09799 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
BUILDING PROJECT IDFNTIFICATig& gppLICATION & PER PERMIT NUMBER
NW I
a aooRE ✓• r
BUILDING - ELECTRICAL-PLUMBING-MECHANICAL 09799
•CANNER. - - PLAN CHECK VALIDATION
"A CITY. ELECTRIC PERMIT FEE
CONP_ NAAMTRAcroR's -- UTLETS-SWITCHES-RECEP 10.00/1.00
_ Lc.No. LIGHTING FIXTURES 10.00/1.00
CDRRACrons
ADDRESS
DNRAC - PPLIANCES-RESIDENTIAL 4.00
PHONE " PANELS 10.00 DATE OF APPLICATION
ARCHITECT - PANELS (OVER 200 AMP) 20.00 PLAN CHECK FEE P.C.N0.
OR
ENGINEER
' LIC.No. SIGNS TRANS: ' 3.00
Apo KESS ENG, a SPECIAL CIRCUIT 6.00 PERMIT VALIDATION
ZIP TEMP.METER OR POLE INS. 20.00
ADDRESS rs - - MOTORS SEE FEE SCH. �J -
_ SERVICE CHANGE 20.00
F o o LICENSED CONTRACTORS DECLARATION TEMP.POLE ` 30.00 / O/
a u E, 1 [,,ruby Airm that I am licensed under provisions of Charier 9 ( IS/UANCE DATE
wz a (commencing with Section 7000)of Division 3 of the Business and
¢ g - BLDG. ELECT. PLG. MECH.
F w i Professions Code,and my license is in full force and effect. ❑ ❑ ❑
Z o w - License Class Lic.Number -
o m r w Data Contractor
¢ ING PERMIT
in ¢o n ° OWNER-BUILDER DPCLARATION r INFORMATION
w g ca 1 hereby collo that 1 am exempt from the Contractor's License
MISC.- REFER TO ORD
HLLO¢ Law for the following reason.(Sec.7031.5,Business Professions PERMIT ISSUANCE 10.00 (�ru(yT1QppC S/FT.
Code'Any city orcounly which}equiresa pcnnit to conslrucf,ober,
Q �m r ELEC.CONTR. ' LIC.NO, (/
¢ 0 improve, or repair any structure,prior to its issuance.also ELECv pg
O M requires the applicant for such permit to file a signed statement that - TOTAL „ O VyV I�QO rJ G
he is licensed pursuant to the provisions ol'ti a Contractor's License - 1z v'`E/
Law Chapter 9(commencing with Section 7000)of Division 3 of the
io, Business and Professions Code)or that he is exempt therefrom and DTV. PLUMBING PERMIT FEE g7Z
SE the basis for the alleged exemption.Any violation of Section 7031.5 - ^STORIES TYPE CONSTR,
T; _ by any applicant Tor a permit subjects the applicant to a civil penalty ALTER-DRAIN&VENT-WATER (EA.) 5.00 `
of not more than five hundred dollars(b500)J:
❑ 1,as owner of ilia property,or my employees with wages as BACK F LOW 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 Contractur's,Licene,Law does not apply to an owner of .,
property who builds or improves thereon,and who docs such work FIXTURES-PER TRAP 5.00 SO.FT.FLOOR AREA TOTAL ACREAGE.
himself or through his own employees,provided that such improve= -
1� meats are not intended or offered for sale.If,however,the budding GAS-EA.SVSTEM-11NC.40UTLETS 6.00 -
`�
or improvement is sold within one year of completion,the owner- GAS-EA.SYSTEM-OVER 4 IEA.) 2.00
ori pr will have sthe's burden of proving that he did not build w er- BUILDING USE
P r for purpose of suleJ: INDUSTRIAL•WASTE INTER. 30.00 RES IND CON PR Other
1 as owner of the property,am exclusively contracting with ❑ ❑ ❑ '❑ ❑
'
.is n •I contractors to construct the project(Sec.7044,Business LAWN SPR IN KLERS- 1 INC 5 V.B. 6.00 ASSESSORS PARCEL NO.
and Professions Codc:The Contractor a License Law docs not apply. -
%�ffi,m
property who builds or improves thereon,and who LAWN SPR IN KLER S-OVER 5(EA.) 1.00
ch projects with a contractorts)licensed pursuam to - SEWER-SANITARY-STORM EA.200ft/10.00
it, '.s License Law. - TRACT NO. PARCEL NO.
apt unde,S c. BAP.C,for this WATER HEATER W/VENT 6.00
'Dam WATER SYSTEM 5.00 - ACC.GATE ACC.FILE NO,
KS ENSATION DECLARATION WATER TREATING EQUIP. 5.00
rm tat ave a certificate of consent to self-insure,
ora certificate of Workers'Compensation Insurance,or a certified ZONING ENG:SITE NO.
copy thereof(See.3800,Lab,CJ. '
'Policy No. Company
O ❑ Certified copy is hereby furnished. FIRE SPRINK ENERGY TQC
Z Z - ❑ Certified copy is fled with the city inspection division.
0 Applicln f' - MISC.- REFER TO ORD. V❑ N❑ V ❑ N❑
CC y CERTIFICATE OF FXIi MP'I ION FROM WORKERS' PERMIT ISSUANCE 10.00 FLOOD ZONE A.L.U.C.
LU ICOMPENSATION INSURANCE ' PLG.CONTR. 'LIC.NO. PLG.
CL Z (This Section need not be completed if the permit is for one TOTAL V'❑ •N❑ V❑ N❑
hundred dollars IS 100)or less.)
U O 1 certify that in ilia performance of the work for which this per DTV. MECHANICAL PERMIT FEE FEE SUMMARY
LL I- ,mit is issued, I shall not employ any person in any manner so as to
O W become subject to the Workers Compensation Laws of California., BUILDING
G- Dae - Applicant ALTER OR ADD TO MECH. 5.00 J-0
} N NOTICE TO APPLICANT: If,after making this Certificate of Ex-
Z - emption;you should become subject to the Workers'Compensation APPLIANCE 5.00 PLAN CHECK -'
provisions of the Labor Code, you must Ibrthwilh'comply with FEE
U such provisions or this permit shall he deemed revoked. AIR HANDLING UNIT(TO 10,000 C.F.M.1 4.00
CONSTRUCTION LENDING AGENCY AIR HANDLING UNIT(OVER 10MC.RM.) 6.00 SEISMIC FEE J-3
I hereby affirm that there is a construction lending agency for EXHAUST HOOD(WITH DUCT) 5.00
ilia 3097�CivrC'ncc of the work for which this permit is issued(Sec. HEATINGUNIT(TO 100,000 B.T.U.) 8.00 MICROFILM
Lender's Name
Lender's Address HEATING UNIT(OVER 100,000 B.T.U.)9.50 ELECTRIC
I certify that I have read this application and state did the above VENTILATION FAN (SINGLE) 4.00
infor naion is correct. I agree to comply with all city and county PLUMBING
!. ordinances and state laws relating to building construction, and BOILER-COMP(3 H.P.or 100,000 B.T.U.) 6.00
hereby authorize representatives of.this city to enter upon the BOILER-COMP(Over 100,000 BTU)SEE FEESCH. MECHANICAL
above-mentioned property for inspection purposes r.
(Wo'.9'ree to save, indemnify and keep harmless the City of MISC.- s , REFER TO ORD.
Cupertino against liabilities,judgments, costs and expenses which PERMIT ISSUANCE 10.00 CONST.TAX
ayin any way accrue against said'City in consequence of the
grand of ibis permit `g ECH.CONT. - LIG NO. MECH.
'DT"`, TOTAL 33
.ignotu a of i' n Contactor
s - OFFICE COPY
POSTTHISCgg�
D NEAR FRONT-OF BUILDING „ER ,.,1N ,BER
CIT09.719*
• ,
�Y�UF CUPERTINO 97
INSPEC,TION'DIVISION
5 c JOB,INSPECTION RECORD 4
PERMIT EXPIRATION
L IOI �! J' /i •s _ ~` - t
J . / UNIT • -LOT#
OB ADDRESS
- .. w PERMIT EXPIRES IF WORK
s 1 OWNER ` - CONTRACTOR - L_IS NOT'STA- N'WITHIN �.
'INSPECTION t DATE' INSP CTOR - INSP ION'RECORD :' - .'. 180 SAYS OFRERMIT'ISSU- _
FOUNDATION-,. ANCE OR•180 DAYS FROM
LAST,CALLED INSPECTION: ,
' UFER -- ,
PREGUNITE, - v f PERMIT VAuoATION
• POUR NO CONCRETE UNTIL ABOVE HAS BEEN SIGNED
UNDERGROUND /SLAB .
PLUMBING lo 41
ELECTRICAL - ISSUANCEDATE
MECHANICAL. , 1 •.BE G , ELECT.' TPL.a MECH ♦'y' .
DO NOT POUR FLOOR UNTIL ABOVE HAS BEEN SIGNED - +-'BUILDING PERMIT
INFORMATION .,v.
.WOOD FLOOR awanoN, s/PT.
PLUMBING
. MECHANICAL - - - •
ELECTRICAL '+ - P/E/H/M�I'IT,To
'FRAMING e' �,�
INSULATION' STORIES. TYPE CONSTR'
. + OCC GROUP, RES.UNITS
PLACE,NO SUBFLOOR UNTIL ABOVE HAS BEEN SIGNED
G , ROOF SG,IT,`[,00F3AREA TOTAL ACREAGE
DIAPHRAGM
•BUILDING USE
RES IND CON PB O'L"
10,"1 APPLY NO ROOFING UNTIL ABOVE HAS BEEN SIGNED 1:1as�ssoR�ARcONo. O
ROUGH ,
v`S PLUMBING
GAS TEST - - ,. TRACT NO. PARCEL NO.
' MECHANICAL '
ELECTRICAL ' - - FINALS DATE` INSP. ACC.DATE -ACC.FILE NO.
•
FRAMING� ' ,�•, SAN # - �zowNG ENG:SITE No.
INSULATION PLUMBING I
GAS
• F,IRE SPIT INK ENERGY T39
. . ICAL
MECH ❑ N,❑ v O No,
COVER NO WORK UNTIL ABOVE HAS BEEN SIGNED HEA IN '' '
-- - LATH—INTERIOR _ -- EL TRI AL FLOOD zoNE-, A.L.0 c.
LATH—EXTERIOR FIR DEPT. Y0 NO ' v
SHEETROCK - GRA E - '• : . .FEE SUMMARY '
SHEAR INTERIOR BUILD • — -
I''' �, SHEAR EXTERIOR - TEMPORARY APPROVALS BUILDING
FIREWALLS : '• ELECTRIC ". 'PLAN CHECK - -
2, .. �. .. -
GAFEE
11rS -
i NO TAPE OR PLASTER UNTIL ABOVE HAS,BEEN SIGNED OCCUPANCY SEISMIC FEE
' OCCUPANCYOF BUILDING IS NOTPERMITTED UNTIL BUILDING FINAL ISSIGNED By BUILDING INSPECTOR. MICROFILM
ARRANGE,FOR'INSP,.ECTION BY.PHONING 252-4505„ ELECTRIC .
�� ONE WORKING DAY,BEFORE REQUIRED INSPECTION-
;PLUMB IN c
o PLEASE GIVE JOB ADDRESS WHEN PHONING:
Z'} S MECHANICAL
PERMIT'FOR,EXPIRATION DATE =
I.. -IMPORTANT! coNsr.Tnz'
' PLEASE READ REVERSE SIDE BEFORE ' TOTAL
CALLING FOR FINAL INSPECTION:
OFFICE COPY • ;-'r -
+