14710 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
: .BUILDING PROJECT IDENTIFICATION PERMIT NUMBER
" EDLOING APPLICATION.& PERMIT,
AOORESS 1 A 71
10372 QC A,MZRa ,1-5WQ BUILDING -ELECTRICAL-PLUMBING-MECHANICAL I T,1 I O
PLAN CHECK VAL ATON
NaMEC y-j-UR� ►,rr.p/a4..11�N ��. O�T�Q. -ELECTRIC PERMIT FEE - - p 0- '
PHONE
RAVERAcraRs UTLETS-SWITCHES-RECEP 10.00/1.00
uc.No41 rj Ob LIGHTINGFIXTURES 10.00/1.00 '
CONTRAS Pd�C3'49'$6'% 4�� PPLIANCES-RESIDENTIAL 4,00
ADDRESSDDRESS . '
-iaastTaDc 161 PHONE 2 (I PANELS 10.00 DATE OF APPLICATION
ARCHITECT PLAN CHECK FEE D.C.NO.
OR II .S�� PANELS (OVER 200 AMP) 20.00
ENGINEER H f�S LIC. SIGNS TRANS. 3,00 '
XARCH.ORENG. 4a>TS��67-T4#-� SPECIAL CIRCUIT 5,00 PERMIT VALIDATION
ADDRESS
�$afi 32 I ZIP EMP.METER OR POLE INS. 20.00
APPLICANT'S
ADDDRESSDRESSMOTORS SEE FEE SCH.
SERVICE CHANGE " 20.00
O o LICENSED CONTRACTORS DECLARATION S/ (•
U U I hereby affirm that I am licensed under provisionsof Chapter9 ISSUANCE DATE
r 2Q,m (commencing with Section 7000)of Division 3 of the Business and BLDG. ELECT. PLG. MECH.
professions C .i¢�se is In full force d ffect,
z o w - License Cl 7 Lic.Number � � ❑ ❑ ❑.
2 w r w Date Contractor
" - s - +� LDING PERMIT
X ¢w - OWNER-BUILDER DECLARATION \ NFORMATION
w;LL H 1 hereby often that I am exempt from the Contractor's License MISC.- .. REFER TO ORD VALU,EKION S/FT.
FLL0< Law for the following reason.(Sec.7031.5,Busmessand Professions 'PERMIT ISSUANCE Code:Any Any city or county which requires a permit to construct,alter,
c improve,demolish,or repair any structure,prior to its issuance,also ELEC.GONTR, LIC.NO. ELIC.
i w m u requires the applicant for such permit to file a signed statement that TOTAL - PER
he is licensed pursuant to the provisions of the Contractor's License
riaLaw(Chapter 9(Commencing with Section 700().f Di,ismn3.fthe �n/TE.Q/O!L
Business and Professions Code)or that he is exempt therefrom and V. "PLUMBING PERMIT FEE
$ the basis for the alleged exemption.Any violation of Section 7031.5 STORIES TYPE CONSTR,
w. by any applicant for a permit subjects the applicant maceil penalty
of not more than five hundred dollars($500).1: ALTER-DRAIN&VENT-WATER (EA.) 5.T0
❑ I,as owner of the property,or my employees with wages as BACK FLOW PROTECT.DEVICE 4.00 OCC. RES.UNITS
their sole compensation,will do the work,and the structure is not
intended or offered for sale(Sec. 7044, Business and Pm cssions DRAINS-FLOOR,ROOF,AREA,COND. 5.00
Code:The Contractor's License Law does not apply to an owner of s
property who builds or improves thereon,and who does such work FIXTURES-PER TRAP 5.00 SO.FT,FLOOR AREA TOTALACREAGE
himself or through his own employees.provided Ont such improve-
meals are not intended or offered for sale.If,however,the building GAS-EA.SYSTEM-I INC.4 OUTLETS 6.00 "
or improvement is sold within one year of completion,the owner- GAS-EA.SYSTEM-OVER 4 IEA.) 2.00
builder will have the burden of proving 111.1 he dill not build or im- BUILDING USE
prove for purpose of sale.). INDUSTRIAL WASTE INTER30.00 RES -IND CON PB Om.,
❑ I,as owner of th .e property,am exclusively contracting with ❑ ❑ ❑ ❑ ❑
licensed contractors to Construct Ole project(Sec. 7044,Business LAWN SPRINKLERS-1 INC 5 V.B. 6.00 ASSESSORS PARCEL NO.
and Professions Code:'The Contractor's License Law docs not apply
to an owner of properly who builds or improves thereon,and who LAWN SPRINKLERS-OVER 5(EA.) 1.00
contracts forsuch projects with a contmetoAs)licensed pursuant to SEWER-SANITARY-STORM EA.200ft/10.00
the Contractors License Law. TRACT NO. PARCEL NO.
❑ 1 am exempt under Sec..,BARC.for this WATER HEATER W/VENT 6.00
reason
Owner Date WATER SYSTEM 5.00
ACC.DATE ACC.FILE NO.
WORK ERS'COMPENSATION DECLARATION WATER TREATING EQUIP. 5.00 '
I hereby affirm that I have a certificate of consent to self-insure, ZONING ENG.SITE NO.
or a certificate of Workers'Compensation Insurance,or a certified
r, copy thereof(Sec.3800,Lab.CJ.
y(J Policy.No. Company
0 ❑ Certified Copy is hereby furnished. FIRE SPRINK ENERGY T-24
z � . ❑ Certified opy is filo with lh cit in firm division.
F-' ox A�ppcant / r /{9/�/�/ / /nsi MISC- REFER TO ORD. IY❑ No Y ❑ N❑
'X N CERTTTCATB OF EXEMPTION I7ROM WORKERS' PERMIT ISSUANCE le:e0 1 FLOOD ZONE A.L.U.C.
LL > COMPENSATION INSURANCE: PLG.CONTR. LIC.NO. PLG. �SI
d O 111u; section need not be completed if the permit is for one TOTAL (.TO v(] N❑ V [:] NEI hundred dollars 151001 or less.) -
U O I certify that in the performance of the work for which this per- QTY MECHANICAL PERMIT FEE FEE SUMMARY
LL 1- mit is issued,I shall not employ any person in any manner so as m
U become subject to the Workers'Compersation Laws of Califoraia. y
y Date Applicant ALTER OR ADDTO MECH. 5.00 BUILDING
} H NOTICE TO APPLICANT: If,after making this Certificate of Ex- -
F. ? emption,you should become subject m file Workers Compensation APPLIANCE 5.00 PLAN CHECK
provisions m the Labor Code, you must forthwith comply with FEE
V such provisions or this permit shall be deemed revoked. AIR HANDLING UNIT(TO 10=C.F.M.) 4.00
CONSTRUCT ION LENDING AGENCY AIR HANDLING UNIT(OVER IO=C.EM.) 6.00 SEISMICFEE
1 hereby affirm just (here is a construction lending agency for EXHAUST HOOD-(WITH DUCT) 5.00
the performance of the work for which this permit is issued fSec. MICROFILM i
. 3097,Cie.C.), HEATING UNIT(TO 100,000 B.T.U.) 8.00
Lender's N.
Lender's Address - HEATING UNIT(OVER 100,000 B.T.U.0.50 ELECTRIC t
1 certify that 1 have read this application and state that the above VENTILATION FAN (SINGLE) 4.00 �q a
information is correct. 1 agree to comply with all city and county PLUMBING R O
ordinances and state laws relating to building construction, and BOILER-COMP(3 H:P.o-100,000B.T.U.) 6.00
hereby enthoricc representatives for ins of this city to enter upon the BOILER-COMP (Over 100,000 BTU)SEE FEE SCH. MECHANICAL
above-mentioned property forinsp Ofth i purposes.
(We) agree to save, indemnify and keep harndess the City of MISC.- REFER TO ORD.
7 \ ape In d against liabilities,judgments, costs and expenses which PERMIT ISSUANCE 10.00 CONST.TAX
ay m an y accrue against said City in consequence of the
Ca
O iK cant, MECH.CONT. LIC.NO. MECH. f
s�� TOTAL TOTAL
Signature of Applicant/Contractor Date -
OFFICE COPY
POST THIS CARD NEAR,FRONT OF BUILDING PERMIT NUMBER
CITY OF. CUPERTINOA
INSPECTION'DIVISION 1471.0 ;
JOB,INSPECTION•RECORD
// F� /� PERMIT EXPIRATION
JOB ADDRESS l d 370 S, C A f rfr� I–'✓2b -UNIT# LOT#
/J �1 PERMIT EXPIRES IF WORK
OWNER . LAN7 cJ /�E6,4 t- &-j - CONTRACTOR A,�,I• ,c�iLL . ,• LO^!(7 IS NOT .STARTED WITHIN
INSPECTION DATE INSPECTOR INS ECTI ON RECORD 180 DAYS OF PERMIT ISSU-
FOUNDATION ANCE OR'180 DAYS FROM
_ NOTE: - LASTCALLED INSPECTION: +
UFER ALL GRADING AND DRAINAGE SHALL"BE INSTALLED
PREGUNITE TO COMPLY WITH THE APPROVED PLANS AND CITY OF PeRnuT VALIDATION
CUPERTINO STANDARDS.
GARAGE SLABS
POUR NO CONCRETE UNTIL ABOVE HAS BEEN SIGNED — *, i�,-=•-"L•A'r'"`�4��
6^ �- J C21 CL
. UNDERGROUND /SLAB r. �,.� f
PLUMBING,
ELECTRICAL - Is`suarvcE DATE
MECHANICAL ELECT PLO.
❑ LEI ❑
DO NOT POUR•FLOOR UNTIL ABOVE HAS BEEN SIGNED w/IG BUILDING PERMIT
INFORMATION
WOOD.FLOOR - - 2 MK VALUATION $JET.
PLUMBING -
MECHANICAL ° Q
ELECTRICAL - PERMIT To .
'FRAMING
INSULATION' STORIES TYPE CONSTR.
'OCC.GROUP RES.UNITS
\� PLACE NO SUBFLOOR UNTIL ABOVE HAS BEEN SIGNED
SD.FT FLOOR AREA TOTAL ACREAGE
'ROOF' NOTE:.NO FINAL INSP.SHALL BE MADE BEFORE -
DIAPHRAGM - THE CONSTRUCTION TAX IS PAID
BUILDING USE '
ROOF SHEATHING . - - ,RES IND CON •EB 00",
APPLY NO ROOFING UNTIL ABOVE HAS BEEN SIGNED FINALS DATE INSP.' ❑ ❑ ❑'` ❑ ❑
ASSE550RS PARCEL NO
ROUGH SAN.N
PLUMBING. ELECT.ENERGY
TRACT NO PARCEL NO
• TUBS&SHOWER PAN - PLUMBING ENERGY ,
MECHANICAL . MECH,ENERGY
.'ELECTRICAL BUILDING ENERGY ACC.DATE ACC FILE NO
'FRAMING' C-1 Lie ELECT.FINAL TEST;
INSULATION' - PLUMBING ZONING - ENC.SITE No.
GAS TEST GAS,
MECHANICAL FIRE SPERRY ENERGY T24
COVER NO WORK UNTIL ABOVE HAS BEEN SIGNED HEATING Y E] Nb Y E] N[
EXTERIOR SHEAR. ELECTRICAL RELEFLOODZONE . A.L.U.C. .
INTERIOR SHEARFIRE DEPT. v F] E] ' Y L7No
SHEETROCK J GRADE FEE SUMMARY
EXTERIOR LATH BUILDING
INTERIOR LATH , TEMPORARY APPROVALS BUILDING Kra'y C'4
SCRATCH COAT ELECTRIC PLAN CHECK
GAS FEE
NO TAPE OR PLASTER UNTIL ABOVE HAS BEEN SIGNED OCCUPANCY SEISMIC FEE
- OCCUPANCYOF BUILDING IS NOT PERMITTED UNTIL BUILDING FINAL IS SIGNED BY BUILDING INSPECTOR: 'MICROFILM
ARRANGE FOR INSPECTION BY PHONING 252-4505, ELECTRIC 27
r,{
ONE-WORKING DAY BEFORE REQUIRED 0•I INSPECTION.) PLUMBING'
Z Y PLEASE GIVE JOB ADDRESS WHEN PHONING.
I — -,SEE PERMIT FOR EXPIRATION DATE - rE
ANICAL
IMPORTANTI T.TAX
PLEASE READ REVERSE SIDE BEFORE TOTAL
CALLING FOR FINAL INSPECTION.
OFFICE COPY