02582 (2) `APPLICANT TO FILL'IN INFORMATION WITHIN RED LINES - USE BALLPOINT PEN ONLY
.r `� BUILDING PROJECT IDENTIFICATION PERMIT NUMBER
a.ILDING APPLICATION & PERMIT
GT` 12582
aooRE�s� �3® O2 BUILDING -ELECTRICAL-PLUMBING-MECHANICAL
LrN
OWNER'S PLAN CHECK VALIDATION
NAME / , 3-7o 2_ OTV. ELECTRIC PERMIT FEE
69 PHONE
NAME. croR'$.. q�U� �3L UTLETS-SWITCHES-RECEP 10.00/1.00 i
NAME. .4p
Tg - wx<L LIC.No./J'33 S.3 LIGHTING FIXTURES 10.00/1.00
rolvrRAcroR's / f PPLIANCES-RESIDENTIAL 4.00
a DgrjE_55�� O 7 I_`, PHONE f,(pJ PANELS 10.00 DATE OF APPLICATION
ARCHITECT PANELS (OVER'200 AMP) 20.00 PLAN CHECK FEE P.C.NO.
OR
ENGINEER
LIC.No. SIGNS TRANS. 3.00
ARCH.OR ENG. - 5,00 PERMIT VALIDATION
ADDRESS SPECIAL CIRCUIT )
ZIP TEMP.METER Ofl POLE INS. 20.00 r
APPLICANTS MOTORSE SCH.
ADDRESS Q
SERVICE CHANGE 20.00 J� I e
w O o LICENSED CONTRACTORS DECLARATION APR 9 7
¢ u U I hereby aflino that 1 out licensed under provisions of Chapter 9 L C.(%z- l% ISSUANCE DATE
aN (commencing with Section]000)of Division 3 of the Business and BLDG. ELECT. H.
H D z 'rofessions Co and m�license is in full 1'orc d $f Q`Kjt�`I�y
Z 0 I$ icats,Class `�g_Lic.NumbeV� ,
2 r w Date �- Conlracto 2�
BUILDING PERMIT
¢ ¢ w < OWNER-BUILDER DECLARATION INFORMATION
OAU MISE.- REFER TO ORD
w3 LL H 1 hereby affirm that 1 am exempt from the Contractor's License N $/FT.
¢ o a Co.for the following reason,(Sec]031.5,Business and Professions PERMIT ISSUANCE 10.00 w
L NN+ Code:Any city orcounly whichrequiresapermittoconstrucLulte', �/
QQ Q Q Improve,demolish,Ol.pair any,truvluY,prior IO Its Imoance,also ELEC.CONTR. LIC.NO. ELEQ c/7F3;;P
requires the applicant for such permit(o file a signed statement that TOTALERMIT TO
d w m u. he is licensed pursuant to the provisions of the Contractor's License (�
Horn Law(Chapter 9(conunencing with Section 7000)ofDivision 3 oflhe Seuir-r/,,/Y, (Vrp_ t
F 4 or Business and Professions Code)or that he is exempt therefrom and CITY. PLUMBING PERMIT FEE
¢ $ the basis for the alleged exemption.Any violation of Section 7031.5 - STORIES TYPE CONSTR.
by any applicant for a permit subjects the applicant too civil penally gLTER-DRAIN& VENT-WATER (EA.) 5.00
.Inot more than five hundred dollars(5500).):'
❑ I,as owner of the properly,or my employees with wages as BACK FLOW PROTECT. DEVICE 4.00 OCC.GROUP RES,UNITS
their sole compensation,will do the work,and the structure is nol
intended or offered for sale (Sec. 7044, Business and Professions DRAINS-.FLOOR,ROOF,AREA,COND. 5.00
Code:The Contractor's License Low docs not apply to an owner of
t(., LAILproperty who builds Or improves thereon,and who does such work FIXTURES,PER TRAP 5.00 so.IT PLOOR AREA TOTAL ACREAGE
himself or through his own employees,provided that such improve- GAS-EA.SYSTEM-11NC.40UTLETS 6.00
no nts are not intended or offered for sale.If,however,the building
or improvement is sold within one year of completion, the owncr-
p p GAS-EA.SYSTEM-OVER 4 (EA.) 2.00 BUILDING USE
builder will have the burden of proving that he did nut build or im- RES IND CON PB Omer
prove for,owner of theJ. INDUSTRIAL WASTE INTER. 30.00
O d as owner rs the property,he exclusively. 7044,Bu with ❑ ❑ ❑ ❑ ❑
licensed contractors to construct the project(Sea 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(EA.) 1.00
contracts for such projects with a contactor(s)licensed pursuant to gEWER-SANITAR V- .200ft/10.00 TRACT N0. PARCEL rv0.
the Contractor's License Law.
❑ I am exempt under Sec.-,B&P C.for Ibis WAT Il HEATLW ENTIIII6.00
reason
Owner Date WATER SVSTE 5,00 . ACC.DATE ACC.FILE NO.
WORK F:RS'CONPIiNSAI'ION DECLARATION WATER TREAT QUIP. 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 /
'copy The r`¢ �1BQ0 b.C.l. lr- _0
Pn1icY Np._( P C7ntanY � �
O U Certi ied copy is herebyfunu d. FIRE SPRINK ENERGYT44
Z1" -`° with lhccity inspection division. MISC.-' REFER TO ORD. YE] N❑ Y ❑ NE]
y CERTIFICATE OF EXEMPTION FROM WORKERS' PERMIT ISSUANCE 10.00 , RLooD ZONE ILL.u.C.
137 >. COMPENSATION INSURANCE PLG.CONTR. LIC.NO. TPLO
OTAL Q ,u ❑ ❑ ❑ ❑
CL 0 ('Phis section need not be completed if the permit is for one Y N Y N
Z hundred dollars(SI00)or less,)
U O 1 eertify'lhal in the performance of the work for which this per CITY MECHANICAL PERMIT FEE FEE SUMMARY
LL P mit is Issued.I shall not employ any person in any Inanner so as to
U becomesubject to the Workers Compensation Laws of California. FFEE '
ISS
O w Dam Applicant ALTER OR ADD TO MECH. 5.00
} N ' NOTICE'f0 APPLICANT: If,after making this Certificate of Ex-
F-1 ? coalition,you should become subject to the Workers'Compensation APPLIANCE 5.00
i provisions of the Labor Code, you must forthwith comply with such provisions or this permit shall be deemed revoked. AIR HANDLING UNIT(TO 10,000 F.M.) 4.00 .CONSTRUCTION LENDING AGENCY - AIR HANDLING UNIT(OV F.M.) 6.00 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(Sea 3097,Civ.C.). - - HEATING UNIT IT 0 T. . .g.00Lender's Name HEATINGUNITIO 100,000 B.T. 50 ��'
Lender's Address _
' I I certify Boni I have read this application and state that the above - VENTILATION FAN I 4.00
7 ihlormalion is correct. I agree to comply with all city and county PLUMBING
I ordinances and state laws relating to budding construclion,'and BOILER-COMP(3 H.P.Or 0 ,000 B.T.U.1 6.00
• hereby authorize representatives of this city Ur asscr upon the BOILER-COMP (Over 100,000BTUISEEFEESCH. MECHANICAL --
above-mentioned property for inspersion purP(
s' (We) agree to save, indemnify and keep harmless the City of MISC.- REFER TO ORD. '
Cupertino against liabilities,judgments, costs and expenses which PERMIT ISSUANCE 10.00 w`- CONST.TAX
may in any way accrue against said City in conscyuance of the
ECKCONT. LIG NO. MECH.
. � • , TOTAL �2h�L. TOTAL
SignaNre oI Applicant/Contractor Dale M
OFFICE COPY -
POST THIS CARD'NEAR FRONT OF BUILDING "
J • . PERMIT NUMBER .
CITY OF. CUPERTINO 12582;
INSPECTION DIVISION`
JOB INSPECTION RECORD
�; PERMIT EXPIRATION
may%•. �J JOB ADDRESS '/D 73'd O�'/'�NL' 710730 OT li>01D11T# LOT#
,PERMIT EXPIRES IF WORK
OWNER ' " WonWWong CONTRACTOR T & I Construction - IS NOT STARTED WITHIN
'. INSPECTION DATE NSIGNED
INSPECTION RECORD 180DAVSOFPERMITISSU-
FOUNDATION ANCE OR 180 DAYS FROM
LAST CAL LEDI NSPECTION.
LIFER
PREGUNITE syr-gt7PERMIT vnuonnoN
POUR NO CONCRETE UNTIL ABOVE HAS BE .�;'✓ 11 r
-UNDERGROUND /SLAB
PLUMBING -
ELECTRICAL ISSUANCE DATE
MECHANICAL • BLDG. ELECT. PLG. MECH.
n E El ,❑
DO NOT POUR FLOOR UNTIL ABOVE HAS BEEN SIGNED BUILDING PERMIT
' INFORMATION
WOOD FLOOR
VALUATION SIFT.
PLUMBING:
MECHANICAL '„ '
PEHMIr TO
ELECTRICAL' - - + ' _ ;G�, � -� ,_•� _ L
FRAMING `-
STORIES TYPE CONSTR.
INSULATION
OCC,GROUP, RES.UNITS
IP,L•A.'CE NO SUBFLOOR UNTIL ABOVE HAS BEEN SIGNED '
�� [ ROOF _ - - - 50.FT.FLOOR AREA lOTAL,ACHEAGE
'/` , DIAPHRAGM -
BW LUING USE
RES IND CON PB OI�Yr
' El 1:1
"APPLY NO ROOFING UNTIL ABOVE HAS BEEN SIGNED - El
ASSESSORS PARCEL NO.
,ROUGH
PLUMBING - '
TRACT NO. PARCEL NO.
GAS TEST - -
I
MECHANICAL,.' --
ACC.DATE ACC.FILE NO.
ELECTRICAL- - ' FINALS DATE INSP. -
FRAMING - SAN #
ZONING ENG.SITE NO.
INSULATION PLUMBING -
GAS
FIRE SPRINK ENERGY T 2 _
-
MECHANICAL •
COVER NO WORK UNTIL ABOVE HAS BEEN SIGNED ' I HEATING Y 0'', -N❑ Y NE]
FLOOD ZONE A.L.uc,
' LATH-INTERIOR � � ELECTRICAL � - "
LATH-EXTERIOR - FIRE DEPT. Y-0 NY I] N� -
. SHEETROCK • GRADE . FEE SUMMARY
SHEAR INTERIOR BUILDING - J
. BUILDING
SHEAR EXTERIOR TEMPORARY APPROVALS '
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 SIGNEDBY BUILDING INSPECTOR. MICROFILM
ARRANGE FOR INSPECTION BY PHONING 252-4505, ELECTRIC -
- , �IwT � ONEWORKING DAY BEFORE'REQUIRED INSPECTION. PLUMBING
�,�
C•5 PLEASE GIVE JOB ADDRESS WHEN PHONING. -
E MECHANICAL -
''Otl„�t?"^ter `- - SEE PERMIT, FOR, EXPIRATION DATE
IMPORTANT! coNsr.TAX
PLEASE READ REVERSE SIDE BEFORE ' .,TOTAL
CALLING FOR FINAL INSPECTION.
' OFFICECOPY