12548 (2) d APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
Da BU I LDING PROJECT IDENTIFICATION PERMIT NUMBER
BUILDING APPLICATION & PERMIT 12548
AD Dn SS �i ' / � ��
BUILDING-ELECTRICAL-PLUMBING -MECHANICAL
b 0 NE� PLAN CHECK VALIDATION
"AM Ji ?'
f OTY. ELECTRIC PERMIT FEE
! ¢a/UfT vNorvE
CONTRACTORSOUTLETS-SWITCHES-RECEP 10.00/1.00
AME
LIC.NO. LIGHTING FIXTURES 10.00/1.00
CONTRACTOR'S
ADDRESSDRESSPPLIANCES-RESIDENTIAL 4.00
A
PHONE PANELS 10,00 DATE OF APPLICATION
ARCHITECTPANELS (OVER 200 AMP) 20,00 PLAN CHECK FEE P.C.NO.
OR
ENGINEER
LIc.ND. SIGNS TRANS. 3.00
ARCN.OF ENG, S.00 PERMIT VALIDATION
ADDRESS SPECIAL CIRCUIT
Zap EMP.METER OR POLE INS. 20.00
ADDDRESSDRESS
AMOTORS SEE FEE SCH.
SERVICE CHANGE 20.00 7
'09 LICENSED CONTRACTORS DECLARATION
rt u U 1 hereby affirm;hut I am licensed Under provisions of Chapter 9 ISSUANCE DATE
of Q m (commencing with Section 7000)of Division 3 of the Business and LECT. PLG. MECH.
F m 2 Professions Code,and my license is in full force and effect. ❑ ❑ ❑
Z o w - License Class Lic.Number.
9 H w Date Contractor
w¢ OWNER-BUILDER DECLARATION .IMG PERMIT
U REFER TO ORD ' R s I FdRMAT10N
w;u EE. 1 hereby affirm that I am exempt from the Contractor's License MISC.- VALUATI S/FT.
H LL o J Law for the following reason.(Sec.7031.5,Business and Professions PERMIT ISSUANCE 10.00 yrt ®fjyne "no
Code:Any city or county which requires a permit to construct,aIle, L7�o.rry
Se ,Q 2 improve,demolish,or repair any Structure,prior to its issuance,also ELEC.CONTE. LIC.NO. ELEC.
D¢ requires the applicant for such permit to file a signed statement that TOTAL PERMIT 0
A �
K
m�` he is licensed pursuant to the provisions of the Contractor's License
H z i Law(Chapter 9(commencingwith Section 7000)of Division 3 ofthe A4
Business and Professions Code)or that he is exempt therefrom and OTYPLUMBING PERMIT FEE Q �'t..7
a .
F x OSTORIES TYPE CONSTR.
SE _r the basis for the alleged exemption.Any violation of Section malty
3 of not morecant than five r ahundred doermit lects the llars(S500)oanuoacivil penalty ALTER-DRAIN& VENT-WATER (EA.) 5.00
❑ 1,as owner of the property,or my employees with wages as BACK FLOW PROTECT.DEVICE 4.00 DCC.GROUP RES.UNITS
their sole compensation,will do the work,and the structure is nut
intended or offered for sale (Sec. 7044, Business and Professions DRAINS-FLOOR,ROOF,AREA,CONDE 5.00
Code:The Contractor's License Law does not apply to an owner of
y� property who builds or improves thereon,and who does such work FIXTURES-PER TRAP 5.00 SO.FT,FLOOR AREA TOTAL ACREAGE
himself or through his own employees,provided that such improve-
memsarenotintendedoroffered for sale.If,however,the building GAS-EA.SYSTEM-11NC.40UTLET$ 6.00
or improvement is sold within one year of completion,the owner-
4,
wner- GAS-EA.SYSTEM-OVER 4 (EA.) 2.00 BUILDING USE
builder will have the burden of proving that he did not build or am-- RES IND CON PB Orhar
prove for purpose of sale.). INDUSTRIAL WASTE INTER. 30.00
❑ 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 IEA.) 1.00
contracts for such projects with a contractor(s)licensed pursuant to
SEWER-SAN ITAR V-STORM EA.200ft/10.00 TRACT N0. PARCEL rv0.
the Contractor's License Law.
❑ exemptun Sec. ,B.&P.C.for(his WATER HEATER W/VENT 6.00
Ow on
lea D+tP, WATER SYSTEM 5.00 ACC.DATE ACC FILE NO.
WORKERS'COMPENSATION DECLARATION WATER TREATING EQUIP, 5.00
1 hereby affirm that I have a Certificate ofconsent to self-insure, ZONING ENG.SITE NO.
or a certificate of Workers'Compensation Insurance,or a certified
copy thereof(Sec.3800,Lab.C.).
Policy No. Company
O O Certified copy is hereby furnished. FIRE SPRINK ENERGY T44
Z Z ❑ Certified copy is filed with the city inspection division. MISC.- REFER TO ORD. Y ❑ NE] Y ❑ N❑
O Applicant
CERTIFICATEOF EXEMPTION FROM WORKERS' PERMIT ISSUANCE 10.00 FLOOD ZONE A.L.u.C.
LLQ COMPENSATION INSURANCE PLG.CONTE. LIC.NO. PLG. Y❑ N❑ Y ❑ N❑
d O IThis section need not be completed if the permit is for one TOTAL
D Z hundred dollars IS 100)or less.)
U 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
O W become subject to the Workers'Compensation Laws of California. BUILDING >
Date /Applicant ALTER OR ADD TO MECH. 5.00 QBE �
} US NOTICE TO APPLICANT: If,after making this Certificate of Ex-.
F, Z 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 or this peri;shall be deemed revoked. AIR HANDLING UNIT(TO 10)000C.F.M.) 4.00
CONSTRUCTION LENDING AGENCY AIR HANDLING UNIT(OVER IOAOOC.F.M.) 6.00 SEISMIC FEE SO
I hereby affirm that there is a construction lending agency for EXHAUST HOOD(WITH DUCT) 5.00
the performance of;he work for which this permit is issued(Sec. HEATING UNIT(TO 100,000 B.T.U.) 8.00 MICROFILM
3097,Civ.C.).
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. 1 agree to comply with all city and county BOILER-(DMP(3 H.P.or 100,000 B.T.U.) 6.00 PLUMBING
ordinances and state laws relating to building construction, and
hereby authorize representatives of this city to enter upon the BOILER-COMP IO ver 100,000 BTU)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.
p Dino against Iiabi Yies,judgments, costs Z.uO�of
which PERMIT ISSUANCE 10.00 CONST.TAX
ay in any way a against said Cily in the
Ia Of this pen ;t. MECH.CONT. LIO,NO. TOTALTOTALignature of Ap icxnt/Contractor Date
OFFICE COPY
POST THIS CARD NEAR FRONT OF BUILDING
' 'PFlin+lr rlumeeR
CITY OF CUPERTINO 12548
INSPECTION DIVISION
JOB INSPECTIONRECORD
IIf/11/ PERMIT EXPIRATION
JOB ADDR ESS �L�C! LNI7# _LOT#
PERMIT EXPIRES IF WORK
OWNER CONTRACTOR IS NOT STARTED WITHIN
INSPECTION DATE INSPECTOR INSPECTION RECORD 180 DAYS OF PERMIT ISSU-
ANCE OR 180 DAYS FROM
LAST CALLED INSPECTION.
UFER
PERMIT VALIDATION
PREGUNITE
POUR NO CONCRETE UNTIL ABOVE HAS BEEN SIGNED
UNDERGROUND /SLAB
PLUMBING I 11 oD 1
ELECTRICAL ISSUANCE DATE
BLDG. ELECT. PLG. �B EO
MECHANICALR.
❑ ❑ ❑e.
DO NOT POUR FLOOR UNTIL ABOVE HAS BEEN SIGNED BUILDING PERMIT
INFORMATION
WOOD FLOOR VALUATION $/FT.
PLUMBING
MECHANICAL PERMIT To
ELECTRICAL 1 , /— e_,
FRAMING sTOR IES TYPE CONSTR
INSULATION
OCC.GROUP RES.UNITS
PLACE NO SUBFLOOR UNTIL ABOVE HAS BEEN SIGNED
ROOF 50 FTFLOONAIiEa TOTAL ACREAGE
DIAPHRAGMII
auILOI UBE
RES IND CON
PB Omer
APPLY NO ROOFING UNTIL ABOVE HAS BEEN SIGNED ❑ Cl E3 ❑ ❑
ASSESSORS PARCEL NO.
ROUGH
PLUMBING
TRACT NO. PARCEL NO.
GAS TEST
MECHANICAL
ACC.DATE ACG FILE NO.
ELECTRICAL FINALS DATE INSP.
FRAMING SAN #
ZONING ErvG.SITE NO.
INSULATION PLUMBING
GAS
FIRE SPRINK ENERGY T 2E
MECHANICAL Y ❑ NEJ Y ❑ No
COVER NO WORK UNTIL ABOVE HAS BEEN SIGNED HEATING
FLOOD ZONE A.L.U,C,
LATH—INTERIOR ELECTRICAL
LATH—EXTERIOR FIRE DEPT, Y❑ NF] Y 0 N❑
SHEETROCK GRADE FEE SUMMARY
SHEAR INTERIOR BUILDING
SHEAR EXTERIOR TEMPORARY APPROVALS BUILDING �O
FIREWALLS ELECTRIC PLAN CHECK
FEE
GAS
NO TAPE OR PLASTER UNTIL ABOVE HAS BEEN SIGNED OCCUPANCY SEISMIC FEE
OCCUPANCY OF BUILDING IS NOTPERMITTED UNTIL BUILDING FINAL ISSIGNED BY BUILDING INSPECTOR. MICROFILM
ARRANGE FOR INSPECTION BY PHONING 252-4505, ELECTRIC
"' ONE WORKING DAY BEFORE REQUIRED INSPECTION. PLUMBING
0 PLEASE GIVE JOB ADDRESS WHEN PHONING.
Z MECHANICAL
— SEE PERMIT FOR EXPIRATION DATE —
IMPORTANT! CONST,TAX
PLEASE READ REVERSE SIDE BEFORE TOTAL
CALLING FOR FINAL INSPECTION.
OFFICE COPY