15574 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
BUILDING PROJECT IDENTIFICATION PERMIT NUMBER
BUILDING APPLICATION & PERMIT 15574
ADDRESSBUILDING —ELECTRICAL—PLUMBING—MECHANICAL
OWNER' PLAN CHECK VALIDATION
NAM �� •� QTY. ELECTRIC PERMIT FEE
PHON
C N RACTOR'
N En UTLETS-SWITCHES-RECEP 10.00/1.00
LIC.Ng5�g 2 LIGHTING FIXTURES 10.00/1.00
CONTRACTOR'S A/DRESSPPLIANCES-RESIDENTIAL 4.00
A DRESS �-j�t� 44
,S 5c,, J(. PHON%�1 " b 1PANELS 10.00 DATE OF APPLICATION
OR
ARCHITECT PANELS (OVER 200 AMP) 20,00 PLAN CHECK FEE P,C.NO:
ENGINEER
LIC NO. SIGNS TRANS. 3.00
ADDRESS ENG. SPECIAL CIRCUIT 5.00 PERMIT VALIDATION
ZIP TEMP. METER OR POLE INS. 20.00
APPLICANT'S
ADDRESS MOTORS SEE FEE SCH.
SERVICE CHANGE 20.00 r
woo LICENSED CONTRACTORS DECLARATION / �v/
�u lu I hereby affirm that I am licensed under provisions of Chapter 9 ISSUANCE DATE
F Z a (commencing with Section,7000)of Division 3 of the Business and
w, < BLDG. I ELECT. I PLG. MECH.
r °z Professions Co n Icense is in full to d e ❑ ❑
Z o N - License Class Lic.Numbe
Z - ° Date Contractor.
a Y BUILDING PERMIT
¢� o a OWNER-BUILDER DECLARATION INFORMATION
x I hereby affirm that 1 am exempt from the Contractor's License MISC.— REFER TO ORD
LL N VALUATION $/FT.
W
LL o Q Law for the following reason.(Sec.7031.5,Business and Professions PERMIT ISSUANCE 10.00
~ N N Code:Any city or county which requires a permit to construct,alter,
er ¢ improve,demolish,or repair any structure,prior to its issuance,also ELEC.CONTR. LIC.NO. ELEC.
a a o u requires the applicant for such permit to file a signed statement that TOTAL PERMIT TO
X ODhe is licensed pursuant to the provisions of the Contractor's License
z i Law(Chapter 9(commencing with Section 7000)of Division 3 of the [� -
Business and Professions Code)or that he is exempt therefrom and QTY. PLUMBING PERMITTE
F o the basis for the alleged exemption.Any violation of Section 7031.5 �` STORIES TYPE CONSTR.
a 3 m by any applicant for a permit subjects the applicant to a civil penalty ALTER-DRAIN&VENT-WATER (EA.) 5. 0
of not more than five hundred dollars($500).):
O I,as owner of the property,or my employees with wages as BACK FLOW PROTECT. DEVICE 4.001 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. e'
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 SQ.FT.FLOOR AREA TOTAL ACREAGE
himself or through his own employees,provided that such improve-
ments GAS EA.SYSTEM 1 INCA OUTLETS 6.00
are not intended or offered for sale.If,however,the building
or improvement is sold within one year of completion,the owner- GAS EASYSTEM OVER 4 (EA) 200 BUILDING USE
builder will have the burden of proving that he did not build or im- . . .
RES IND CON PB Ocher
prove for purpose of sale.). INDUSTRIAL WASTE INTER. 30.00 1:1 ❑ 1:1❑ I,as owner of the property,am exclusively contracting with
11 1:1
licensed contractors to construct the project(Sec. 7044,Business LAWN SPRINKLERS-I INC 5 V.B. 6.00 ASSESSORS PARCEL NO.
and Professions Code:The Contractor's License Law does not apply h.,
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 contractor(s)licensed pursuant to
the Contractor's License Law. SEWER-SAN ITARY-STORM EA.200ft/10.00 TRACT NO. PARCEL NO.
❑ 1 am exempt under Sec. B.&P.C.for this
reason WATER HEATER W/VENT
6G?
Owner Date WATER SYSTEM 5.00 ACC.DATE CC.FILE NO.
WORKERS'COMPENSATION DECLARATION WATER 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 a certified ENG.SITE NO.
copy ttyer��-0, b.C�� It
Policy l��grlt Com any
❑ C tied copy is her by furnished. FIRE SPRINK ENERGY T-24
Z O Ifi opy is ed with the city inspection division. MISC.- REFER TO ORD. ❑ ❑ ❑ ❑
Iicant V N Y N
N CERTI brATE OF EXEMPTION FROM WORKERS' PERMIT ISSUANCE 00 ,clC' FLOOD ZONE A.L.U.C.
LUQ COMPENSATION INSURANCE PLG.CONTR. LIC.NO. TOTAL Y[:] N❑ v[:] N❑
CL Z (This section need not be completed if the permit is for one
hundred dollars($100)or less.)
U O 1 certify that in the performance of the work for which this per- OTY. MECHANICAL PERMIT FEE FEE SUMMARY
L!_ F 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
CL Date Applicant ALTER OR ADD TO MECH. 5.00
} (» 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 10,000 C.F.M.) 4.00
CONSTRUCTION LENDING AGENCY AIR HANDLING UNIT(OVER 10=C.F.M.) 6.00 SEISMIC FEE
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(Sec. MICROFILM
3097,Civ.C.). HEATING UNIT(TO 100,000 B.T.U.) 8.00
Lender's Name H EATI NG U N IT(OVER 100,000 B.T.U.)9.50
Lender's Address ELECTRIC
1 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 BOILER CUMP(3 H.P.or 100,000 B.T.U.) 6.00 PLUMBING /
ordinances and state laws relating to building construction, and
hereby authorize 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 o save, indemnify and keep harmless the City of MISC.- REFER TO ORD.
upertino agai st liabilities,judgments, costs and expenses which PERMIT ISSUANCE 10.00 CONST.TAX
ay in any w accrue against said City in consequence of the
a ing of this ermit MECH.CONT. LIC.NO. MECH.
L TOTAL TOTAL
n ure of App icant/Contrac or V Date
OFFICE COPY
POST THIS CARD NEAR FRONT OF BUILDING PERMIT NUMBER
CITY OF CUPERTINO 15574
INSPECTION DIVISION
JOB INSPECTION RECORD
PERMIT EXPIRATION
JOB ADDRESS /1) IVOr-L- UNIT# _LOT#
PERMIT EXPIRES IF WORK
OWNER uS-F!•j CONTRACTOR �-C �3� IS NOT STARTED WITHIN
INSPECTION DATE INSPECTOR INSPECTION RECORD 180 DAYS OF PERMIT ISSU-
ANCE OR 180 DAYS FROM
FOUNDATION NOTE: LAST CALLED INSPECTION.
LIFER ALL GRADING AND DRAINAGE SHALL BE INSTALLED
TO COMPLY WITH THE APPROVED PLANS AND CITY OF PERMIT VALIDATION
PR EGUN 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
o ❑ ❑ 1 ❑
DO NOT POUR FLOOR UNTIL ABOVE HAS BEEN SIGNED BUILDING PERMIT
INFORMATION
WOOD FLOOR 0
tJ VALUATIONS/FT
PLUMBING
MECHANICAL city of cup rtino _T
PERMIT TO
ELECTRICAL
FRAMING
INSULATION S DRIES TYPE CONSTR
OCC GROUP RES UNITS
PLACE NO SUBFLOOR UNTIL ABOVE HAS BEEN SIGNED
SO FT FLOOR AREA TOTAL ACREAGE
ROOF NOTE:NO FINAL INSP.SHALL BE MADE BEFORE
DIAPHRAGM THE CONSTRUCTION TAX IS PAID
BUILDING USE
ROOF SHEATHING RES IND CON PB Othl,
El El El El El
APPLY NO ROOFING UNTIL ABOVE HAS BEEN SIGNED FINALS DATE INSP.
ASSESSORS PARCEL NO
ROUGH SAN.#
PLUMBING ELECT.ENERGY
TRACT NO PARCEL NO
TUBS&SHOWER PAN PLUMBING ENERGY
MECHANICAL MECH.ENERGY
ACC DATE CC FILE NO
ELECTRICAL BUILDING ENERGY
FRAMING ELECT.FINAL TEST
ZONING ENG SITE NO
INSULATION PLUMBING `
GAS TEST GAS
FIRE SPRINK ENERGY T 24
MECHANICAL Y ❑ NL Y L No
COVER NO WORK UNTIL ABOVE HAS BEEN SIGNED HEATING
FLOOD ZONE ALuc
EXTERIOR SHEAR ELECTRICAL RELEASE
INTERIOR SHEAR FIRE DEPT. Y❑ No YL NL
SHEETROCK GRADE FEE SUMMARY
EXTERIOR LATH BUILDING
BUILDING
INTERIOR LATH TEMPORARY APPROVALS
SCRATCH COAT ELECTRIC PLAN CHECK
GAS FEE
NO TAPE OR PLASTER UNTIL ABOVE HAS BEEN SIGNED OCCUPANCY SEISMIC FEE
OCCUPANCY OF BUILDING IS NOT PERMITTED UNTIL BUILDING FINAL ISSIGNED BY BUILDING INSPECTOR. MICROFILM
uJ ARRANGE FOR INSPECTION BY PHONING 252-4505, ELECTRIC
ONE WORKING DAY BEFORE REQUIRED INSPECTION. PLUMBING O17
O PLEASE GIVE JOB ADDRESS WHEN PHONING.
z
— SEE PERMIT FOR EXPIRATION DATE — MECHANICAL
IMPORTANT! CONST.TAX
PLEASE READ REVERSE SIDE BEFORE TOTAL
CALLING FOR FINAL INSPECTION.
OFFICE COPY