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APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
WILDING PROJECT I DENT[ FICATI ON
APPLICATION & PERMIT
BUILDING - ELECTRICAL- PLUMBING - MECHANICAL
PERMIT NUMBER
1471 7
IfiVIRDING
ADC Ess
m
OWNERS
NAME esi-4449
QTY. ELECTRIC PERMIT FEE
PLAN CHECK VALIDATION
WIASRAK HONE
CONTRACTORS C53•I Z
NAME
lMIIC.NG
UTLETS-SWITCHES-RECEP 10.00/1.00
LIGHTING FIXTURES 10.00/1.00
CTORS
ADDRESS
APPLIANCES -RESIDENTIAL 4.00
PANELS 10.00
�NON S
DATE OF APPLICATION
RLHRECT
OR
ENGINEER
LIC . No.
PANELS (OVER 200 AMP) 20.00
PLAN CHECK FEE P.C. NO.
SIGNS TRANS. 3.00
.`m" .0. ENG.
AODRESs
SPECIAL CIRCUIT 5,00
PERMIT VALIDATION
EMP. METER OR POLE INS. 20.00
Z1p
R
Az-
PAID /��
APPLICA
ADDRESS
MOTORSNTS SEE FEE SCH.
SERVICE CHANGE 20.00
LICENSED CONTRACTORS DECLARATION
E LAG - O p L
1 hereby affirm that I am licensed under provisions of Chapter 9
(commencing with Section 7000) of Division 3 of the Business and
Professions Com� �gpp license is in full f
Lio (
License IassSra7 c. Number
ISSUANCE DATE
BLDG. ELECT. PLG. MECH.
1AO(��
Date�'Z_�8`y. Contractor
OWNER -BUILDER DECLARATION `
1 hereby affirm that 1 so exempt from the Cons and Pr License
Processions
Law for Anycity-, cng ounty whichequire .5. a permit to
Cod Any city or county which structure permit Lo constructealter,
impro demolish, or repair any structure, prior to its issuance, also
for such permit to file a Cont statement that
he is licen pursuant to the provisions of the ) ofDivision 3iwnu
re is ho a applicant in
in
Law (Chard essioeCode)ior Section is exempt theefoofthe
IT IT
Business and P essied Code) or that he is exempt therefrom and
the basis (or thea tied exemption. Any violation of Section 7031.$
MISC. - REFER TO ORD
� ILDDII{NGGPP�ERMIT
Cal _ "MR ION
VALUATION S/FT.
(O
/
PERMIT T
//
Sf(-/fq GeV 6' DD`
PERMIT ISSUANCE 10.00/!/
ELEC. CONTR. LIC. rv0.
ELEC p
TOTAL 3
T
QTY. • PLUMBING PERMIT FEE
STORIES
TYPE CONSTR.
gLTER-DRAIN-WATER IEA.) 5.00
by any applicant fo permit subjects the applicant macivil Penalty
of not more than five ndred dollars (5500).):
/`
b ✓ N I %Is
BACK FLOW PROTECT. DEVICE 4.00
OCC. GROup
RES. UNITS
: ❑ 1, as owner of th roperty, Or my employees with wages as
ITOr
their sole compensation, 'll do the work, and the S oieture is not
intended or offered for sa (Sec. 7044, Business and Professions
DRAINS -FLOOR, ROOF, AREA, COND. 5.00
Code: The Contractor's Lice Law does not apply to an owner of
property who builds or impro •r thereon, and who does such work
himself or through his own emp yees, provided that such improve-
ments are not intended or offem or sale. If, however, the building
FIXTURES - PER TRAP 5.00
SIX FT. FLOOR AREA
TOTAL ACREAGE
GAS-EA.SVSTEM-11NC.40UTLETS 6.00
or improvement is sold within one ear of completion, the owner-
builder will have the of prov that he did not build or im-
prove for purpose of sale.).
❑ 1, as owner of the property, am elusively contracting with
licensed contractors to construct the pro ct (Sec. 7044, Business
GAS - EA. SYSTEM -OVER 4 (EA.) 2.00
BUILDING USE
REB IND CON Firs Other
INDUSTRIAL WASTE INTER. 30.00
LAWN SPRINKLERS- 1 INC 5 V.B. 6.00
ASSESSORS PARCEL NO.
and Professions Code: The Contractors Lice Law does not apply
to an owner of property who builds or impr es thereon. and who
LAWN SPRINKLERS - OVER 5 (EA.) 1.00
contracts for such projects with a ensed pursuam to
the Contractors License Law.
SEWER -SANITARY -STORM EA. 2006/10.00
TRACT NO.
PARCEL NO.
WATER HEATER W/VENT 6.00
❑ I am exempt under Sec. , &P.C.formis
reason
Owner Dat
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.
or a certificate of Workers' Compensation Insurance, or a certified
ZONING
ENG. SITE NO.
copy thereof (Sea 3800. Lab .c_ 1.
Policy No. Company
p edified copy is hereby furnished.
FIRE SPRINK
ENERGY T-24
erplCacQEco�r, Lfi1 �i I�i 'ty }ZljorVQivision.
t �y�+�J
Applicant
MISC. - REFER TO ORD.
y E] NEI
Y El NO
PERMIT ISSUANCE 10.00 -
FLOOD ZONE
Y [:) N
A.L.U.C.
Y 0 N
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
Tor section need not be completed if the permit is for one
PLG. CONTR. LIC. NO.
PLG
TOTAL
QTY. MECHANICAL PERMIT FEE
FEE SUMMARY
hundred dollars ($100) or less.)
I certify that in the Performance of the work for which this pus
mit is issued. I shall not employ any person in any nmnner so as LLr
become subject to the Workers' Compensation Laws of California.
Applicata
NOTICE TO APPLICANT: If, after making this Certificate of Ex.
emption, you should become subject to the Workers' Compensation
provisions of the Labor Code, you must forthwith comply with
such provision or this Permit shall he deemed revoked.
CONSTRUCTION LENDING AGENCY
BUILDING
/�� -qDale
ALTER OR ADD TO MECH. 5.00
APPLIANCE 5.00
PLAN CHECK
FEE
AIR HANDLING UNIT (TO 10MOC.F.M.) 4.00
AIR HANDLING UNIT (OVER 10=C.F.M.) 6.00
SEISMIC FEE
/i
EXHAUST HOOD (WITH DUCT) 5.00
MICROFILM
I herebyffnn, that theca is a co ,io,l on lending agency lot
the performance of the work for which this permit is issued ISte.
3097. CNC.).
HEATING UNIT (TO 100,000 B.T.U.) 8.00
HEATING UNIT (OVER '100,000 B.T.U.)9.50
ELECTRIC
Lenders Name
Lender's Address
VENTILATION FAN (SINGLE) 4.00
1
PLUMBING
� -
I certify that I have read this application and state that the above
information is correct. I agree to comply with all city and county
ordinances and state laws rotating to building contraction, and
hereby authorize representatives of this city to enter upon the
above-mentioned property for inspection purposes.
(We) agree to save, indenmify and keep harmless the City of
Cupertino against liabilities, judgments, costs and expenses which
may in any way accrue against said City in consequence of the
ranln t er/n' .
Iap)
BOILER-COMPI3 H.P. or 100,000 B.T.U.) 6.00
BOILER -COMP Over 100,0008TU) SEE FEE SCH.
MECHANICAL
fT
MISC. - 12o, e- REFER TO ORD.
CONST. TAX
PERMIT ISSUANCE 10.00 d
MECH. CONT. LIC. NO. MECH.L
TOTA
ignatureof Applicant/Contractor Date
*`';-`~"•`i'�c'�"'
OFFICE COPY
POST THIS CARD NEAR FRONT OF BUILDING
CITY OF CUPERTINO471
INSPECTION DIVISION
JOB INSPECTION RECORD
JOB ADDRESS - ^Z/�0 MQ-n/r /fr CT UNIT 4!P— LOT
OWNER CONTRACTOR LINE A ,'J 20c&—r
PERMIT NUMBER
PERMIT EXPIRATION
PERMIT EXPIRES IF WORK
IS NOT STARTED WITHIN
180 DAYS OF PERMIT ISSU.
00.1-E OR 180 DAYS FROM
LAST CALLED INSPECTION.
r ;`?,,- "INSPECTIONIgtA,;;� t �:DATEL"? ;INSP.ECTORr
i _ iFT �'41NSP.ECTION.RECORD^'�'+ ''," �
FOUNDATIONEL
NOTE:
ALL GRADING AND DRAINAGE SHALL BE INSTALLED
TO COMPLY WITH THE APPROVED PLANS AND CITY OF
CUPERTINO STANDARDS.
LIFER
PREGUNITE 3 a /-
PERMIT VALINATIUN
•';r"
f ISSUANCE DATE
GARAGE SLABS
zPOUR,NOCONCRETEIUNTILI:ABOVEiHAS,�BEEN,SIGNEVj
y = 0;b:^P-7J'-w4 ( fi
UNDERGROUND/SLAB
PLUMBING;
p
ELECTRICALJe,
MECHANICAL-
MPR '
ELECT.
41 ❑
PLG. MECR.
"o o
JOOMOT'POUR;F.,LOOR_UNTIL�ABOVE',HAS BEEN;SIGNED;
C1r!
y,,; 48U1LDING PERMIT`x:-7,a
rr�' ;�.,:-INFORMAT_ION,4tZ� T}
WOOD FLOOR --
VALUATION
„§JFT.;
PLUMBING
MECHANICAL
ELECTRICAL. -
PERMIT TO
✓ —
FRAMING!'
INSULATION - - +�
STORIES
TYPE CONSTR.
-_
OCC. GROUP
RES. UNITS
�PFACE;NO"SUBF,L'OORJUNTILI ABOVEIHAS BEEN(SIGNEDS
ROOF -
NOTE: NO FINAL INSP. SHALL BE MADE BEFORE
THE CONSTRUCTION TAX IS PAID
so. FT. FLOOR AREA
TOTAL ACREAGE
DIAPHRAGM
ROOFSHEATHING
-
BUILDING USE
RES IND CON PB Omer
El El CD El 0'
t'-'APPLY,'ND':ROOFIN G:UNTIL':ABOVEMAS;BEEN'SIGNEDr;
' ROUGH
? e FINALS ;ri y'DATE S `.INSP, b
SAN.#
ASSESSORS PARCEL NO,
-
PLUMBING
ELECT. ENERGY
TUBS 8 SHOWER PAN
PLUMBING ENERGY
TRACT NO.
PARCEL NO,
MECHANICAL
MECH.ENERGY
ELECTRICAL
BUILDING ENERGY
ACCDATE
.
ACC. FILE NO,
,
FRAMING,
ELECT. FINAL TEST igf
INSULATION
PLUMBING
zoNlNc
ENc. SITE No.
GAS TEST,;.
GAS
•!I
MECHANICAL
DIRE SPRINK
Y El" ❑
ENERGY T-20
` [j" F)j.
COVER,NO WORK UNTIL -ABOVE HAS-BEEN SIGNEO';��'
HEATING pp -
EXTERIOR SHEAR
ELECTRICAL RELEASE
F LOO- ZONE
Y N
A.L.0 C.
Y L N❑
INTERIOR.SHEAR
FIRE DEPT.
SHEETROCKf"-"`�"1.
GRADE
%'•5�•
�: -., -. FEE SUMMARY ':.._ -'
EXTERIOR LATH
BUILDING L.
BUILDING
INTERIOR LATH
TEMPORARY APPROVALS
SCRATCH COAT
ELECTRIC .
PLAN CHECK
FEE
GAS
NO TAPE OR PLASTER UNTIL ABOVE HAS BEEN SIGNED
OCCUPANCY
SEISMIC FEE
._
OCCUPANCYOF BUILDING IS NOT PERMITTED UNTIL BUILDING FINAL ISSIGNED BY BUILDING INSPECTOR.
MICROFILM
ARRANGE FOR INSPECTION BY PHONING 252-4505,
Iw— ONE WORKING DAY BEFORE REQUIRED INSPECTION.
0� PLEASE GIVE JOB ADDRESS WHEN PHONING.
z
— SEE PERMIT FOR EXPIRATION.DATE —
ELECTRIC.
—
PLUMBING
— -
MECHANICAL
CONST. TAX
IMPORTANT!
PLEASE READ REVERSE SIDE BEFORE
CALLING FOR FINAL INSPECTION.
TOTAL
OFFICE COPY