15070 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
BUILDING PROJECT IDENTIFICATION PERMIT NUMBER
BUILDING APPLICATION & PERMIT • 15070
T ADDRESS •. 9�
Iv
3L/3 J1/D�(. BUILDING-ELECTRICAL-PLUMBING-MECHANICAL
OWNER'S PLAN CHECK VALIDATION
J` NAME /^/ QTY, ELECTRIC PERMIT FEE
E� _J. V 1_Sd1C�PHONE �7
CONTRACTOR'S
NAME 'LO OUTLETS-SWITCHES-RECEP 10.00/1.00 ()
LIC NO. , LIGHTING FIXTURES 10.00/1.00 1A
CONTRACTOR'S APPLIANCES-RESIDENTIAL -4
ADDRESS 7
PHONE PANELS 10.00 oZ DATE OF APPLICATION
ARCHITECTPANELS (OVER 200 AMP) 20,00 PLAN CHECK FEE P.C.NO.
r OR
ENGINEER 5t
w. hbt LIC.No. SIGNS TRANS. 3.00
AR. ENG. V-0 0 0_o SPECIAL CIRCUIT 5.0Q PERMIT VALIDATION
ADDDDRESSSS
3147 'a&Vn,v ZIP/71oy.t EMP.METER OR POLE INS. 20.00
APPLICANT'S Zi MOTORS SEE FEE SCH. 174--
ADDRESS
g SERVICE CHANGE 20.00
0 0 2 LICENSED CONTRACTORS DECLARATION
UJ
a 5�y_ I hereby affirm that I am licensed under provisions of Chapter 9 ISSUANCE DATE
y C a (commencing with Section 7000)of Division 3 of the Business and BLDG. ELECT. I PLG. MECH.
r z Professions Code,and my license is in full force and effect.
Z O Ln — License Class Lic.Number
o Date Contractor
a Y i" BUILDING PERMIT
¢ ¢w OWNER-BUILDER DECLARATION INFORMATION
X 3 LL I hereby affirm that I am exempt from the Contractor's License MISC.— REFER TO ORD
w LL o a Law for the following reason.(Sec.703 1.5,Business and Professions PERMIT ISSUANCE 0 �� VALUATION $/FT.
44)-00
L N u _J Code:Any city or county which requires a permit to construct,alter, t„
2 f D0 O
Q p
U, improve,demolish,or repair any structure,prior to its issuance,also ELEC.CONTR. LIC.NO. ELEC. [( v
I¢ requires the applicant for such permit to file a signed statement that TOTAL �V PERMIT TO
a W m N he is licensed pursuant to the provisions of the Contractor's License
F Z a Law(Chapter 9(commencing with Section 7000)of Division 3 of the �a�/Tl.dV VL c0el-
i o Business and Professions Code)or that he is exempt therefrom and QTY. PLUMBING PERMIT FEE
¢ o the basis for the alleged exemption.Any violation of Section 7031.5 STORIES TYPE CONSTR.
a 3 by any applicant for a permit subjects the applicant to civil penalty ALTER-DRAIN&VENT-WATER (EA.)+6.90
of not more than five hundred dollars($500).):
❑ 1,as owner of the property,or my employees with wages as 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 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 improve-
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 BUILDING USE
builder will have the burden of proving that he did not build or im- RES IND CON PB Other
pr for purpose of sale.). INDUSTRIAL WASTE INTER. 30.00
1,as owner of the property,am exclusively contracting with ❑ ❑ ❑ ❑ ❑
licensed contractors to construct the project(Sec.7044,Business LAWN SPRINKLERS-1 INC 5 V.B. 6.00 ASSESSORS PARCEL NO.
and Professions Code:The Contractor's License Law does not apply
to an owner of property who builds or improves thereon,and who LAWN SPRINKLERS-OVER 5(EA.) 1.00
contracts for such projects with a contractors)licensed pursuant to
the Contractor's License Law. SEWER-SANITARY-STORM EA.200ft/10.00 TRACT NO. PARCEL NO.
❑ 1 am exempt under Sec. B.&P.C.for this WATER HEATER W/VENT 6.00
reason
Owner Date v WATER SYSTEM 5.00
ACC.DATE ACC.FILE N0.
ORKERS'COMPENSATION DECLARATION WATER TREATING EQUIP, 5.00
1 hereby affirm that 1 have a certificate of consent to self-insure, ZONING ENG.SITE NO.
or a certificate of Workers'Compensation Insurance,or a certified
copy thereof(Sec.3800,Lab.C.).
Policy No. Company
O ❑ Certified copy is hereby furnished. FIRE SPRINK ENERGY T-24
Z Z ❑ Certified copy Is filed with the city inspection division. MISC.- REFER TO ORD.
p Applicant Y ❑ N❑ Y ❑ N❑
~ cn
CERTIFICATE OF EXEMPTION FROM WORKERS' PERMIT ISSUANCE 4"0 FLOOD ZONE A.L.U.C.
�
W > COMPENSATION INSURANCE PLG.CONTR. LIC.NO. PLG.
CL z
(This section need not be completed if the permit is for one TOTAL Y❑ N❑ Y [:] N❑
D O hundred dollars($100)or less.)
1 certify that in the performance of the work for which this per- QTY. MECHANICAL PERMIT FEE FEE SUMMARY
U_ H 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. do
a Date Applicant ALTER OR ADD TO MECH. 5-M — BUILDING 3i o
} rn 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 forthwith comply with FEE
V such provisions or this permit shall be deemed revoked. AIR HANDLING UNIT(TO 10,D00C.F.M.) 4.00
CONSTRUCTION LENDING AGENCY AIR HANDLING UNIT(OVER 10=C.F.M.) 6.00 SEISMIC FEE 3Y
I hereby affirm that there is a construction lending agency for EXHAUST HOOD(WITH DUCT)
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
Lender's Address HEATING UNIT(OV ER 100,000 B.T.U.)9.50 ELECTRIC J4—r-0-1
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 of this city to enter upon the BOILER-COMP (over 100,000 BTU)SEE FEE SCH. MECHANICAL `7 `l "
above-mentioned property for inspection purposes.
(We) agree to save, indemnify and keep harmless the City of MISC.- REFER TO ORD.
upertino against liabilities,judgments, costs and expenses whichPERMIT ISSUANCE _ CONST.TAX
ay in an accrue against said City in consequence of the o
\/ ra it. MECH.CONT. LIC.NO. TOTAL o
7� TOTAL
Si ature of Applicant/Contractor/Date
OFFICE COPY
POST THIS CARD NEAR FRONT OF BUILDING PERMIT NUMBER
CITY OF CUPERTINO 15070
INSPECTION DIVISION
JOB INSPECTION RECORD
PERMIT EXPIRATION
JOB ADDRESS 10343 Noel Avenue UNIT# _LOT#
PERMIT EXPIRES IF WORK
OWNER Ted Olson CONTRACTOR IS NOT STARTED WITHIN
INSPECTION DATE INSPECTOR INSPECTION RECORD 180 DAYS OF PERMIT ISSU-
ANCE OR 180 DAYS FROM
FOUNDATION NOTE:
LAST CALLED INSPECTION.
UFER -J� ALL GRADING AND DRAINAGE SHALL BE INSTALLED
TO COMPLY WITH THE APPROVED PLANS AND CITY OF PERMIT VALIDATION
PR EGU N I TE CUPERTINO STANDARDS.
GARAGE SLABS
POUR NO CONCRETE UNTIL ABOVE HAS BEEN SIGNED-
UNDERGROUND /SLAB
PLUMBING
ELECTRICAL ISSUANCE DATE
MECHANICAL BLDG ELECT PLG MECH
1:1 ❑ ❑
DO NOT POUR FLOOR UNTIL ABOVE HAS Bq_7-
BUILDING PERMIT
INFORMATION
WOOD FLOOR VALUATION SBFT.
PLUMBING O
MECHANICAL y—/- PERMIT To
ELECTRICAL
FRAMING
INSULATION STORIES TYPE CONSTR
OCC GROUP RES UNITS
PLACE NO SUBFLOOR UNTIL ABOVE HAS BEEN SIGNED
ROOF NOTE:NO FINAL INSP.SHALL BE MADE BEFORE SO FT FLOOR AREA TOTAL ACREAGE
DIAPHRAGM THE CONSTRUCTION TAX IS PAID
BUILDING USE
ROOF SHEATHING RES IND CON PB Oihe,
APPLY NO ROOFING UNTIL ABOVE HAS BEEN SIGNED FINALS DATE INSP. El El Q 1:1 0
ASSESSORS PARCEL NO
ROUGH SAN.#
PLUMBING ELECT.ENERGY
TRACT NO PARCEL NO
TUBS&SHOWER PAN PLUMBING ENERGY
MECHANICAL MECH.ENERGY
ELECTRICAL BUILDING ENERGY ACC DATE ACC FILE NO
FRAMING _ ELECT.FINAL TEST — 0 ZONING ENG SITE NO
INSULATION WAA
PLUMBING p
GAS TEST GAS
FIRE SPRINK ENERGY T 24
MECHANICAL r D Y ❑ NE] Y ❑ NE]
COVER NO WORK UNTIL ABOVE HAS BEEN SIGNED HEATING
FLOOD ZONE A L U C
EXTERIOR SHEAR _ �}- Fy �' ELECTRICAL RELEASE p
INTERIOR SHEAR FIRE DEPT. Y❑ N[ Y ❑ N�
SHEETROCK GRADE FEE SUMMARY
EXTERIOR LATH BUILDING BUILDING
INTERIOR LATH TEMPORARY APPROVALS
SCRATCH COAT IELECTRIC PLAN CHECK
GAS FEE
NO TAPE OR PLASTER UNTIL ABOVE HAS BEEN SIGNED JOCCUPANCY SEISMIC FEE
OCCUPANCYOF BUILDING ISNOTPERMITTED UNTILBUILDING FINALISSIGNED BY BUILDING INSPECTOR. MICROFILM
ARRANGE FOR INSPECTION BY PHONING 252-4505, ELECTRIC
o� ONE WORKING DAY BEFORE REQUIRED INSPECTION. PLUMBING
z PLEASE GIVE JOB ADDRESS WHEN PHONING.
— SEE PERMIT FOR EXPIRATION DATE — MECHANICAL _.
IMPORTANT! CONST.TAX
PLEASE READ REVERSE SIDE BEFORE TOTAL --'
CALLING FOR FINAL INSPECTION.
OFFICE COPY