11840 (4) APPLICANT TO FILL'IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
- BUI LDI NG PROJECT I DENTI FI ON PERMIT NUMBER
APPLICATION & IT
ewl.olNa ^ n A 0
' PO ES I }Ue4
&k-DING-ELECTR ICAL-PLUMBING-MECRAN ICAL
PLAN CHECK VALIDATION ,
QTY. ELECTRIC PERMIT FEE 1 •�
J G
rv0MFR cr RS OUTLETS-SWITCHES-RECEP 10.00/1:00 '7
LIC.LJ
'LIGHTING FIXTURES - 10.00/1.00
ADDRESS ons - PPLIANCES-RESIDENTIAL 4.00 - -
CONTRA -
PHONE PANELS 10.00 DATE OF APPLICATION
ARCHITECT PANELS (OVER 200 AMP) 20.00 PLANCHECK FEE P.C.NO.
OR
ENGINEER
uc.No. - SIGNS TRANS. 3.00
ARCH.OR ENG. PERMIT VALIDATION
ADDRESS SPECIAL CIRCUIT 5.00
zip EMP.METER OR POLE INS. 20.00
APPLICANTS
MOTORS SEE FEE SADDRESSCH.
SERVICE CHANGE 20.00
F O o LICENSLD CONTRACT ORS DECLARATION
¢ U U I hereby affirm that I am licensed under provisions of Chapter 9 ISSUANCE DATE
y< H (commencing with Section 7000)of Division 3.f the Business anJ _ BLDG. ELECT. PLG. MECH.
z Professions Codi,and my license is in full force and effect ❑ ❑ ❑
z o w- License Class Lic.Number
o m - o Date Contractor
¢ m s BUILDING PERMIT
¢ ¢w¢ OWNER-BUILDER DECLARATION _ _
¢ oar' MISC.- REFER TO ORD INFORMATION
w g I N I hereby affirm that I am exempt from the Contractor's License VALUATION $/FT.
F ¢
04 Law for the following reason.(Sec.7031.5,Businessand Professions PERMIT ISSUANCE 10.00
Code:Any city or county which requires a permit to construct,alter, ry/J QOD
e, Q Q Improve ,demolish,or repair any slNClnre,prior t0 its issuance aI50 ELEQ C.NO.CONTR. -LI $LEC. ✓C�
¢ requires the applicant for Such permit LO file a signed statement[hut • TOTAL PERMIT 0
¢ w lit is licensed'pursuant to the provisions of the Contractor's License
H z r Law(Chapter 9(commencingwitb Section 7000)of Division 3 ofthe
¢ Business and Professions Code)or that he is exempt therefrom and QTY. PLUMBING PERMIT FEE
Y ¢ D RI's TYPE C STB.
¢r$ the basis for the alleged exemption.Any violation of Section 703 LS '
ig _ by any applicant for a permit subjects the applicant too Civil penalty ALTER-DRAIN&VENT-WATER (EA.) 5.00
of not more than five hundred dollars($500).):
❑ I,as owner of the property,or my employees with wages us BACK FLOW PROTECT. DEVICE 4,00 OCC.GROUP RES.UNITS
their sole compensation,will do the work,and the structure is not
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 to an owner of
property who builds Or Improves lhercon,and who does such work FIXTURES,PER TRAP 5.00 SO.FT.FLOOR AREA TOTAL ACREAGE
himself or through his awn employees,provided that such improve- ' GAS-EA.SVSTEM-1 6.00
ments are not intended or offered for sale.If,however,the building
or improvement is sold within one year of completion,the owner- GAS-EA.SYSTEM-OVER 4 (EA.) 2.00
builder will have lite burden of,proving that he did not build or im- BUILDING USE
for purpose of sale.). INDUSTRIAL WASTE INTER. 30.00 RES IND CON PB. Other
`ll as uwnto of the property,ant exclusively contracting with ❑ ❑ ❑ ❑ ❑
ce s d contractors to construct the project(Sec:7044,Business LAWN SPRINKLERS- 1 INC 5 V.B. 6.00 ASSESSORS PARCEL NO.'
and rofessions Code:The Contractor's License Law docs not apply
to an owner of property who builds or improves thereon,and who LAWN SPRINKLERS-OVER 5 MAY 4.00
contracts for such projects with a contractors)licensed pursuant to SEWER-SANITARYV•STORM EA.200ft/10.00
the Contractor's License Law. TRACT NO. PARCEL NO.
" ❑ -1 am exempt under Sec. ,Ii.&P.C.far Ihis WATER HEATER W/VENT 6.00
awn
OwnerDade WATER SYSTEM, - - 5.00 ACC.DATE ACCoF ILE NO.
WORKERS'COM iN ATION DECLARATIONWATER TREATING EQUIP. 5.00
1 hereby affirm that I have a certificate of consent to self-insure, ZONING
or a certificate of Workers'Compensation Insurance,or a certified ENG.SITE NO.
copy thereof(See.3800,Lab.CJ,
• Policy No. Company -
O ❑ Certified copy ishereby furnished. FIRE SPANK ENERGY T24
Z Z ❑ Certified copy is filed with the city inspection division. MISC.- REFER TO ORD.
o Applicant Y [D N❑ Y❑ NL]
CC.N CERTIFICATE OF EXEMPTION PROM WORKERS' PERMIT ISSUANCE' 10.00 FLOOD ZONE A.L.U.C.
LU COMPENSATION INSURANCE PLG.CONTR. LIC.NO. PLG,
CL Z (This section need not be completed if the pen..it is for one TOTAL _ Y❑ N❑ Y❑ N❑
hundred dollars($100)or less.)
U O 1 certify that in the performance of the work for which this per. QTY.- MECHANICAL PERMIT FEE FEE SUMMARY
LL F mit is issued, I shall not employ any person in any manner so as to
U become subject to the Workers'Compensation Laws of California. n
LU Date Applicant ALTER OR ADD TO MECH. 5.00 BUILDING
} w NOTICE"f0 APPLICANT: If,after making this Certificate Of Ex-, _
F ? emption,you should become subject to the Workers'Compensation APPLIANCE -5.00 PLAN CHECK
provisions of the labor Code, you most forthwith comply with FEE
U such provisions or this permit shall be deemed revoked. AIR HANDLING UNIT(TO 10p00 C.F.M.) 4.00
CONSTRUCTION LENDING AGENCY AIR HANDLING UNIT(OVER I0)000C.F.M.) 6.00 SEISMIC FEE - ,�' /o
1 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 ISec. MICROFILM
3097,Civ.C.). ` HEATING UNIT(TO 100,000 B.T.U.) 8.00
Lenders Name HEATING UNIT(OVER 100,000 B.T.U.)9.50
Lender's Address 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 PLUMBING'
ordinances and state laws relating to building construction, and. BOILER-COMM H.P.or 100,000 B.T.U.) 6.00
hereby authorize representatives ec 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 ofMISC.- "REFER TO ORD.
Cupertino against liabilities,judgments, costs and expenses which CONST.?AX
may in any way accrue against said City.in consequence of the PERMIT ISSUANCE 10.00
gra•j5ng oft si^ MECH.CONT. LIC.NO. MECH.
TOTAL 79
x TOTAL 6- /0
/1I` Signalu a KApplc#(E.ntoaet., Mte ,
/ V OFFICE COPY
POSTTHI .. ''RD NEAR 'FRONT.OFBUILDING 1 ` '
PTOM IT NUMBER -
CI OF IV
CUPERTINO
` ..INSPECTION DISION• 118 •a
O '
JOB INSPECTION RECORD
` - • �' PERMIT EXP AATI,ON.
,
JOB ADDRESS UNIT LOT# PERMIT EXPIRES,IF WORK`
OWNER TOR'+ , - IS NOT STARTED WITHIN
INSPECTION DATE I INSP CTOR - - INSPECTION RECORD, 180 DAYS OF PERMIT ISSU-
FOUNDATION vi ANCE OR 180 DAYS FROM
LASTCALLED INSPECTION. '
UFER
PERMIT VALIDATION
PREGUNITE ` -„•,- 1 -
POUR NO CONCRETE UNTIL ABOVE HAS BEEN SIGNED ^ ti
' UNDERGROUND'/SLAB
PLUMBING r
ELECTRICAL WNFORMATIO
'
. MECHANICAL - MECR.
❑
DO NOT POUR FLOOR UNTIL ABOVE HAS BEEN SIGNED T
�� - -
WOOD FLOOR VALUATION $/FT.
PLUMBING - _ s . •i r : A �^
MECHANICAL "
• ELECTRICAL PE MIT T
FRAMING 'y
INSULATION - I, - STORIES - YP ,�STR.
"ufy ..
- OCC,GROUP Dcs,,UNITS
PLACE NO SUBFLOOR UNTIL ABOVE HAS BEEN SIGNED
ROOF - ` 50,FT,FLOOR AREA TOTAL ACREAGE
DIAPHRAGM
BUILDING USE
HE$ IND'. CON PB O'he,
APPLY NO ROOFING UNTIL ABOVE HAS BEEN SIGNED ❑ ❑ ❑ ❑ ❑
ASSCSSORS PARCEL NO,
ROUGH
. PLUMBING 6 . 7 -
TRACTNO. ' PARCEL NO.
GAS TEST
MECHANICAL , ACC.DATE ACC.FILE N0.
ELECTRICAL _ FINALS DATE INSP.
FRAMING' SAN # zoNING ENG.SITE No.
INSULATION 7 PLUMBING `- '
GAS
'PIPE$PRINK ENERGYT,24
MECHANICAL
COVER NO WORK UNTIL ABOVE HAS BEEN SIGNED HEATING" ❑ N❑ ❑ N❑
FLOOD ZONE A.L.U.C.
LATH-INTERIOR-, - ' - ELECTRICAL v❑ NO yo N❑
LATH-EXTERIOR" - FIRE DEPT.
SHEETROCK - GRADE - FEE SUMMARY
SHEAR'INTERIOR BUILDING
SHEAR EXTERIOR TEMPORARY APPROVALS BUILDING'
' FIREWALLS' - ,� . ELECTRIC -/ f PLAN CHECK ,
? GAS g -}. .FEE - 'S
NO TAPE OR PLASTER UNTIL ABOVE HAS BEEN SIGNED OCCUPANCY. SEISMIC FEE a _
OCCUPANCVOF BUILDING I'S NOT PERMITTED UNTIL BUILDING FINALISSIGNED BY BUILDING INSPECTOR. rM ICROFILM
uJ ARRANGE FOR INSPECTION BY PHONING'252-4505, ELECTRIC ,'
ONE WORKING DAY BEFORE REOUIRED'INSPECTION PLUMBING
0� PLEASE GIVE'JOB ADDRESS WHEN',PHONING
Z
- SEE PERMIT FOR EXPIRATION DATE --
s. MECHANICAL
IMPORTANT!.' .' coNsr.rnx <
PLEASE READ REVERSE,SIDE BEFORE
-CALLING FOR FINAL INSPECTION. TOTAL /L/ w
OFFICECOPV rTl ;