12998 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
PERMIT NUMBER
' � BLhLDING PROJECT IDENTI FICATION
FOAME
IND FE APPLICATION & PERMIT
ESS \ {� r F� C'` 12998
\pezN� .JLC � l BUILDING — ELECTRICAL—PLUMBING—MECHANICAL1, RS CLQ E• PLAN CHECK VALID T10N
ELECTRIC PERMIT FEE �HONE ,RACTOR'S V V
AME J� J �' NJ
OUTLETS-SWITCHES-RECEP 10.00/1.00 Q ��
/ �
/ C (� /// LIC.Nth/' 93 6 LIGHTING FIXTURES 10.00/1.00
x/
ADDRESS R's
RESAPPLIANCES-RESIDENTIAL 4.00
Y- CONTRAS �yy (J C
O '1✓G PHONE PANELS 10.00 DATE OF APPLICATION
ARCHITECT PLAN CHECK FEE C.NO,
OR PANELS (OVER 200 AMP) 20.00
ENGINEER
LIc.No. SIGNS TRANS. . 3.00
ono ESS era SPECIALCIRCUIT 5.0Q PERMIT VALIDATION
2,P TEMP.METER OR POLE INS. 20.00 /s
ASMOTORS SEE FEE SCH. l//a-��p�,'�•_•�-�-'
ADDRESS
SERVICE CHANGE 20.00
woo LICENSED CONTRACTORS DECLARATION
Z U u 1 hereby affirm that I am licensed under provisions of Chapter 9 ISSUANCE DATE
y¢ w (commencing with Section ]000)of Division 3 of the Business and ' BLDG. T. PLG. MECH.
F y Professions Code,' my license is in lull fur f 9 0,
Z i m W ianse ss Lm.Number J (� I�
h H Dutc Cpntmctor_ ».nen!)• �G 1�
¢ — f v
E ar w OWNER-BUILDER DGCLA RA'f10N C FORMATION IT
toxo 0'h 1 hereby affirm that I am exempt from the Contractor's License MISC.— REFER TO ORD C\
t- u o j Lew for the following reason.(Sec.]03 LS,Business and Professions PERMIT ISSUANCE VALUATION S/FT.
fw>F Code:Any city or county which requiresx permit to construct,alter. /� .h.1>.
2 Q O improve,demolish,or repair any structure,prior to its issuance,also ELED,CONTR. LIC.NO.• ELEC. s
O a requires the applicant for such permit to file a signed statement that TOTAL
A wU5.
m u he is licensed pursuant to the provisions of the Contractor's License T ppPERMIT TO /
Law(Chapter 9(commencing with Section 7000)of Division 3 ofthe 4b li/T46,\
Business and Professions Code)or that he is exempt therefrom and OtV. PLUMBING PERMIT FEE
m the basis for the alleged exemption.Any violation of Section 7031.5 J� STORIES TYPE CONSTR.
by any applicant for a permit subjects the applicant to a civil penalty q ALTER-DRAIN&VENT-WATER IEA.)
of not more than five hundred dollars(5500).): 3
Cl I,as owner of the property,or my employees with wages as BACK F LOW PROTECT. DEVICE 4.00
their sole compensation,will do the work,and the structure Is not OCC.GROUP RES.UNITS
intended or offered for sale (Sec. 7044, Business and Professions DRAINS-FLOOR,ROOF,AREA,CON_D. 5.00
s, T '\ 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 -"o SO.FT.FLOOR AREA TOTAL ACREAGE
himself'or through his own employees,provided that such improve-
ments are not intended or offered for sale.IL however,the building GAS-EA.SYSTEM-11NC.40UTLETS 6.00
or improvement is sold within one year of completion,the owner-
_ builder will have the burden of proving that he did not build or im- GAS-EA.SYSTEM-OVER 4(EA.) 2.00 BUILDING USE
prove for purpose of sale.). INDUSTRIAL WASTE INTER. ' 30.00 RES IND CON PB Omer
❑ 1,as owner of the property,am exclusively contracting with El Ellicensed contractors to construct the project(Sec.7044,Business LAWN SPRINKLERS-1 INCr5 V.B. 6.00 ASSESSORS PAREl El
CEL 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 contractor(s)licensed pursuant to
do,Contractor's License Law. SEWER-SANITARY-STORM EA.200ft/10.00 TRACT NO. PARCEL NO.
re'0 n lamexemptunder Sea ,B.&P.C.for this WATER HEATER W/VENT •Bv80
Elf If
Owner ale WATER SYSTEM 5.00 ACC.DATE ACC.FILE NO.
WORK ERS'COMP:NSATION DECLARATION WATER TREATING EQUIP. 5.00
1 hereby affirm that I have a certificate of consent to self-insure,
or a certificate of Workers'Compensation Insurance,or a certified ZONING ENG.SITE NO.
copy the reof(Sec.3800,Lab.C.I r7 -
Policy No. Company YAT : F-ce,.y 0.
0 ❑ Certi fied cop is hereby furnished. FIRE SPRINK ENERGYT
Z ❑ Certif en fe with�``�Ity�i spection division. 24
FO Applicant I f"-f� MISC- REFER TO ORD. v0 Nv ❑ NE]y CIiRTIFICATE OF EXEMPTION FROM WORKERS' PERMIT ISSUANCE TggQ
FLOOD ZONE A.L.U.C.
W �_ COMPENSATION INSURANCE PLG.CONTR. LIC.NO. PLO
CIL D This section need not be completed if the permit is for one TOTAL Y❑ NY N[
Z hundred dollar.Ci 100)or less.)
U 0 1 certify that in the performance of the work for which this per- QTY. MECHANICAL PERMIT FEE FEE SUMMARY
LL I- mit is issued.I shall not employ any person in any manner so as to
Ow become subject to the Worker Compensation Laws of California.
a Dalc Applicant ALTER OR ADDTO MECH. BUILDING
>_
U, NOTICE TO APPLICANT: If,after making this Certificate of fix y
Z emption,you should become subject to the Workeri Compensation APPLIANCE 5.00 PLAN CHECK
tx provisions of the Labor Code, you must forthwith comply with FEE
��VVV such provisions or this permit shall be deemed revoked. AIR HANDLING UNIT(TO 10,000C.F.M.) 4.00
CONSTRUCTION LENDING AGENCY AIR HANDLING UNIT(OVER 10=11EM.) 6.00 SEISMIC FEE /Z
p� 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. MICROFILM
3097,Civ.C.). HEATING UNIT (TO 100,000B.T.U.) 8.00
Lender's Namc
Lender's Address HEATING UN IT(OVER 100,000 B.T.U.)9.50 ELECTRIC 3d� QL
I 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 13 H.P.or 100,000 B.T.U.) 6.00 OC @
hereby authorize representatives of this city to enter upon the BAILER-COMP(Over 100,000 BTU)SEE FEE SCH.
above-mentioned property for inspection purposes. MECHANICAL
(We) agree to save, indemnify and keep harmless the City of MISC.- REFER TO ORD.
copertin �tamsl liabilities,judgments, costs and expenses which PERMIT ISSUANCE CONST.TAX
may iI I§ way ncerue against said City in c nsequel ce o the 36]00
gruntin (this no MECH.CONT, LIC.NO. MECH
lice, /Co tractor . ^ �5,�,
- TOTAL tx V r/ TOTAL Se, 01 /
i a r t Ua[ _
OFFICE COPY /
t
POST THIS CARD NEAR FRONT OF BUILDING
CITY OF CUPERTINO PERI,ITNDMBER
1299 INSPECTION DIVISION
JOB INSPECTION RECORD
PERMIT EXPIRATION
JOBADDRESS�O T E �5�+9%rTS �Q UNIT# LOT# PERMIT EXPIRES IF WORK
OWNER N/ t:E CONTRACTOR Q N C 7, IS NOT STARTED WITHIN
INSPECTION DATE INSPECTOR INSPECTION RECORD 180 DAYS OF PERMIT ISSU-
is ANCE OR 180 DAYS FROM
FOUNDATION `a.7' FS ��'� Exlzb4jc-w
LASTCALLED INSPECTION.
UFER `o17`S$
PREGUNITE PEHmrt vAUDAn ON
POUR NO CONCRETE UNTIL ABOVE HAS BEEN SIGNED
UNDERGROUND /SLAB
PLUMBING I L'
ELECTRICAL uP ISSUANCE DATE
MECHANICAL ELEcr. PLc. mECR.
OO NOT POUR FLOOR UNTIL ABOVE HAS BEEN SIGNED il RILDING PERMIT
I
WOOD FLOOR y F MATION
PLUMBING SIFT,
MECHANICAL
ELECTRICAL- ,�11 P��ERMIITT TO
FRAMING
INSULATION STORIES TYPE CONSTR.
OCC.GHOUP . RES.UNITS
PLACE NO SUBFLOOR UNTIL ABOVE HAS BEEN SIGNED
ROOF SO.FT,FLOOR AREA TOTAL ACREAGE
r
DIAPHRAGM
BUILDING USE
R RES IND CON PB 00"APPLY NO ROOFING UNTIL ABOVE HAS BEEN SIGNED ❑ ❑ ❑ ❑ ❑
ROUGH ASSESSORS PARCEL NO.
PLUMBING
GAS TEST TRACT No. PARCEL No.
MECHANICAL
ELECTRICAL2- - FINALS DATE P.
ACC.DATE ACC.FILE NO.
-
FRAMING _ SAN #.
INSULATION _ PLUMBING ZONING ENG.SITE NO.
GAS
MECHANICAL FIRE SPRINK ENERGY T.ZE
COVER NO WORK UNTIL ABOVE HAS BEEN SIGNED HEATING Y ❑ N❑ ° ❑ No
LATH—INTERIOR ELECTRICAL FLOOD ZONE A.L. _
LATH—EXTERIOR I FIRE DEPT. Y ❑ N❑ v 0 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 OCCUPANCY SEISMIC FEE
OCCUPANCY OF BUILDING IS NOT PERMITTED UNTIL BUILDING FINAL IS SIGNED BY BUI LDING INSPECTOR. MICROFILM
I
ARRANGE FOR INSPECTION BY PHONING 252-4505, ELECTRIC
44 f"J ONE WORKING DAY BEFORE REQUIRED INSPECTION. PLUMBING
O� PLEASE GIVE JOB ADDRESS WHEN PHONING.
Z '----
- SEE PERMIT FOR EXPIRATION DATE -
MECHANICAL
CONST.TAX
IMPORTANT!
PLEASE READ REVERSE SIDE BEFORE TOTAL
CALLING FOR FINAL INSPECTION. d 1
OFFIC@COPY