C 9205 (2) I APPLICANT TO FILL IN INFORMATION WITHIN-RED LINES - USE BALL POINT PE ONLY
CBUILDING PROJECT IDENTIFICATION PERMIT NUMBER
APPLICATION & PERMIT
AopR .9205 '
UILDING-ELECTRICAL-PLUMBING.-MECHANICAL
N R'S ^ F - PLAN CHECK VALIDATION
"AM 60K4 -v IVT ..-?�t bT ELECTRIC PERMIT FEE
PHONE
CON CTOn$
NA OUTLETS-SWITCHES-RECEP 10.00/1.00
I'D,No. LIGHTING FIXTURES 10.00/1.00
CONTRACTOR
ADDRESS
-� APPLIANCES-RESIDENTIAL 4.00
CO
PHONE PANELS 10,00 DATE OF APPLICATION
RcufTper - PANELS (OVER 200 AMP) 20.00 PLAN CHECK FEE P.C.No.
OR
O
ENGINEER
• LIC,No. SIGNS TRANS. 3.00
ADDRESS ENG.
- SPECIAL CIRCUIT 5.00 PERMIT VALIDATION
ZIP TEMP.METER OR POLE INS. 20.00 AUGfi 138
ADDRESS MOTORS SEE FEE SCH. M l.1 1 !�
ADDRESS
SERVICE CHANGE 20.00 City of Cupertino .
o o LICENSED.CONI'RACTORS DECLARATION TEMP. POLE ' 30.00
a o U I hereby affirm that I am licensed under provisions of Chapter 9 - ISSUANCE DATE
y< n (commencing with Section 7000)of Division 3 of the Business and - SLOG. ELECT. J. PLG. MECH.
r w z Professions Code,and my license is in full force and effect. ❑ ❑ ❑
oi a G License Class Lie.Number
F m J Date Contractor
a m s BUILDING PERMIT
¢ ¢ a OWNER-BUILDER DECLARA'1'[ONa o a vINFORMATION
w g u m I hereby affirm that [',in exempt from the Contractor's License MISC.- REFER TO OR
Fu0J Law forthe following reazan.(Sec.703L5,Businessand Professions PERMIT ISSUANCE' 10.00 VALUATION $/FT. ,
m� Code:Anycity orcounty whichrequiresapvTp1h tOconstruct,a oh,
i[ 2 a'p improve,demolish,or repair any structure,prior to its issuance,also ELEC.CONTR. LIC.NO. ELEC. o
u w m¢ requires the applicant for such permit to file a signed statement that TOTAL. PERMIT TO
he is licensed pursuant to the provisions of tin Contractor's License q
H z a Law(Chapter 9(commencirg with Section 7000)of Division 3 ofthe
4 D Business and Professions Code)or that he is exempt therefrom and OTY. PLUMBING PERMIT FEE
¢ H $ the basis for the alleged exemption.:Any violation of Section 7031.5 STORHIF TV S R.
by any applicant for a permit subjects the applicant to a civil penalty ALTER-DRAIN&VENT-WATER (EA.) 5.00
.four more than live hundred dollars(S50W.): -
❑ L as owner of the property,or my employees with wages as BACK FLOW PROTECT, DEVICE 4.00
their sole compensation,will Jo 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:'I'lie Contractor's License Law does not apply to an owner of
property who builds or llllproves(hereon,and who floes such work FIXTURES-PER TRAP 5.00 SO.FT.FLOOR AREA TOTAL ACREAGE
• himself re through his own employees. le.I ,provided Iho1 such improve. ,
ments improvement
not meet tended w thinoffered
onefor
year
If,however,the owner. GAS-EA.SYSTEM-1 INC.4OUTLETS 6.00
or improvement is sold within one year of completion, the owner GAS-EA.SYSTEM-OVER 4 (EA.) 2.00
builder will have the burden of proving that he did not build or im- BUILDING E
pov for purpose of sale.). INDUSTRIAL WASTE INTER. 30.00 RES 1ND PB Other
I,as owner of the property,am exclusively contracting with 1:1 0 0
licensed contractors to Construct the project(See. 7044,Business LAWN SPRINKLERS-1 INC 5 V.B. 6.00 ASSESSOVSPKRCFI NO.
and Professions Code:The Contractor's License Law does not apply --
to an owner of properly who builds or folooves thereon,and who LAWN SPRINKLERS-OVER 5.(EA.) 1.00
contracts for such projects with it contractions)licensed PnDLImat to SEWER-SANITARY-STORM EA.200ft/10.00
the Contractors License Law. TRACT NO. PARCEL NO.
❑ lamexemptunder See. ,B.&P.C.for this WATER HEATER W/VENT 6.00
reason
Own Date WATER SYSTEM 5.00 ACC.DATE ACC.FILE N0.
O RKF:RS'COMPSNSA'I'ION DI CL WATER TREATING EQUIP. 5.00
I hereby affirm that I have it certificate of consent to self-insure, 20NING .ENG.SITE NO.
or a certificate of Workers'Compensation Insurance,or a certified
copy thereof(Sec.3800,Lab.C.). - -
Policy No. Company _
N O Certified copy is hereby furnished.
FIRE SPRINK ENERGY T24
Z Z ❑ Certified copy is filed with,the city inspection divisimv
O Applicant - REFERTOORD..MISC. y .N❑ Yo N[J
- +'
CERTIFICATEOF EXEMPTION PROM WORKERS' PERMIT ISSUANCE 10,00 FLOOD ZONE ' A.L.U.C.
LU > COMPENSA'T'ION INSURANCE PLG.CONTR. LIC.NO. PLG. V N� V N[3d 0 This section need not be completed if lire permit is for one _ TOTAL
Z hundred dollar,IS 100)car less.)
U O I certify that in the performance oI the work for s'vhicls this per OTV. MECHANICAL PERMIT FEE FEE SUMMARY
LL, F mit is issued,I shall not employ any person in any Insurer so as Io
Ow become subject to the Workers'Compensation Laws of California.
DBUILDING
a ate Applicant ALTER OR ADD TO MECH. 5.00
} So NOTICE TO APPLICANT: If,after making this Certificate of I;x-
? 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 permit shall be deemed revoked. AIR HANDLING UNIT(TO 10=C.F.M.) 4.00
CONSTRUCTION LENDING AGENCY AIR HANDLING UNIT(OVER 10MC.F.M.) 6.00 SEISMIC FEE, '
I hereby affirm that there is a construction lending agency for I 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 HEATING UNIT(OV ER 100,000 B.T.U.)9.50
Lender's Address ELECTRIC
I certify'that l have read this application and state that the above VENTILATION FAN (SINGLE) 4.00
• information n correct I agree i comply with all city and county BOILER-COMP(3 H.P.or 100,000 B.T.U.) 6.00 PLUMBING
ordinances and stain laws
en relating to building construction, and
hereby above-mentioned
representatives of this city to enter upon the BOILER-COMP (Over 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. -
Cupertino against liabilities,judgments, costs and expenses which PERMIT ISSUANCE 10.00 CONST.TAX
may in any way accrue against said City in consequence of the
granting of this P "l. MECH.CONT. LIQ No. MECH.
86 OTAL TOTAL /13t
S' n lure of App¢ant/Contractor [)(,(a -11 �'✓ .
h OFFICE COPY -
ly a POSTTHIS.CARD NEAR FRONT OF:BUIL'DING r
CITY OF, CUPERTINO PERMIT
ND„BER
INSPECTION DIVISION --0.205
"JOB INSPECTION•RECORD,
PERMIT EXPIRATION
JOB ADDR ESS1Sd2G�-+ UNIT# _LOT# -
_ O - PERIM IT”E XPI R ES,IF,WORK
OWNER '[� CONTRACTOR IS NOT STARTED WITHIN:
INSPECTION DATE INSPECTOR INSPECTION RECORD _ 180 DAYS OFPERMIT.ISSU-
FOUNDATION - yg r^ ua7xocA!bb.L -ANCE OR 180 DAYS FROM, ,
U PERLASTCALLEDINSPECTION.-
PREGUNITE ,,,,q �J'%�
PE 61 ATION '
D_ . Jl—Pili .
Cvn/u'nT• _ 1 1 A
POUR NO CONCRETE UNTIL ABOVE HAS BEEN SIGNED AUG'1 }�$5
UNDERGROUND /,SLAB _
PLUMBING - ' 'x• ."`' �' .QIty,Df'CDpelflflo '
ELECTRICAL ISSUANCE DATE '
MECHANICAL „�P•" . BLDG, ELECTI PLG. MECK., ,
E]
DO NOT POUR FLOOR UNTIL ABOVE HAS BEEN SIGNED .• .- BUILDING PERMIT
INFORMATION
WOOD.FLOOR VALUAnoN
PLUMBING
MECHANICAL . /'' '.
ELECTRICAL - _ .. ^� PERMITTC
rvu. FRAMING • 'I
INSULATION' • . - a sr, 1E5 /+rvPE/c_NSTR j
- .. OCC-GROUP/ I RES.UNITS': f
PLACE NO SUBFLOOR UNTIL ABOVE HAS BEEN SIGNED- ,' 4
$ - ROOF •. SQ'FL F 1.00.A R E A TOTAL ACREAGE
DIAPHRAGM'.
BUILDING USE .
RES IND •_CON PB OU,r '
APPLY NO ROOFING UNTIL�ABOVE HAS BEEN SIGNED - 0. Q J 0 0
ROUGH ,
A5SE550R5Y
ARCEL NO. - +;
�• '� .
PLUMBING-
I -
GAS TEST TRACT NO. PARCEL NO,
- -
' MECHANICAL
ACC.DATE' ACC.FILE NO.
,ELECTRICAL .FINALS DATE INSP.
FRAMING -b:✓ ,. SAN'# -
' zoNlNa . �'ENc.SIL E No..
INSULATION - PLUMBING
GAS
MEC NI AL FIRE SPRINK ENERGY T 2
COVER NO WORK UNTIL ABOVE HAS BEEN SIGNED HE IN J •"� `Y 0- "�
LATH-INTERIOR EL CTJU— iP �F LOODZONE A.L.U.L. .
R C
LATH—EXTERIOR ' - Y ❑. ,,NC pvl] No
SHEETROCK GRADE - FEESUMMARY ,
SHEAR INTERIOR BUILDING D721.2-5947 '
SHEAR EXTERIOR TEMPORARV APPROVALS, ; ^�:.' I .BUILDING
FIREWALLS .' ELECTRIC - ,PLAN CHECK '
' 'a�.•a, ..,,. GAS FEE -
f
NO TAPE.0 PLASTER UNTIL ABOVE HAS BEEN SIGNED OCCUPANCY s SEISMIC FEE . I
OCCUPANCY OF BUILDING IS NOT PE WITTED UNTIL BUILDING FINAL'ISSIGNEb BY BUILDING INSPECTOR. MICROFILM -
j' a
! ARRANGE FOR INSPECTION BY PHONING 252-4505, ELECTRIC
ONE.WORKING DAY�BEFORE'REQUI.RED INSPECTION�PPLursewc .
,PLEASE GIVE JOB ADDRESSWHENHONING.
r rZ t`'I ' MECHANICAL -`
I , —SEE PERMIT FOR EXPIRATION DATE =,,
J
., I a •y - a, vCONST..TAX .. -_
IMPORTANT! - or
'
1f PLEASE.READ REVERSE SIDE BEFORE � ., 'r , r TOTAL I
CALLING FOR.FINALINSPECTION.,
- : n OFFICE COPY I -