9150 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
` BU I LDING PROJECTIDENTIFICATION PERMIT NUMBER
V BUILDING APPLICATION & PERMIT
ADDREss
BUILDING - ELECTRICAL-PLUMBING-MECHANICAL
ra wer, aCo��r �� 9150
OWNERS 4 (VPLAN CM CK VALIDATION
NAME DTV. ELECTRIC PERMIT FEE
1 _ I PHONE
NAIVE. T B UTLETS-SWITCHES-RECEP 10.00/1.00
4 IS M LK.N0.
.t. 'agrj(111 LIGHTING FIXTURES 10.00/1.00
C
CONTRA ORa 7/5 PPLIANCES-RESIDENTIAL 4.00
ADDRESS
LA` PHONE dj PANELS 10.00 DATE OF APPLICATION
AR rtECi +ia� R7TD PANELS (OVER 200 AMP) 20.00 PLAN CHECK FEE P.C.NO.
OR Jul
`RI!
ENGINEER F'1 Aj�,L dSTJM
.No. SIGNS TRANS. 3.00
ARCH.OR ENG, I PERMIT VALIDATION
ADDRESSfr q _ SPECIAL CIRCUIT 5.00
77 ryG G ZIP EMP.METER OR POLE INS. 20.00
APPLICANT'S /
ADDRESS MOTORS SEE FEE SCH. f
SERVICE CHANGE 20.00 //1 �-
W oo LICENSED CON TRACTORS DECLARATION TEMP.POLE 30.00 o [ S
a u U I hereby ifflrm that I am licensed under provisions of Chapter 9 I ISSUANCE DATEIF
re A"' (commencing with Section 7000)of Division 3 of the Business and
¢ H BLDG. ELECT. PLG. MECH.
F w z ProfL.cions Code,;uul nIY license is in fall force and effect. ❑ ❑ ❑ ❑
z o m - License Class Lie.Number y,//
o w t Date (iii - Contractor
a x E o c BUILDING PERMIT
¢ ¢ ¢ OWNER-BUILDER DECLARATION
' o a ° MISC.- REFER TO ORD .� INFORMATION
X 3 N 1 hereby affirm that 1 am exempt front the Contractors License
i. 00 a Law for the following reason.(Sec.7031.5,Business and Professions PERMIT ISSUANCE 10.00 ; VALUATION $/FT.
Code'.Any City or county which requires permit to construct,alter,
QQ Q 2 Improve,demolish,Or repair any structure',prior to Its issuance,also ELEC.CONTE. LIC.NO. ELEC. V ✓ "
ym or requires the applicant for such permit to file a signed statement that TDTAL PERMIT TO
A w he is licensed pursuant to the provisions of the Contractor's License Y
r
Law(Chapter 9(commencing with Section 7000)of Division 3 ofthe />.4
r a Business and Professions Code)or that he is exempt therefrom and OTV. PLUMBING PERMIT FEE
¢ Ii-o the husis for the alleged exuntption.Any vinldtion of Section 7031.5 STORIES TYPE CONSTR.
a _ by any applicant(or a permit subjectslhe applicant to a civil penalty ALTER-DRAIN& VENT-WATER (EA.) $,00
of not umre than five hundred dollars(5500).1:
❑ I,as owner of the property,or my employees with wages as BACK FLOW PROTECT.DEVICE 4.00
(heir sole compensation,will do the work,and the structure is not OCC.GROUP REB.UNITS
intended or offered for sale (Sec. 7044, Business and Professions DRAINS-FLOOR,ROOF,AREA,COND. 5.00
Cade: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 SD.FT FLOOR AREA TOTAL ACREAGE
i
0 himself Or through his own employees.Provided that such improve
merits are not intended or offered for sale.Il',however,lire building GAS-EA.SYSTEM-1 INC.4 OUTLETS 6.00
or improvement is sold within one year of completion,the owner- GAS-EA.SYSTEM-OVER 4 (EA.) 2.00
builder will have the burden of proving that he did not build or ion- BUILDING USE
prove for purpose of sale.). INDUSTRIAL WASTE INTER. 3000 REs IND CON Pa Other
.
❑ I,as owner of the property,am exclusively contracting with ❑ ❑ ❑ ❑ ❑
licensed contractors to construct the project(See. 7044,Business LAWN SPRINKLERS-1 INC 5 V.B. 6.00 ASSESSORS PARCEL NO.
and Professions Code:The Contractor's Liccnsc Law docs not apply
to as owner of property who builds or improves thereon,and who LAWN SPRINKLERS-OVER 5(EA.) 1.00
contracts for such projects will,a contractions)licensed pursuant to
the Contract.,',License Law. SEWER-SAN ITARV-STORM EA.2001t/10.00 TRACT NO. PARCEL NO.
❑ lam exempt under Sec.-,BAP.C.for this WATER HEATER W/VENT 6.00
t reason
Owner Date WATER SYSTEM 5.00 t
ACC.DATE ACC,FILE NO.
WORK ERS'CONPENSATION DECLARATION WATER TREATING EQUIP. 5.00
I hereby affirm that I have a certificate of consent to self-insore,
Or a certificate of Workers Compensation Insurance,or a certified ZONING ENG.SITE NO.
copy lhereoffSec.3800,Lab.CA
Policy N< any
O ❑ Certilied cop,)I parry
lar FJ.
Z Z ❑ Cetlified copy is Eled with the city inspection division. FIRE BPRINK ENERGY T24
O Applicant A n�_� MISC.- REFER TO ORD. Y ❑ N❑ Y ❑ N❑
0: y '-W 01:EXEMPTION MPERMIT ISSUANCE 10.00
LU - CERTIFICATE ENANSU FROM WORKERS' FLOODZONE A-L.L.U.C.
W 7 COMPENSATION INSURANCE PLG.CONTE. LIC.NO. PLG. Y❑ N❑ Y❑ N❑
Z (This dollars need not be completed if the permit is for one TOTAL
hundred dollars($100)or Icss.)
L) O 1 certify that in the performance of the work for which this per- OTY. MECHANICAL PERMIT FEE FEE SUMMARY
LL H mit is issued,I shall not employ any person in any manner so as to
U become subject to the Workers'Compensation Laws of California.
y Dale Applican -f�
t ALTER OR ADD TO MECH. 5.00 BUILDING
} W NOTICE TO APPLICANT: IC after making this Certificate of Ex-
Z_ emplion,you should become subject to lire Workers'Compensation APPLIANCE 5.00 PLAN CHECK
provisions of the Labor Code, you oust linthwith comply with FEE
_U 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 10=C.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. MICROFILM
3097,Civ.C.). (1�t HEATING UNIT(TO 100,000 B.T.U.) 8.00
Lenders Namr Z,!n •lU IC -NO !A<' HEATING UNIT(OVER 100,000 B.T.U.)Lender's Address 1- .A,-- - -- . --- ' � ELECTRIC
1 certify that I have read this application and statrVAMh�LbM VENTILATION FAN (SINGLE) 4.00
information is correct.I agree to comply with all city aifd county PLUMBING
ordinances and stale 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 100,000 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.
Cupertino against liabilities,judgments, costs and expenses which CONST.TAX
may in any way accrue against said City in consequence of the PERMIT ISSUANCE 10.00
grantingofthis peramMECH.CONT. LIC.NO, MECH.
TOTAL TOTAL 9, 7
Sigrl5 ore of A pplica nt/ oittmcmr L
INSPECTOR COPY
PUS'I' l-HIS CARD NEAR FRONT OF BUILDING
CIT)-- OF CUPERTINO
INSPECTION DIVISION � p
JOB INSPECTION RECORD ^ n / — --- --I
Le B17, W PEIiMIT EXPIRA'T'ION
B ADDRESS `� `'" UTWT# _LOT#
eh PERMIT EXPIRES IF WORK
OWNER CONTRACTOR IS NOT STARTED WITHIN
INSPECTION; ,.,:�`. , ;"DATE INSPECTOR INSPECTION RECORD 180 DAYS OF PERMIT ISSU
FOUNDATION ANCE OR 180 DAYS FROM
LIFER LAST CAL LED INSPECTION,
PREGUNITE —' -- ------'-" -- --
rlii4.ii i`v nl iun I I,Ila"
"POUR NO CONCRETE•UNTICABOVE HAS BEEN SIGNED 6/1 S a�
UNDERGROUND /SLAB
PLUMBING
ELEC"fRICAL
ISM lAW I'I.,\I I'
MECHANICAL niur• ILr.a I•L11 rn I;n -
_- T=: --
00 NOT POUR FLOOR'UNTIL'ABOVE,HASBEEN SIGNED --� BUR.bINc PEI3--Nn.1-r - -
WOOD FLOOR INFORMATION
PLUMBING VAI,11 nur,"
MECHANICAL
ELECTRICAL .-..•..._...._._i Iii;iii lil.... .•. _,__.._
FRAMING �f1;�lN/N�;111�4,L
INSULATION
PLACE NO SUBFLOOp UNTIL ABDVE HAS BEEN SIGNED
ROOF
APHRAGM
IIII I IIII.I".I
111:� IIJI11 I'll r
PPLY NO ROOFING UNTIL ABOVE HAS BEEN SIGNED ❑ I. I ❑ 1-1 CI
ROUGHPLUMBING
GAS
GAS TEST
MECHANICAL
E LECI'RICAL
FINALS DATE INSP. nil;Ri,i l'—
FRAMING SAN #
INSULATION PLUMBING
GAS
MECHANICAL
COVER NO WORK UNTIL ABOVE HAS BEEN SIGNED HEATING _° LI ,I I.J ❑ rl0
LATH-INTERIOR ELECTRICAL
LATH-EXTERIOR FIRE DEPT.
SHFETROCK _—'-_'•'— —•_�
GflADE FEE SUMMARY
SHEAR INTERIOR BUILDING =_'_----_-_--
SHEAR EX"TERIOR TEMPORARY APPROVALS BUILI)ING
FIREWALLS
ELECTRIC PLAN CHECK
GAS FEE
NO TAPE OR PLASTER UNTIL ABOVE HAS BEEN SIGNED OCCUPANCY sElsMlc FEE
OCCUPANCY OF BUILDING IS NOT PERMITTED UNTIL BUILDING FINAL ISSIGNED BY BUILDING INSPECTOR.
MICROFILM
ARRANGE FOR INSPECTION BY PHONING 252-4505, ELECTRIC
ONE WORKING DAY BEFORE REQUIRED INSPECTION. PLUMBING,
PLEASE GIVE JOB ADDRESS WHEN PHONING.
— SEE PERMIT FOR EXPIRATION DATE — MECHANICAL
IMPORTANT! CONST. IAX
PLEASE READ REVERSE SIDE BEFORE TOTAL
CALLING FOR FINAL INSPECTION.
OFFICE COPY