1/ (jI OTV. ELECTRIC PERMIT FEE -
y� PHONE(IL _I9f
NONE ACTORS �^� y��` (e3 UTLETS-SWITCHES-RECEP 10.00/1.00
W LICN.3v S�t� LIGHTING FIXTURES 10.00/1.00'
CONTRACTORS 1 APPLIANCES-RESIDENTIAL 4.00
AODRE55 �I//
a< IQIOraE 44b-1913 I IPANELS 10.00 DATE OF APPLICATION
ARCHITECT, PANELS (OVER 200 AMP) 20.00 PLAN CHECK FEE P.C.NO.
OR
ENGINEEfl
�(- IGNS TRANS. 3.00
ARCH,OR ENG. SPECIAL CIRCUIT 5.00 PERMIT VALIDATION
S 4 J�
EMP.METER OR POLE INS. 20.00 MCF,
A114ucnerS p� MOTORS SEE FEE SCH.
ollS Sli UJI,i.L� SERVICE CHANGE 20.00 MAR 5 - 1987
w
00 LICENSED CONTRACTORS DECLARATION
<u w I hereby affirm that 1 am licensed under provisions of Chapter 9of
(commenting h Section 7000)of Division oft Business and VB§LG. ELE T. PL MEC14.
Z
Professions Co and my license is in full far
z a 1'i, License les Lie.Numb
0 m F w pate Contractor_
Q y j I BUIL ING P RMIT
¢ ¢w¢ OWNER-BUILDER DECLARATION INFORMATION
o A U -
w ; w 1 hereby affirm that I am exempt from the Contractor's License
MISC. REFER TO ORD
a_ 0 at Law for the following reason.(Sec.7031.5,Business and Professions PERMIT ISSUANCE 10.00 VALUATION S/FT.
Code:Any cityorcounly which requiresa permit to construct,alter,
/7/��
a a, Q Q improve,demolish,or repair any structure,prior to its issuance,also ELEC.CONTR. LIC.NO. ELEC. J'I (�)I _
-0, requires the applicant for such permit to file a signed statement that TOTAL PERMTO
wa$ he is licensed pursuant to the provisions of the Contractor's License ,, 1
LLaw(Chapter 9(commencing with Section 7000)of Divi,bm3ofthe W
a Business and Professions Code)or that he is exempt therefrom and OTV. PLUMBING PERMIT FEE
¢ the basis for the alleged exemption.Any violation of Sect ion 703 L5 STORIES - TYA C NSTR.
s3 _ 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(5500).): ,
❑ ].is owner of the property,or my employees with wages as BACK FLOW PROTECT.DEVICE 4.00
their sole compensation,will do the work,and the structure is not 0 .GROUP RESUNITS
.
intended or offered for sale(Sec. 7044, Business and Professions DRAINS-FLOOR,ROOF,AREA,GOND. .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 I l F IXTUR ES-PER TRAP 5.00 SO.Ft.FLOOR AREA TOTAL ACREAGE
himself or through his own employees,provided that such improve-
GAS 6.00 //]
mens are not intended or offered for sale.If,however,the building V/
or Improvement is sold within one year of completion,the owner. GAS=EA.SYSTEM-OVER 4 IEA.) 2.00 B ILDING USE
builder will have the burden of proving that he did not build or im-
prove for purpose ofsale.). INDUSTRIAL WASTE INTER. 30.00 RE IND CON PB Other
❑ 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 ASSESSORSPARCEL 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 tO
the Contractor's License Law., SEWER-SANITARY-STORM EA.200tt/10.00 TRACT NO. PARCEL NO.
❑ I am exempt under Sec. ,BAP.C.for this WATER HEATER W/VENT 6.00
reason
Owner Date WATER SYSTEM 5.00 Ace.DnTE ACC.FILE NO.
WORKERS'COMPENSATION DECLARATION WATER TREATING EQUIP. 5.00
I hereby affirm that I have a certificate of consent to self-insure, ZONING ENG.SITE N0.
or a certificate of Workers'Compensation Insurance,or a certified
copy thereof(See.3800,LAC.) xL_
Policy No. - Company �y
Q ❑ Certified copy is hereby furnished. FIRE SPRINK ENERGY T 24
Z Z Certifie -0 y isfiled with the city inspection division. MISC.- REFER TO ORD. C] ❑ C] ❑
20 Itcan[_ V N Y N
P: m PERMIT ISSUANCE 10.00 FLOOD ZONE A.LU.C.
Lu
CERTIFICATE MPENEAF.MPTINS FROM WORKERS'
W Ced not a comp INSURANCE DLG.CONTR. LIQ NO. PLG. Y❑ N❑ Y❑ N❑
d O hundred
section need not be completed if the permit is for one TOTAL
0 Z hundreddollars IS 100)pe less.)
LL O I certify that h the performance of the work for which this per, CITY. MECHANICAL PERMIT FEE FEE SUMMARY
0 � mit is issued.1 shall not employ any person in any manner so is to
become subject to the Workers'Compensation Laws of California.
0 i Date Applicant ALTER OR ADD TO MECH. 5.00 BUILDING
} M NOTICE TO APPLICANT: If,after making this Certificate of Fs-
2 emption,you should become subject to the Workers'Compensation APPLIANCE 5.00 PLAN CHECK /
provisions of the Labor Code, you must forthwith comply will FEE
U such provisions or this permit shall be deemed revoked. AIR HANDLING UNIT(TO 10MC.F.M.) 4.00
CONSTRUCTION LENDING AGENCY AIR HANDLING UNIT(OVER I0,000C.RM.) 6.00 SEISMIC FEE
I hereby affirm that there is a construction lending agency for EXHAUST HOOD (WITH DUCT) v 5.00
the performance the work f which this permit is issued(Sec. MICROFILM ^-
3097,Civ.C.). �C HEATING UNIT IT
100.000 B.T.U.) 8.00 '
Lender's Name HEATI NG UN IT(OV ER 100,000 B.T.U.)9.50 ELECTRIC
Lender's Addrcu r
I certify that 1 have read this application and state 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 love,100.000 BTU)SEE FEE SCH. MECHANICAL
above-mentioned properly for inspection purposes.
(We) agree to Save, indemnify and keep harmless the City of MISC.- REFER TO ORD,
Cmay in any way acerue,agxinst upertino against liabilities,judgments, costs and expenses which CONST.TAX /
said City in consequence of the PERMIT ISSUANCE 10.00
grantin ofth Qer - MECH.CONT. LIC.NO. MECH. / TOTAL /n 1•
Stg eo p icant/Contractor Date sIDIj/ J.
OFFICE COPY /
'I L
POST THIS CWb NEAR. FRONT OF BUILDING
PERMITNUMBER
CITY OF CUPERTINO 12069
INSPECTION DIVISION
/JOB INSPECTION RECORD
,�9I D to PERMIT EXPIRATION
JOB ADDRESS l/ !//lFvo!` UNIT LOT#
PERMIT EXPIRES IF WORK
OWNER CONTRACTOR ISNOT STARTED WITHIN
IN EC ION DATE INSPECTOR 11"PEtTION RECORD 180 DAYS OF PERMIT ISSU.
ANCE OR 180 DAYS FROM
FOUNDATION 3- Z LASTCALLED INSPECTION.'
UFER � � -.��
PR EGUNITE _ 1�1�T�'M IDATION
POUR NO CONCRETE UNTIL ABOVE HAS BE SIGNED MARr5 - 11987
UNDERGROUND /SLAB
PLUMBING qty 0f CUp"no
ELECTRICAL ISSUANCE OnrE
MECHANICAL - BLOfI. ELEC P G MEc Y
DO NOT POUR FLOOR UNTIL ABOVE HAS BEEN SIGNED
I,V—/Jyl\J`BUILDING PERMIT
INFORMATION
WOOD FLOOR VALUATION $/FT.
PLUMBING
MECHANICAL PERMIT TO
ELECTRICAL
FRAMING, -3(—$ _ ,':t' Id!•,I /1
CO
INSULATION .Z—� - I, sroRlEs T11 II i I .
V� OCC.GROUP RES.UNITS
I PLACE NO SUBFLOOR UNTIL ABOVE HAS BEIN SIGNED ` Fl
1 50„F`.FLOOR AREA TOTAL ACREAGE
I1I1 ROOF
DIAPHRAGM
_ BUIL u5E
' RFSf CON IND CON Pa Olney
APPLY NO ROOFING UNTIL ABOVE HAS BEEN SIGNED 13 El El E) ❑
/ ASSESSORS PAHCELNO,
ROUGH.
PLUMBING 311wif AV Xc TTN S
GAS TEST - 7 TRACT NO. PARCEL N0.
MECHANICAL - I `
ELECTRICAL _ FINALS DATE INSP. ACC:OATE Acc.FILE No,
FRAMING `1-LO SAN ZONING , ENG.SITE NO.
INSULATIONclix PLUMBING —y
CST GAS
FIRE SPRINK ENERGY T 7
MECHANICAL Y ❑ No Y ❑ N❑
COVER NO WORK UNTIL ABOVE HAS BEEN SIGNED HEATING ,
FLOOD ZONE A.L.U.C.
LATH-INTERIOR Sf ELECTRICAL
LATH-EXTERIOR FIRE DEPT, _ Y❑ N❑ Yo. No
SHEETROCK GRADE FEE SUMMARY
SHEAR INTERIOR d- S7-k? BUILDING BUILDING f .• '�
SHEAR EXTERIOR S'=7 TEMPORARY APPROVALS
FIREWALLS ELECTRIC - PLAN CHECK
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
LU
ONE WORKING DAY BEFORE REQUIRED INSPECTION. PLUMBING C
O� PLEASE GIVE JOB ADDRESS WHEN PHONING.
Z MECHANICAL
— SEE PERMIT FOR EXPIRATION DATE —'
•.IMPORTANT!
CONST.Tnx � )
PLEASE READ REVERSE SIDE BEFORE TOTAL
CALLING FOR FINAL INSPECTION.
• OFFICE COPY