17717 (2) AFS?LICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
BUILDING PROJECT IDENTIFICATION PERMIT NUMBER
APPLICATION & PERMIT ),.
BDILrIN91862 Shasta Spri Lot 339
AOOREss ,r,,, 17717
' A.. � BUILDING - ELECTRICAL-PLUMBING-MECHANICAL (°.
OWNER'S f�w'tnL PLAN CHECK VALIDATION
NAME Gregcxy "'"W'e IAC. OTV. ELECTRIC PERMIT FEE
ONE 415/595-210(
NAMERAcioas `regory Group, Inc. OUTLETS-SWITCHES,RECEP 10.00/1.00
""^'N LIC.No. B430097 LIGHTING FIXTURES 10.00/1.00
ADDRESS Toms 220-0 Twin Dolphin Drive APPLIANCES-RESIDENTIAL 4.00
PHONE415/595-210( PANELS 10.00 DATE OF APPLICATION
ARCHITECT PLAN CHECK FEEP.C.NO,
OR Basseniankagoni kchltects PANELS (OVER 200 AMP) 20.00 ..
ENGINEER
/�,,,,1�, ry,uc.No. � SIGNS TRANS. 3.00
ARCH SS ENG. 2031 Orrhard Drive #100 PERMIT VALIDATION
ARCHER L SPECIAL CIRCUIT 5.00
Santa /111a Heights, CA i ZIP 9270] EMP.METER OR POLE INS. 20.0(1 Syy9(b 1
APPLICANT'S yW_ 7
Aooq(dp. �20�p�nn Dolphin Drive MOTORS SEE FEE SCH. ���1112
1tW1.a l.H 7rilA`j SERVICE CHANGE _ 20.00 ,�`II
0,-02 LICENSED CONTRACTORS DECLARATION ` 1- - yv'
a v s, I hereby affirm that 1 atm licensed under provisions of Chapter 9 ISSUANCE DATE
N 2 H (commencing with Section 7000)of Division 3 of the Business and BLDG. ELECT, PLG. MECH.
F m z 14ofessium Code,a my license is in full force a \
z O m - License Class 6 Lie.Number `_ -
O Z t2 w Date Contractor !4
a " 5L BUILDING PERMIT
¢ ec w a OWNER-BUILDER DECLARATION
o A INFORMATION
u, ; m 1 hereby affirm that 1 am exempt from the Contractor's License MISC.- REFER TO ORD
u o j law for the following reason.(Sec.7031.5.Business and Professions VALUATION $/FT.
- PERMIT ISSUANCE 10.00
F m40 Code:Any molish rou mywhiny structure P prior ttoconsuancalter.
¢ Q Q O improve,demolish,ortepair any structure,prior to its issuance,also ELEC.DDNTfl. ,LIG NO' ELEC. 194 540
iL O ¢ requires the applicant for such permit to I It a signed statement(hat
o u OTAL
a w m he is licensed pursuant en the provisions of the Contractor's License P 9 ITO
z 1 Law(ChapterProfessions
de)with is7000)
exemfl7theren3 of the JI W
rc ¢ O Business and Professions Code)or that he is exempt echo tom and OTV. PLUMBING PERMIT FEE
¢ H the basis for the alleged exemption.Any applicant
o to action malty STORIES TYPE CONSTR.
by any applicant lora hundred
dollars the applicannoacivil penalty ALTER-DRAIN -WATER (EA.)•5.00 2 5NH2
of mol more than five hundred dollars IS500)J:
❑ Las owner at the willdproperty,ti of my employees with wages as BACK F LOW PROTECT. DEVICE- 4,00 OCC.GROUP RES.UNITS
their sole compensation,will do(he work,any the structure is net
intended Or offered for sale (Sec. 7044. Business and Professions DRAINS-FLOOR,ROOF,AREA, 5.00 R-3 1
Code:The Contractor's License Law docs not apply to an owner of
Property who builds of improves thereon,and who does such work FIXTURES-PER TRAP 5.00 SO.FT.-FLOOR AREA TOTAL ACREAGE
himself re through his own employees,provided that such improve- 304]
mems are not intended w thin one]Or year
If,however,thebuildingowner-
GAS-EA.SYSTEM-1 1NC.4OUTLETS 6.00 ("')AA.r5 LAV Or improvement is sold within one year of completion,the owner- LE �✓ 1-1
builder will have the burden of proving that he did not build or int- GAS-EA.SYSTEM-OVER 4 (EA.) 2.00 BUILD( USE
prove for Purpose of sale.). INDUSTRIAL WASTE INTER. 30.00 RES IND❑SORS P❑ARCEL NN I's Other
❑ O.
❑
. ❑ I,as owner of(he property,am exclusively contracting with
licensed contractors to construct the project(Sec. 7044,Business LAWN SPRINKLERS- 1 INC 5 V.B. 6.00 ASSES
and Professions Code:The Contractor's License Law does not apply
to an owner of property who bonds or improves thereon,and who LAWN SPRINKLERS-OVER 5(EA.) 1.00 Z2'J �`
contracts for such projects will,a contractors)licensed pursuant to ack iJ LJ«
the Contractor's License Law, SEWER-SANITARY-STORM EA.200ft/10.00 TRACT NO. PA L_EO( .
❑ lam exempt under Sec..,B.&P.0-lar this WATER HEATER W/VENT 80%
reason6.00
Owner Date WATER SYSTEM 5.00
ACC.GATE ACC.FILE NO.
WORK E RS'COMPENSA1 ION DECLARATION WATER TREATING EQUIP. 5.00
1 hereby affirm that I have a certificate ofconsem m self-imeufe.
or a certificate of Workers'Compensation Insurance,or a certified ZONING ENG,SITE NO.
copy thereof(Sec.3800,Lab,CJ.
Policy No. Company-
0 ❑ Cer(il icy copy is hereby furnlS,UT
Z Z X1 Ceftific ¢iz filed with r} city inspcmion division. FIRE SPRINK ENERGY T 24
Applicant Misc.- REFER TO ORD. Y[D N❑ Y [ NC]
~ rn PERMIT ISSUANCE
UJ - CIiR'fIFICCOMONSATIOTINS FROM WORKERS' - 10.00 FLOOD ZONE A.L.U.C. 1
W COMPENSATION INSURANCE PLG.CONTE. LIC.NO, PLG.
CL Z (This action need not be completed if O,c permit is for one TOTAL Y NO Y N�
hundred dollar(S 100).,less.)
00 1 certify that in the performance of the work for which this per- JAiLTER
MECHANICAL PERMIi FEE FEE SUMMARY
LL U mit is issued,I shall not employ any person in any manner so as to
O W become subject to the Workers'Cnn.pensati.n Laws of Califomiu.
a Date APnhwm R ADD TO MECH. BUILDING972.00
} W NOTICE "f0 APPLICANT: If,after making this Certificate of Es-
emption,you should become subject to the Worker'CompensationCE PLAN CHECK15.50Provisions of the Labor Code, you must forthwith comply withsuh provisions.,thispermit shall be deemed revoked, LING UNIT(TO 10A CC. FEE 6 00
coNSTkucl'ION LIiNDwc ncliNcy LING UNIT(OVER 10p00SEISMIC FEE13.65
1 hereby affirm that there is a construction leading agency forT HOOD (WITH DUCT)
the performance of the work for which this permit is issued(Ste.
n7,Civ,
Lender's Name HEATING UNIT(TO 100,000 B.T.U.) 8.00 MICROFILM
Le
Lender's Address HEATI NG UN IT(OV ER 100,000 B.T.09.50 ELECTRIC 73.13
I certify that I have read(his application and start that the above VENTILATION FAN (SINGLE) 4.00
infornmrion is correct. I agree to comply with all ci,y and County PLUMBING
cNina.ces and state laws relating to building construction, and BOILER-OO MP(3H.P.or100,000B.T.U.) 6.00 73.13
,13
hereby eulhormc representatives of this city to anter upon the -COMP (Over 100.000 BTU(SEE FEE SCH.
above-mentioned property for inspection purposes. g01 LER MECHANICAL
(We) agree to save, Indemnify and keep harmless the City of MISC-- REFER TO ORD.
73.13
[ay
peftim,again,( liabilities,judgments, costs and expenses which CONST.TAX
in any way accrue against said City in consequence of the PERMIT ISSUANCE 10.00 302.02
an ' his permit ECIT CONT. LIG NO. MECH.
TOTALTOTAL
gnature Of Applicant/Contractor Date
OFFICE COPY
POST THIS CARD NEAR FRONT OF BUILDING
PERMIT NUMBER
CITY OF CUPERTINO 17717
INSPECTION DIVISION
JOB INSPECTION RECORD
• `/ �2 PERMIT EXPIRATION
JOB ADDRESS ����-�' SI��.S�7 ��� �T UNIT# _LOT#t 3 `�
PERMIT EXPIRES IF WORK
OWNER CONTRACTOR IS NOT STARTED WITHIN
INSPECTION DATE I INSPECTOR INSPECTION RECORD 180 DAYS OF PERMIT ISSU-
FOUNDATION (e ANCE OR 180 DAYS FROM-
NOTE: LASTCALLED INSPECTION.
UFER ALL GRADING AND DRAINAGE SHALL BE INSTALLED
PREGUNITE TO COMPLY WITH THE APPROVED PLANS AND CITY OF 1, PERMIT VAL IDA LON
CUPERTINO STANDARDS. 1L rL7�,, I,
GARAGE SLABS 1 IY r/Av UC G�
POUR NO CONCRETE UNTIL ABOVE HAS BEEN SIGNED II A"N:v .�
UNDERGROUND'
/SLAB € '
PLUMBINGI t 1 (�,
ELECTRICAL
ISSUANCE DATE
MECHANICAL at oupfro BLDG ELECT PLC, MECR
DO NOT POUR FLOOR UNTIL ABOVE HAS BEEN SIGNED BUILDING PERMIT
WOOD FLOOR INFORMATION
VALUATION SIFT.
PLUMBING
MECHANICAL 194 550
ELECTRICAL PER111T TO
FRAMING • 9w
INSULATION STORIES TYPE CONSTR.
2 'a
OCC GROUP RES.UNITS
PLACE NO SUBFLOOR UNTIL ABOVE HAS BEEN SIGNED R-3 1
$O FT FLOOR AREA TOTAL ACNEAGf
ROOF NOTE:NO FINAL INSP.SHALL BE MADE,BEFORE 37 • `' I I
DIAPHRAGM THE CONSTRUCTION TAX IS PAID
2S BUILDING USE
ROOF SHEATHING RES J INu CON PB OF,...
APPLY NO ROOFING UNTIL ABOVE HAS BEEN SIGNED FINALS DATE 'INSP. El El El El
ROUGH
ASSESSORS PARCEL.NO
PLUMBING �(o �q
- E6-CG
' (g ELECT,
T.ENERGY 1.
TUBS 8 SHOWER PANPLUMBING ENERGY TRACT NO PARCEL NO
MECHANICAL o MECH.ENERGY
.ELECTRICAL BUILDING ENERGY ACC DATE ACC.FILE NO
FRAMING ELECT.FINAL TEST
INSULATION 2-.�J PLUMBING ZONING ENG SITE NO.
GAS TEST GAS
MECHANICAL EIRE SPRINK ENERGY T.24
COVER NO WORK UNTIL ABOVE HAS BEEN SIGNED HEATING Y ❑ N❑ ° ❑ N❑
EXTERIOR SHEAR ELECTRICAL RELEASE FLOOD ZONE A.L UC
INTERIOR SHEAR FIRE DEPT. Y❑ N❑ Y ❑ NO
SHEETROCK L GRADE
FEE SUMMARY
EXTERIOR LATH BUILDING
INTERIOR LATH - TEMPORARY APPROVALS BUILDING W2.1D
SCRATCH COAT ELECTRIC FEA�,CH EC-K 621.00GAS
NO TAPE OR PLASTER UNTIL ABOVE HAS BEEN SIGNED OCCUPANCY SEISMIC FEE 13.65
OCCUPANCYOF BUILDING ISNOTPERMITTED UNTILBUILDING FINAL ISSIGNED BY BUILDING INSPECTOR. MICROFILM
ARRANGE FOR INSPECTION BY PHONING 252-4505, ELECTRIC 7313
o� ONE WORKING DAY BEFORE REQUIRED INSPECTION. PLUMBING 7313
Z PLEASE GIVE JOB ADDRESS WHEN PHONING.
- SEE PERMIT FOR EXPIRATION DATE - MECHANICAL 73.13
IMPORTANT! CONST.TAX 3(}2,pL
PLEASE READ REVERSE SIDE BEFORE
CALLING FOR FINAL INSPECTION. TOTAL
OFFICE COPY