09753 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
•BUI LDI NG PROJECT 1 DENTI FICATI ON - PERMIT NUMBER
BUIL 7 . - .. IwL APPLICATION & PERMIT 09753
goORESS /07-1: 0 I•a�l .
Q BUILDING - ELECTRICAL-PLUMBING-MECHANICAL
OWNER'S PLAN CHECK VALIDATION
NAME QTV. ELECTRIC'LLPyyERMIT FEE
PHONE*
i. i'kF
CONTRACTORS E
NAUTLETS-SWITCHES-RECEP ,10.00/1.00
M
S Lie.No. LIGHTING FIXTURES 110.00/1.00
CONTRACTOR - APP LIANCES-RESIDENTIAL 4.00
ADDness
Z, PHOrvE ZAYM 3 PANELS 10.00 DATE OF APPLICATION
ARCHITECT PANELS (OVER 200 AMP) 20.00 PLAN CHECK FEE P.C.NO.
OR
ENGINEER
O LIC.Na. SIGNS TRANS. 3.00
AARC
DDIT OR RESS ENG SPECIAL CIRCUIT S.00 PERMIT VALIDATION
ZIP EMP:METER OR POLE INS. 20.00 _12-AID
APPLICANTS MOTORS SEE FEE SCH.
ADDRESS
1- SERVICE CHANGE 20.00
0 0 o LICENSED CONTRACTORS DECLARATION TEMP.POLE 30.00 I .{ I
U v' I hereby affirm that 1 am licensed under provisions of Chapter 9 Be CE DATE
v¢i (commencing with Section]000)Of Division-3 of the Business and ELECT. PLG. MECH.
F N z Professions Code,DlAry license is in full force and a kct.
z O"A - License Class Lic.Number_ L
OS, El Cw Date Contract.,
Contractor -
Q y 2 j . BUILDING,PERMIT -
¢ W w ¢ OWNER-BUILDIiR DECLARATION . INFORMATION
aaaD MISC.- REFER TO ORD -
w ;,� H I hereby nelson that I am exempt from line Contractor's License
n o a Law for the following reason.(Sea 7031.5.Businessi nd Professions PERMIT ISSUANCE 10.00 VALUATION SIFT.
- 0 Code:Any city orcounty which requires a permit tOconstruct.alteq
¢ ¢ improve,demolish,or repair any structure,prim to its issuance,also ELEC.CONTR. LIC.NO.
ELEC.ar
- ✓ -
¢ he Melee elle applicant t t the permit t0 file d signed acors statement that TOTAL �prERM�IT TO ,
¢ w m" he is licensed pursuant en the provisions Of the .1 Division License , ✓ /n,V,,fI/�J
r z r Law(Chapter 9 Professions
Cod ) rhSection is exempt therefrom
omtitle net
4 4 o Business and Professions script or that vi is exempt Therefrom and QTV. PLUMBING PERMIT FEE
¢ � the basis for the alleged exemption.Any violation ofSection 7031.5 1 STORIES TYPE CONSTR.
n ; $ by any appin.rt for a permit subjects the applicant too civil penalty ALTER-DRAIN& VENT-WATER (EA.) 5.00
of nor more than five hundred dollars(5500).)i
_
❑ 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,COND. 5.00
Code:The Contractor's License Law does not apply t0 an owner of
properly who builds or imptoves thereon,and who does such work FIXTURES-PER TRAP 5.00 Sp,fr„FEooR onto TOTAL ACREAGE
himself or through his own employees,provided that such improve- O'O.✓4Y/�_!/-7 J.
ments are not intended or offered for sale.If however,the building' GAS-EA.SYSTEM-1 INC.4 OUTLETS 6.00
y or improvement is sold within one year of completion,the owner. GAS-EA.SYSTEM-OVER 4 (EA.) 2.00 BUILDING USE
builder will have the burden of proving that he did not build or im- IND CON PB Other
prove for purpose of Sale.). - INDUSTRIAL WASTE INTER. 30.00
❑ 1,as..net of the property,am exclusively contracting with ❑ ❑ ❑ ❑
licensed contractors t0 construct.the project l Sec. 7044,Business LAWN SPRINKLERS- 1 INC 5 V.B. 6.00 ASSESSORS PARCEL NO.
• and Professions Codea'he Contractor's License Law docs 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 commetngs)licensed pursuant to
the Contractor's License Law. SEWER-SANITARY-STORM EA.200ft/10.00 TRACT NO. PARCEL NO.
eon Co
❑ I am exempt under Sec. It.&P.C.fou His WATER HEATER W/VENT •6.00 �CS
reinstall
Owner Data WATER SYSTEM 5.00 ACC. ATE ACC.FILE NO.
WORKERS'COMPEN$ATION DECLARATION WATER TREATING EQUIP. 5.00 -
I hereby affmn that I have a certificate of consent to self-insure, ZONING ENG.SITE NO.
m a certificate of Workers'Compensation Insurance,or a certified
copy thereof(Sec.3800,Lab.C.). - 1
Policy No. CompanYbVM..�I<isG1S�__
KCertified copy'is hereby furnished. FIRESPRINK ENERGY T-24
z Z ❑ Cetil'ied copy is Filed with the city inspection division. M C.- REFER TO ORD.
0 Applicant Y❑ N❑ Y ❑ N❑
N CE III'I FICA TI;OF Ii X tial PFION FROM WORKERS' PERMIT ISSUANCE 10.00 FLOOD ZONE A.L.U.O.
LU _> COMPENSATION INSURANCE PLG.CONTR. LIC.NO. PLG.
1 0 (This section need not be completed it the penmil is for one TOTAL YE] N❑ Y❑ N❑
Z) Z hundred dollars IS 100)or less.) -
U 0 1 certify thm
Ill.[ in the performance of the work for whlcb this per- TY.OMECHANICAL PERMIT FEE FEE SUMMARY
LL 1- mit is issued,I Shall not employ any person in any manner so as to -
U become subject to the Workers'Compensation Laws ofCalifornia' BUILDING
n
Date.Applicant ALTER OR ADD TO MECH.
} to NOTICE 1'O APPLICANT: If after making this Certificate of Ex-
H Z
Lot,liun,you should become Subleet In the Workers'Compensation APPLIANCE 5.00 PLAN CHECK
U such provisionrovisiolls of,fie or this peeor n t shot[be deemou musted revoked.comply with AIR HANDLING UNIT(TO 10=C.F.M.) 4.00 FEE
CONS'rRI_CrION LENDING AGENCY AIR HANDLING UNIT(OVER IOJWOC.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.). HEATING UNIT(TO 100,000 B.T.U.) 8.00 ,
Lender's Name HEATI NG UN IT(OV ER 100,000 B.T.U.)9.50 ELECTRIC
Lender's Address
I certify that I have reed this application and state that he shove VENTILATION FAN (SINGLE) 4.00
r information is correct I agree to Comply_wnt
ith all city and couy BOILER-COMP(3 H.P.or 100,000 B.T.U.) 6.00 PLUMBING
ordinances and state laws retailing to building consul¢lion, and
hereby aullionLe representatives of this city to enter upon the BD ER IOver 100,000 BTU)SEE FEE SCH. MECHANICAL
above-mentioned property for inspection purposes.
'(We) agree to save, indemnify and keep hil'odess the City of MISC.- REFER TO ORD.
Cupertino against liabilities,judgments, casts and expenses which CONST.TAX
may in any way accrue against suit] City in consequence of the PERMIT ISSUANCE 10.00
granting of this permit. MECH.CONT. . LIC.NO. MECH.
TOTAL TOTAL
Signa Contractor Date
OFFICE COPY
POST THIS CARD NEAR FRONT OF'BUILDING.
PFIIMIT NUMBER
1 "CIT,Y 'OF CUPERTINO
X97,53
q :INSPECTION DIVISION -,
JOB INSPECTION RECORD
.f S. _
A . PERMIT-EXPI RATION
_'" __ - 'i•- - - PERMIT '-EXPIRES IF WORK
OWNER CONTRACTOR ,r ' IS NOT STARTED WITHIN,
INSPECTION DATE INSPECTOR :. INSPECTION RECORD - 780 DAYS OF PERMIT ISSU-
FOUNDATION �'}j- _ ANCEO 80 DAYS FROM
LIFER"
JC
DINSPECTION.
a / PERW ALIUATIONl
POUR NO CONCRE hNTIL ABOVE HAS AM SIGNED
UNDERGROUND /SLAB,
PLUMBING
ELECTRICAL Z. ISSUANCE DATE •.
MECHANICAL RLOG: ELECT, PLG. pi
m R.
❑ ❑
DO NOT POUR FLOOR UNTIL ABOVE HAS BEEN SIGNED BUILDING PERMIT
WOOD FLOOR n.. ,,, INFORMATION
.VAWATION SIFT.
-PLUMBING
MECHANICAL -
ELECTRICAL �
.. FRAMING'
$TORI[ TYPE CONSTR.
INSULATION ,
OCdC,.GROUP RES.UNITS
•gRLACE NO SUBFLOOR UNTIL ABOVE HAS BEEN IGNED
i.ff�•.` .S ROOF ' - • • . .' SO,FT FLOOR AI 'A 1m AL ACREAGE
�(
'DIAPHRAGM l w
f :i, • .� RES' INUUIIOC'I USEPR 00-..
-"-
—4- ED—yAPP.LY NO ROOFING UNTIL ABOVE HAS BEEN SI NED - • "--0 " E3
,I[�-'ASSESSORS PARCEL NO.
1. . ROUGH -
PLUMBING - - _ '
GAS TEST. rRACT No.: - PARCEL No
,
MECHANICAL -yr, ( -7 `
.ELECTRICAL T�yi- FINALS ATE INSP.
ACC DATE, Acc.FILENo. -.:
FRAMING _ SAN #: x' " ZONING ,ENG.SITE No.
INSULATION . _ PLUMBING �" '��
I GAS'
FIRE$PRINK,. 'ENERGY i 24
. �Q MECHANICAL '/ '' FI ❑ - N❑, v 2 Q
COVER N RK UNTIL ABOVE HAS BEEN SIGNED HEATING -
FLOOD ZONE iA.L,U.C.
LATH-INTERIOR - ELECTRICAL,-
LATH-EXTERIOR
LECTRICAL;LATH-EXTERIOR - FIRE,DEPT; - v N� „ :v;�. riJ❑
SHEETROCK -..��-ff' GRADE - FEE SUMMARY
SHEAR INTERIOR _( _ 6 UILDINCkO"
" BUILDING
SHEAR EXTERIOR , _ -h(" V' TEMPO. ARY•APPROVALS '
FIREWALLS . ELECTRIC '. - PLAN CHECK • 'it. .
FEE
GAS-
NO TAPE OR PLASTER UNTIL ABOVE HAS BEEN SIGNED OCCUPANCY ' SEISMIC FEE' ' f �
OCCUPANCY OF BUILDING IS NOTPERMITTED UNTIL BUILDING FINAL ISSIGNED BY BUILDING INSPECTOR. 'MICROFILM I
ARRANGE FOR INSPECTION BY PHONING 252-4505; 7 ELECTRIC
" LU ONE WORKING DAY BEFORE'REQUIRED INSPECTION I PLUMBING. ..
C) PLEASE GIVE JOB ADDRESS,WHEN PHONING. .
' , . -SEE PERMIT FOR EXPIRATION DATE MECHANICAL
c CONST.TAX'-
IMPORTANT!,
PLEASE READ'REVERSE.SIDE BEFORE •' TOTAL •t.
CALLING FOR FINAL INSPECTION.
.. -OFFICE COPY' • .' I I' ,?.