14295 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
BUILDING PROJECT IDENTIFICATION PERMIT NUMBER
BUILD"' APPLICATION & PERMIT 14295
a...Ess- ^ ^ �.�•�' / / 1
J( �f (C// / //J/ N BUILDING-ELECTRICAL-PLUMBING-MECHANICAL
OWNER'S PLAN CHECK VALIDATION
NAME OTY. ELECTRIC PERMIT FEE
. Q�x,1 PHON S
corvrRacroRs OUTLETS-SWITCHESRECEP 10.00/1.00
NA E
L7�►/d crv0(/ra��3� LIGHTING FIXTURES 10.00/1.00
r. DRESS ACTORS
- PPLIANCES-RESIDENTIAL 4.00
ADDRESS �(/ //�� 1�1//�
MJ SD. / PNONE / B/V/ PANELS 10.00 DATE OF APPLICATION
ARCHITECT PANELS (OVER 200 AMP) 20,00 PLAN CHECK FEE P.C.NO.
OR
4 Jr
ENGINEER
LIC,NO. SIGNS TRANS. 3.00
noon Ess ENG' SPECIAL CIRCUIT 5.00 PERMIT VALIDATION
ZIP EMP.METER OR POLE INS, 20.00
APPLICANT'S MOTORS SEE FEE SCH. Qd-�A�J
ADDRESS PPLICA
SERVICE CHANGE 20.00 ., {/ Y/1ro'
w o o' LICENSED CONTRACTORS DECLARATION r
<v u I hereby affirm that I am licensed under provisions of Chapter 9 ISSUANCE DATE
N a a (commencing with Section 7000)of Division 3 of the Business and - BLDG. ELECT. PLG. MECH.
r °i Professions Codr�raW3y6license is in full fully I�dp c
iou"i - License Class Lie.Number�lJ_( ❑ ❑ ❑ ❑
Q w H Date f%Contractor
ne a ¢ OWNER-BUILDER DECLARATION BUILDING PERMIT
_ ¢w D INFORMATION
o MISC.- REFER TO ORD
X ;e. y I hereby affirm that I am exempt from the Contractor's License VALUATION $)FT.
LOQ CLaw orla my citylowingreawliol,,.703L5,Businessand Professions PERMIT ISSUANCE 10.00
Code:Any city or county whiny structure.
u tore.prior
to Consuance,also
5 K OR improve,demolish,or repair any structure,prior to its issuance,also ELEC.CONTR. LIC.NO. ELEC.
a - D S, requires the applicant for such permit to file a signed statement that TOTAL PERMIT TO
whe is licensed pursuant to the provisions of the Contractor's License
z i Law(Chapter 9(commencingwith Section 7000)of Division 3 ofthe L� G
a Business and Professions Code)or that he is exempt therefrom and OTV. PLUMBING PERMIT FEE
W sem-m the basis for the alleged exemption.Any violation of Section 7031.5 STORIES TYPE CONSTR.
a; _ by any applicant for a permit subjects the applicant to a civil penalty ALTER-DRAIN&VENT-WATER (EA.) 5.00
of mat more than five hundred dollars(8500).): -
❑ I,as owner of the properly,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:Tire Contractor's License Law does not apply to an owner of
• property who builds or improves thereon,and who does such work FIXTURES-PER TRAP 5.00 S6 FT.FLOOR AREA TOTAL ACREAGE
himself or through his own employees,provided that such improve-
mentsamnot intended or offered for sale.ll',however,the building GAS-EA.SYSTEM-11NC.4 OUTLETS 6.00
or improvement is sold within one year of completion,the owner- GAS-EASYSTEM-OVER 4(EA.) 200 BUILDING USE
builder will have the burden of proving that he did not build or im- . . .
RES IND CON PB Other
prove for purpose of sale.). INDUSTRIAL WASTE INTER. 30.00
O I,as 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(EA.) 1.00
contracts for such projects with a conlracmds)licensed pursuant to
the Contractor's License Law. SEWER-SANITARY-STORM EA.200ft/10.00 TRACT NO. PARCEL NO.
❑ lam exempt under Sec. ,B.&P.C,for this WATER HEATER W/VP10 6.00
reason
Owner ,,. ' Date - WATER SYSTEM 5.00 ACC.DATE PCC.FILE NO.
WORKERS'COMP.ENSATI Nb DIiCLARATION WATER TREATING EO I 5.00
�-
IhSmb-certificate
of Woo`lhave a certificate atme Rf Insurance.
W$a PInSure,f ed ZONING ENG.SITE N0,
ar�rtificate of Workers'Compensation Insurance,or a certified
Pally tar�f`f�e}.2d0 Lab.C1,,I�� l
Policy =LJSt�CnI anYlF^ � r
0 ❑ &e ifiAd opy is Im •by furnished. - C FIRESPRINK ENERGY T�24
.Z Z ❑ Cn"tffe pl 'is ed with the cit ins 'tion division. MISC.- REFER TO ORD.
O Applicant Y❑ N❑ Y'❑ NE]
T CERTI VATE OF EXEMPTION FROM WORKERS' PERMIT ISSUANCE 10.00 QOO FLOODZONE - A.L.U.C.
LU >_ COMPENSATION INSURANCE PLO.CONTR. LIC.NO. PLG. /
CL o (This section need not be completed if the permit is for one TOTAL /6.UO v❑ N❑ Y ❑ N❑
D Z hundred dollars(S100)or less.)
U O 1 certify that in the performance of the work for which this per. CITY MECHANICAL PERMIT FEE FEE SUMMARY
LL (- mit is issued, I shall not employ any person in any manner so as to
U became subject to the Workers'Compensation Laws of California.
O w Date Applicant ALTER OR ADD TO MECH. 5.00 BUILDING
} ut NOTICE TO APPLICANT: If,after making this Certificate of Ex.
H ? 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 of this permit shall be deemed revoked. AIR HANDLING UNIT(TO 10MCF.M.) 4.00
CONSTRUCTION LENDING AGENCY AIR HANDLING UNIT(OVER 10PWC.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. HEATING UNIT(TO 100,000 B.T.U.) 8.00 MICROFILM
3097,Civ.(-). HEATING
Lender's Name HEATING UNIT(OVER 100,000 B.T.U.)9.50 ELECTRIC
Lender's Address
I certify that I 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 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 upon the BOILER-COMP(Over 100,0008TU)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 'abilities,judgments, costs and expenses which ,CONST.TAX
ma in any way a -rue against said City in consequence of the PERMIT ISSUANCE 10.00
g n g of II is permi MECH.CONT. LIC.NO. MECH.
�� TOTAL TOTAL 1 -Q0
Signau of is
tractor Uate
I
,' OFFICE COPY
POST THIS CARD NEAR FRONT OF BUILDING
PP,RMIr NUMBER
CITY .OF CUPERTINO 14295
INSPECTION DIVISION
JOB INSPECTION RECORD • ;
PERMIT EXPIRATION
JOB ADDRESS �I7.3 l\ic"�•5-�Li'�� L�< UNIT# LOT# PERMIT EXPIRES IF WORK
OWNER U /LO/Q-!'� CONTRACTOR /:r- -C$ PZ-,a 6- IS NOT STARTED WITHIN
INSPECTION DATE INSPECTOR INSPECTION RECORD 180 DAYS OF PERMIT ISSU-
FOUNDATION ANCE OR 180 DAYS FROM
UFER - LASTCALLED INSPECTION.
PREGUNITE PERMIT VALIDATION
POUR NO CONCRETE UNTIL.ABOVE HAS BEEN SIGNED ( -
UNDERGROUND /SLAB
PLUMBING p ,D
ELECTRICAL, r SSU,ANCE DATE
MECHANICAL BLo I f,ECT. PLG. MECH.
FEs � ❑ ❑ ❑
DO NOT POUR FLOOR UNTIL-ABOVE HAS BEEN SIGNEDpy..e�Y0.0DING PERMIT
WOOD FLOOR Qj1y N"
FORMATION
.PLUMBING• vALunnory $/FT.
MECHANICAL
ELECTRICAL p PERMrz To
FRAMING
STORIES TYPE CONSTR.
INSULATION '
OCC,GROUP RES.UNITS
PLACE NO SUBFLOOR UNTIL ABOVE HAS BEEN SIGNED
$O.FT,FLOOR AREA TOTAL ACRE/GE
ROOF
DIAPHRAGM
BUILDING USE
RBS INO CON PB - Go-
APPLY NO ROOFING UNTIL ABOVE HAS BEEN SIGNED ❑ ❑ Cl ❑ ❑
ASSESSORS PARCEL NO,
ROUGH
PLUMBING
TRACT NO, PARCEL NO
GAS TEST .
MECHANICAL -
- NCC.GATE ACC.FILE NO.
ELECTRICAL FINALS DATE INSP.
FRAMING SAN # - zoNlNc - ENG.SITE No.
INSULATION PLUMBING 6
GAS ;�.[g
FIRE SPRINK _ ENERGY TZC
- MECHANICAL � ^
COVER NO WORK UNTIL ABOVE HAS BEEN SIGNED HEATING v ❑ N❑ v 0 N�
LATH-INTERIOR - ELECTRICAL FLOOD ZONE A.L.U.C.
LATH—EXTERIOR I FIRE DEPT. Y❑ NQ Y ❑ N❑
SHEETROCK; GRADE - FEE SUMMARY
SHEAR INTERIOR BUILDING
SHEAR EXTERIOR TEMPORARY APPROVALS BUILDING
FIREWALLS ELECTRIC PLAN CHECK
FEE -
GAS
NO TAPE OR PLASTER UNTIL ABOVE HAS BEEN SIGNED OCCUPANCY sElsMlc FEE
OCCUPANCY OF BUILDING IS NOTPERMITTED UNTIL13UILDING FINAL ISSIGNED BV BUILDING INSPECTOR. MICROFILM
ARRANGE FOR INSPECTION BY PHONING 252-4505, ELECTRIC
. F
zONE WORKING DAY BEFORE REQUIRED INSPECTION.' PLUMBING
� PLEASE.GIVE JOB ADDRESS WHEN.PHONING.
- SEE PERMIT FOR EXPIRATION DATE = MECHANICAL
IMPORTANT!
CONST.TAX
PLEASE READ.REVERSE SIDE BEFORE TOTALS '
CALLING FOR FINAL INSPECTION.
- - OFFICECOPY .