9427 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
BUILDING PROJECT I DENT[FICATION PERMIT NUMBER
BDILmNG APPLICATION & PERMIT Q� J7
ADDRESS 4
1,1J BUILDING-ELECTRICAL-PLUMBING-MECHANICAL
OWNERS
NAME LAN CHECK VALIDATION
/ yy DTV. ELECTRIC PERMIT FEE
NAMERAcroRs OUTLETS-SWITCHES-RECEP 10.00/1.00
LIC.NO ILIGHTING FIXTURES 10.00/1.00
DRs
ADDRESS PPLIANCES-RESIDENTIAL 4.00
ADDRESS
PHONE PANELS 10.00 DATE OF APPLICATION
ORRCHLECT PANELS (OVER 200 AMPl' 20.00 PLAN CHECK FEE P.C.NO.
ENGINEER
__Lm.NO. SIGNS TRANS. 3.00
ARCH.
ENG. SPECIAL CIRCUIT 5.00 PERMIT VALIDATION
ZIP TEMP.METER OR POLE INS. 20.00
APPLICANTS MOTORS SEE FEE SCH.
ADDRESS
SERVICE CHANGE 20.00
0
,0 O 0 O LICENSED CON'I'RAC'1'ORS UECL\RA'I'ION TEMP,POLE 30.00 O }
a u 0 1 hereby affirm that I am licensed under provisions of Chapter 9 ISSUANCE DATE
ya (commencing with Section 7000)of Division 3 of(he Business and
rt BLELECT. PLG. MECH.
H m z Professions Code,and my license is in full force and effect. ❑ ❑ ❑
z O m - Date Class Lin. olao,
Number
9 y - Dale Contractor
H _
a Se EBUILDING PERMIT
¢ OWNER-BUILDER DECLARATION
E a 4 a INFORMATION
w ; u H I hereby affirm that I am exmnpt from the Con(rador's License MISC.- REFER TO ORD
.. 0 j Law for the following reason.(Sec.7031.5.BueineSsand Professions VALUATION 5/FT.
r _ PERMIT ISSUANCE 10.00
Code Any city or county which o.•quires a permit to cons u a cq
or w Q improve,demolish,or repair any slruclum,prior to its issuance,ce,also ELEC.CONTR. LIC.NO. ELEC.
D IC requires the applicant for such permit to the a signed statement that TOTAL 30 A,
PERM' Is m m he is licensed pursuant to tire ns
e provisions of the Contractor's License IT TO
HZ >
Law(Chapter`Ifconvnencingwilh Section 7000).1 Division 3 of the
gi o Business and Professions Code)or that he is exempt therefrom and QTY. PLUMBING PERMIT FEE lD
H mthe basis for the alleged exemption.Any violation of Section 7031.5 STORIES TYPE CONSTR.
a ; _ by any applicant for a permit subjects the applicant to a civil penalty ALTER-DRAIN -WATER (EA.) 5.00
of not more than five hundred dollars(5500).):
1Y I,as owner of the property,or my employees with wages as BACK F LOW PROTECT.DEV ICE 4.00 DCC.GROUP RES.UNITS
their sole compensation,will do the work,and the structure is not
(mended or offered for sale (See. 7044, Business and Professions DRAINS-FLOOR,ROOF,AR EA,COND. 5.00
Code:The Contractor's License Law docs 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
Tents
fre of intended
ownnemred for sale.
provided thmsuch improve- GAS-EA.SYSTEM-11N C.4 OUT LETS 6.00 '
mens are not intended or offered for sale.IC however-the building
or improvement iswithin one year of completion.the owner- GAS-EA.SYSTEM-OVER 4(EA.) 2.00
builder will have thee burden of proving that he did not build or im- BUI DING USE
prove for purpose of sale.). INDUSTRIAL WASTE INTER. 30.00 R IND CON Pa Other
.131,as owner of the property,am exclusively contracting with ❑ 0 O 0
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
ro;in owner of property who builds or improves thereon,and who LAWN SPRINKLERS-OVER 5(EA.) 1.00
contracts for such projects with a contractogs)licensed pursuant to
the Contractor's License SEWER-SANITARY-STORM EA,200ft/10.00 TRACT NO. PARCEL NO.
❑, Iwo exempthIn r: c. ,ITAP.C.for Illi, WATER HEATER W/VENT 6.00
reason 11 ,
OwnerarDate WATER SYSTEM 5.00 ACC.DATE ACC.FILE NO.
Atific,ite
ORKE S'COil ;NSATION DFCLA RATION WATER TREATING EQUIP, 5.00
affirm that I have a Certificate of consent to self-insure, ZONING ENG.BITE NO.
of Workers'Compensation Insurance,or a certified
copy thereof(Sec 3800,Lay.C.).
Policy No. Company
O ❑ Certified copy Is hereby furnished. FIRES PRINK ENERGY T Y4
z Z ❑ anr(ificd copy is filed with the city inspection division. MISC.- REFER TO ORD. E] ❑ E]
~ oApplicant Y N Y N
PERMIT ISSUANCE 10.00
� - CIiRTI PICAI'Ii OP EXEMPTION FROM WORKERS' FLOODZONE A.LU.c.
LU > COMPENSATION INSURANCE PLG.CONTR. LIC.NO. PLG. yF N� v� N�
tl O 1'1'his section need not be completed if the permit is Ibr one TOTAL
D Z hundred dollars IS 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.
U a Date Applicant ALTAR OR ADD TO MECH. 5.00 ^'01+ BUILDING
} to NOTICE TO APPLICANT:If,after making(his Certificate of Ex-
Z emption,you should become subject to the Workers'Compensation APPLIANCE 5.00 PLAN CHECK
provisions of the Labor Coda you must forthwith comply with FEE
U such provisions or this permit shall be deemed revoked AIR HANDLING UNIT(TO 10)000C.F.M.) 4.00
CONSTRUCTION LENDING AGENCY AIR HANDLING UNIT(OVER I0AODC.F.M.) 6.00 SEISMIC FEE
I 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,CN.C.). HEATING UNIT(TO 100,000 B.T.U.) 8.00
Lender's Name HEATING UNIT 100,000 B.T.U.)9.50
Lender's Address ELECTRIC GV
I certify that 1 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 slate laws relating to building construction, and BOILER-COUP(3 H.P.or 100,000 B.T.U.) 6.00
hereby authorize representatives of this city to enter upon the
above-mentioned property for inspection purposesBOILER-COMP(Over 100,000 BTU)SEE FEE SCH. MECHANICAL
, U V
(We) agree (o save, indemnify and keep harmless the City of MISC.- REFER TO ORD.
i Cupertino against liabilities, 'hufgmenls, costs and expenses which CONST.TAX
may in any way accrue enlist said City in consequence of the PERMIT ISSUANCE 10.00 ,\r/.E
gmm" U his pemut. MECH.CONT. LIC.NO. MECH.
\ TOTAL TOTAL �.36V 3 f
Si [ Ap o c Y Dare
111 INSPECTOR COPY
I
POST THIS CARD NEAR FRONT OF BUILDING
CITY OF CUPERTINO RM1,IT NUMBER
INSPECTION DIVISION . ' � 77
,. .. 7
� / / UNIT LOT#
JOB INSPECTION RECORD
JCDR ESS —� s 106-7Q Gly PERMIT EXPIRATION
. `�
' G PERMIT EXPIRES IF WORK
°W CONTRACTOR T IS NOT 'STARTED WITHIN
4INS CTION DATE INSPECTOR INSPECTION RECORD 180 DAYS OF PERMIT ISSU-
FOpTION ` E� y.,1 �V `� ANCE OR 180 DAYS FROM
UFE \'G VJ-OV�B'M�7P bT¢ LAST CA LLED INSPECTION.
PREITE !Vi
vERMrr vauoA noN
POUR CONCRETE UNTIL ABOVE HAS BEEN SIGNED
I UNDERGROUND /SLAB
PLUMG
ELECT,AL /� /
MECHICAL 19s ANL GATE
•BLOG. ELECT. PLG. MECH,
DO NOOUR FLOOR UNTIL ABOVE HAS BEEN.SIGNED ❑ ❑ ❑
BUILDING PERMIT
WOOD FLOOR INFORMATION
PLUMBI;
VALUATION $/FT.
MECHANAL
ELECTRIAL t .. PERMIT TO
FRAMIN(
INSULgTpN �` V TORIES TYPE CONSTR.
4 OCC.GROUP RES.UNITS
'PLACE NO SUBFLOOR UNTIL ABOVE HAS BEEN SIGNED
ROOF
$O.GT.FLOOR En TOTAL gCREgGE
�.�_''APH RA GM
!! BUILDING USE
APPLY NO ROOFING UNTILVABOVE HAS BEEN SIGNED Es IND CON Pe
❑ ❑ ❑ ❑ ❑
ROUGH
PLUMBING —$ FES ORS PARCEL NO.
1 '
GAS TEST '3 .. TRACT NO. PARCEL NO.
MECHANICAL
ELECTRICAL x
FRAMING Ie � (NSP.
FINALS DACG.OATF ACC FILENO,
�i.b - ATE
INSULATION t SAN #
`t PLUMBING ZONING ENG.SITE NO.
GAS
MECHANICAL L /�6 FIRE SPRINK ENERGY T 24
COVER NO WORK UNTIL ABOVEIHAS BEEN SIGNED HEATING - Y ❑
LATH-INTEIIOR ELECT
N❑ , ❑ N❑
9
RICAL _ FLOOOZONE A.L.U.c.
LATH-EXTEjIOR v FIRE DEPT. -
SHEETROCK _ [:3 N C] Y ❑ NO
SHEAR INTBIOR GRADE
SHEAR EXTIIFEE SUMMARY
1OR BUILDING $•6
FIREWALLS
TEMPORARY APPROVALS BUILDING
ELECTRIC PLAN CHECK
NO TAPE OI
(ASTER UNTIL ABOVE HAS BEEN FEE
SIGNED OCCUPANCY
UCCUPANCI BUILDING IS NOTPERMITTED UNTIL BUILDING FINAL IS SIGNED BY BUILDING INSPECTOR, SEISMIC FEE
MICROFILM
Lu (RRANGE FOR INSPECTION BY PHONING 252-4505, ELECTRIC
- 1AVE WORKING DAY BEFORE REQUIRED INSPECTION..
MASE GIVE JOB ADDRESS WHEN PHONING. PLumelNc
l <
I — SEE PERMIT FOR EXPIRATION DATE — MECHANICAL
IMPORTANT! CONST.TAX
PLEASE READ REVERSE SIDE BEFORE
CALLING FOR FINAL INSPECTION. TOTAL
- . OFFICE COPY . ; /