12867 (2) E "APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL-POINT PEN ONLY
PERMIT NUMBERS
BUILDING PROJECT IDENTIFICATION APPLICATION $I PERMIT
ADORE aBUILDINGs.
12867
aooREss - � BUILDING -ELECTRICAL-PLUMBING-MECHANICAL
22303 Re part
OWNER'S _ PLAN CHECK VALIDATION.
Name QTY. ELECTRIC PERMIT FEE
Jeff Wright PHDNE257-5324
CONTRACTOR'S UTLETS-SWITCHES-RECEP 10.00/1.00
NamE City' 1.iC. 8OSO2]7145, & LIGHTING FIXTURES 10.00/1.00
A.A.A. Furnace..Co.Lm.NO,
CONTRACTOWS PPLIANCES-RESIDENTIAL: 4.00 '
ADDRESS.
1712 Stone Ave- PHONE _ _ PANELS[ - 10.00 GATE OF APPLICATION
aRCNITECT
PANELS
(OVER 200 AMP) " 20.00 PLAN CHECK FEE P.C.NO.
OR
'- ENGINEER i '
Llc.No. SIGNS TRANS. 3.00
ARC.,OR ENG. SPECIAL CIRCUIT 5.00 PERMIT VALIDATION
ADDRESS
ZIP EMP.METER OR POLE INS. '20.00
APPLICANTS - MOTORS SEE FEE SCH.
ADDRESS
- SERVICE CHANGE 20.00
wo a LIC17NSED CONTRACTORS DECLARATION l
¢v U I hereby affil.that I am licensed under provisions of Chapter 9 ISSUANCE DATE
nrt w (commencing with Seclion 7000)of Division 3'ol'the Business and BLDG. ELECT, I PLG. MECH.
r z Professions Code,and my license is in full force and effect ❑
, 00.-o License Class- `( 0_&_Lbe.Number�7-71-4-5-br- ❑
0 H w Data- Contract., I .
C 43- 14-63 El - BUILDINGPERMIT -
¢ at w OWNER-BUILDER DECLARATION INFORMATION
REFER TO ORD
A.
LL y I hereby affirm that I'am exempt from the Cont radon's License MISC.- EVALUATION $/FT.
a o 4 Law for the following reason.(Sec.7031.5,Businessand Professions PERMIT ISSUANCE 10.00
� - Code:Any oily or county whichregaires2peimittoconslnlcl,alle,, _
a Q�, improve,demolish,or repair any structure,prior Io its issuance,also ELEC.CONTR. LIC.NO ELEC.
a - 0,
requires the applicant for such permit to I'toa signed statement Thal TOTAL PERMIT TO -
.w $ he is licensed pursuant to the provisions orrim Contractors License ��� / ,
Hz>0 Law(Chapter 9(commencing with Section 7000)of Division3 ofthe ?
4 B anness and.l'rofessions Code)or that he is exempt therefrom and QTY, PLUMBING PERMIT FEE
2 2 O STORIES VP,E CONSTR.
¢ r$ the basis for the alleged exemption.Any violation nf Section 7031.5 -
a ';; � by any applicant fora permit subitetsthe applicant Ina civil penalty ALTER-DRAIN&VENT-WATER (EA.) 5.00 -
of not more than five hundred dollars(4500).): -
❑ 1,as owner of the property,or my employees with wages as BACK FLOW PROTECT. DEVICE 4.00 OCG GROUP UNITS
Ihcir sole compensation,will do the work,and the structurenot
intended or offered for sale (Sec. 7044, Business and Pmm'eis tons DRAINS-FLOOR,ROOF,AREA,COND. 5.00
Code:The Contractor's License Law does not apply to an owner of
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 imp,ovo-
menti are not intended or offered for sale.If,however,the building GAS-EA.SYSTEM-11NC.40UTLETS 6.00 --
or improvement is sold within one year of completion,the owner.
builder will have the burden.1 proving that he did not build or ire GAS-EA.SYSTEM-OVER 4 (EA.) 0 BUILDING USE
RES' 'IND CON PB Other
prove for purpose of Salo:). INDUSTRIAL WASTE INTER. - 30.00 rl ❑ ❑ ❑ ❑ ❑
❑ I,as owner of the property,am exclusively contracting with'
licensed contractors m construct the project IS".7044,Business LAWN SPRINKLERS-1 INC 5 V.B. ASSESSORS PARCEL NO:
and Professigns Code:The Contractor's License Law does not apply
to anowner of property who builds or improves thereon,and who LAWN SPRINKLERS-OVER ) 1.00 4, ,
contracts for such projects with a co
ulractons)licensed pursuant to SEWER-SAN
ITARY-STORM EA,200(
the Contractors License Law. TRACT NO. PARCEL NO.
to l am exempt under Sec.-.11&PC:for this ,WATER HEATER'W/VENT V 6.00 '
reason
Owner I [)ate_ WATER SYSTEM 5.00 ACC.DATE ACC FILE NO.
WORKF.RS'COMPI:NSATIONDIiCLARA"PION WATER TREATING EQUIP. 5.00
1 hereby affirm that 1 have a certificate.(consent to self-insure. - ZONING ENG.SITE NO.
or a cerdficate'of Workers'Compensation Insurance,or a certified
copy thence' Lab.CC. '
I'.hcy No. Imanvm-Cates mpeasbation .. .
O Certit''it copy i. iamb y for isIned FIRE SPRINK ENERGY T 24
Z Z Certifie i Ile an y nspille{Adliv' n. MISC.- REFER TO ORD.
Applicant .. Y ❑ N❑ Y F-1N13� y
PERMIT ISSUANCE 10.0010.00 FLOOD ZONE
CL ; -CE ' 'ICATI°.OF EXEMPTION 17 M WORKERS'
LLI _ COhIPFNSATION h RANCE PLG.CONTR. LIC.NO. PLG. Y❑ N❑ v f7 N❑
C O (This sTmtiD. need not be completed if the permit'.6' for one _ TOTAL _
::) Z . [limit red dollars IS 100).1 less.I
V O 1 certify tat in the performance of the work for which this per- QTY. MECHANICAL PERMIT FEE FEE SUMMARY
LL H mil is issued,I shall not employ any person in any manner so as to
O U Feature 4ubjecl to the Workers'Conmensation-Laws of California. - -
Date Applicant ALTER OR ADD TO MECH. 5.00 BUILDING
} rail NOTICE TO APPLICANT: If,after making this Certificate of Ex.
F_ Z emption,you should become subject to the Workers'Compensution APPLIANCE 100 PLAN CHECK
provisions of the Labor Code, you must forthwith comply-with 'FEE
CJ such provisions or this permit shall be deemed revoked. AIR HANDLING UNIT(TO 10,000 .Fy :00
CONSTRUCTION LENDING AGENCY I AIRHANOLING UNIT(OV CEM.) SEISMIC FEE
1 hereby affirm that them is a construction lending agency for EXHAUST HOOD (WIT UCT)
the performance of the work for which this permit is issued(Sec. HEATING UNIT(TO 100, .U.1 8.00 MICROFILM
3097,CN.0.). -
Lender'sName
Address
Lender's Address HEATING UN IT(OV E R 100,000 B.T.U.)9.50 tz Cr ELECTRIC
I certify that I have read this application and state that the above VENTILATION FAN (SINGLE) 4.00 .
information is correct. I agree to comply with all city and county r PLUMBING
na
ordinces and state laws relating m building construction, and BOILER•COMPI3 H.P.or 100,000 B.T.U.1 6.00
hereby authorize representatives of this city m enter upon the BOILER-COMP(Over 100,000 BTU)SEE FEE SCM, MECHANICAL
above mentioned property for inspection purposes. '
(We);agree to save, indemnify and keep,huRnless the City of MISC.- .REFER TO ORD.
Cupertino ag liabilities,judgments„costs and ex�pehiclh CONST.TAX
may in way eme•against sin dy in conseyPERMIT ISSUANCE 10.00
gran lin Of this pe il. MECH.CONT. LIC.N0. MECH.
TOTAL 19.5 "
TOTAL
naturae plicanl/Contractor Date J
OFFICE COPY
POST THIS CARD NEAR FRONT OF BUILDING
- NIIT NUMBER
CITY OF. 128_ CUPERTINO` ` 7 .
" INSPECTION DIVISION,.',
JOB INSPECTION RECORD
�99 yT .PERMIT EXPIRATION
JOB ADDRESS o(oC y a3n/A.,E_7UNIT# 'LOT# '
- PERMIT EXPIRES IF WORK
. OWNER• ! CONTRACTOR'• AS NOT STARTED WITHIN
INSPECTION DATE INSPECTOR INSPECTION RECORD - 180 DAYS OF PERMIT ISSU-
ANCE OR 180 DAYS FROM
FOUNDATION ' LASTCALLED INSPECTION. !
UFER
PREGUNITE - „ - r, - PERMIT VALIDATION
POUR NO CONCRETE UNTIL ABOVE HAS BEEN SIGNED
1. UNDERGROUND /SLAB
PLUMBING
ELECTRICAL ��S 1 : ISSUANCE GATE
MECHANICAL- r BLDG, ELECT, PLO. MECH.
00 NOT POUR FLOOR UNTIL ABOVE HAS BEEN SIGNED , - r`y��E euILDwG PERMIT
INFORMATION
WOOD FLOOR - • • .. ".�"' �' .
. "VALUATION '$/FT.
PLUMBING
MECHANICAL + �'
_ ELECTRICAL ' - „ PERMTTTo.
FRAMING. •
` INSULATION " _ - STORIES TYPE Co STH.
OCC.GROUP RES,UNITS
,03
PLACE NO SUBFLOOR UNTIL ABOVE HAS BEEN SIGNED0190
'ROOF • 1. n ' S0.FT.FI.00RAREA TWALALREAGE
DIAPHRAGM • ,I BUIL nlrvG USE
FRES IND CON PR GO,, r'
.APPLY NO ROOFING UNTIL ABOVE HAS BEEN SIGNED 0 . 0 'El' 0 ' ❑
ASSESSORS PARCEL NO
:.,ROUGH ,
.: PLUMBING
GAS TEST .. TRACT NO., PARCEL NO.
•'MECHANICAL � „ ' ,
ACC.DATE ACC.FILE NO.
ELECTRICAL - - FINALS DATE INSP. �,
' FRAMING - SAN.# - - - ' A
ZONING ENG.SITE NO.
INSULATION - PLUMBING
• 'GAS
MECHANICAL - _ ':FIRE SPRINK ENERGY r.za
COVER NO WORK UNTIL ABOVE HAS BEEN SIGNED HEATING (] "(] NE]
FLOOD ZONE A.6.0.C.
LATH-INTERIOR ELECTRICAL
. . LAT,H=EXTERIOR + FIRE DEPT. v N� v 0 "�.
SHEETROCK� - .. GRADE.' ,hI FEE SUMMARY
SHEAR INTERIOR BUILDING
SHEAR EXTERIOR. TEMPORARY APPROVALS ! BUILDING
FIREWALLS - ELECTRIC - PLAN CHECK `
GAS FEE
NO TAPE OR PLASTER UNTIL ABOVE HAS BEEN SIGNED IOCCbPANCY ^ • ' SEISMIC FEE
OCCUPANCYOF BUILDING IS NOT PERMITTED UNTIL BUILDING FINAL.IS SIGNED BY BUILDING INSPECTOR. 'MICROFILM
ARRANGE.F.OR INSPECTION BY PHONING 252-4505, I t.EL�ECTRIC
o� ONE WORKING DAY BEFORE REQUIRED INSPECTION.. PLUMBING
Z PLEASE GIVE JOB ADDRESS WHEN PHONING.
- SEE PERMIT FOR EXPIRATION DATE - MECHANICAL"
IMPQRTANTI CONST.TAX .
PLEASE READ REVERSE SIDE BEFORE TOTAL
CALLING FOR FINAL INSPECTION.
AFFICECOPY - • -