C9236 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
BU LD1 NG PROJECT I DENTI FICATI ON PERMIT NUMBER
BUILDING APPLICATION & PERMIT
T nooaEss 1
OC7CJ 1 1.•IZL)i �' BUILDING - ELECTRICAL-PLUMBING-MECHANICAL 9236
OWNER'S WWW LTi PLAN CHECK VALIDATION
NAME QTY. ELECTRIC PERMIT FEE
/
UAW
NAME RAPHONE
CTOR OUTLETS-SWITCHES-RECEP 10.00/1.00
LIC No. LIGHTING FIXTURES 10.00/1.00
cONTRACTORS APPLIANCES-RESIDENTIAL 4.00
Ao REss 2
V PHONE q /• PANELS . 10001 DATE OF APPLICATION
RCHIT CT PLAN
PANELS (OVER 200 AMP) 20,00
OCHECK FEE P.C.N0.
OR
NGINEER
On,NOi, SIGNS TRANS. 3.00
ARCH.OR ENG. SPECIAL CIRCUIT 5.00 PERMIT VALIDATION
ADDRESSP
EMP.METER OR POLE INS. 20.00 PAID
ADDRESS MOTORS SEE FEE SCH.
ASAUG
SERVICE CHANGE 20.00 fi Vl7
00 LICENSED CONTRACTORS DF-CLARAT'ION TEMP.POLE 30.00
.Q v I herebyaffirm hal I am licensed under provisions of Chapter City of Cuoerty�o
0 Iu " pr p ISSUANCE DA
PP
with Section 7000)of Division 3 of the Business and BLD ELE PL MF
r m" mmen
Z I'w fessions Coit• nil y license is in full fort and act.
^z 0 w, - icense Class�.r`_Lir.Number
0 o r ea Date - - Contractor ) t
Y E O\yN _shC �
¢ o e o ER-BUILDER DECLAR B1IN FORMATIO
K
3 u r I hereby affirm that 12m exempt from tire Contractor's Liceus MISC.- REFER TO ORD VALUATION $/FT.
� ¢ og Law for the following reason.(Sec.7031.5,Business and Nrol'cssians PERMIT ISSUANCE 10.00 -
�� Code:Any cilyorcounty which requires a permit to construct,alter, -
QQ Q p Improve,demolish,or repair any structure,prior t0 It51ssuance,also ELEC CONTR. LIC.NO, ELEC
¢
requires the applicant for such permit W file a signal statement that TOTAL PERMIT TO
a w m Ile is licensed pursuant to the provisions of the Cmitractor LictmV,
Uzi
Law(Chapter 9(commencing with Section 7000)of Division 3 ofthe
a Business and Professions Code)or that he is exempt therefrom and QTY. PLUMBING PERMIT FEE
¢ t$ the basis for the alleged exemption.Any violation of Section 7031.5 STORIES TYPE CONSTR.
ate _ by any applicant for a permit subjects the applicant to a civil penalty ALTER -WATER (EA.) 5AO '
of not mo -
re than live hundred dollars(5500).): _
❑ I,as owner Of the property,or my employees with wages as BACK FLOW PROTECT.DEVICE 4.00
their sole compensation,will do the work,and the structure is not OCC.GROUP RES.UNITS
intended or offered for sale (Sec. 701 Business and Professions DRAINS-FLOOR,ROOF,AREA,GOND. 5.00
Code:'fire Contractor's License Law dues not apply to an owner of G
properly who builds or Ilnprovcs thereon,and who docs Inch work F IXTUR ES-PER TRAP 5.00 SO.FT,FLOOR AREA TOTAL ACREAGE
L himself or through his own employees.provided that such improve- 1
menu are no untended or offered for sale.If,however,the building GAS-EA.SYSTEM-I INC.4 OUTLETS 6.00
or improvement is sold within one year of completion, the owner- GAS EASYSTEM-OVER 4 (EA.) 200
builder will have the burden of proving that h - . . .
e did not build or im- BUILDING USE
prove for purpose ofsaleJ. INDUSTRIAL WASTE INTER30.00 Rs IND CON PB timer
❑ I,as Owner of the property,am exclusively contracting wi .th ❑ ❑ ❑ ❑
licensed contractors to construct the project(See 7044,Business LAWN SPRINKLERS- 1 INC 5 V.B. 6.00 ASSESSORS PARCEL NO. j
and Professions Code:The Contractor's License Law does not apply
to un owner of property who builds or improves thereon.and who LAWN SPRINKLERS-OVER 5 (EA.) 1.00
contracts for such projects with a contracto(s)licensed pursuant to
the Contractor's License Law, SEWER-SANITARY-STORM EA.200ft/10.00 TRACT NO. PARCEL NO.
❑ I am exempt under Scc. ,B.&IsC.for this WATER HEATER W/VENT 6.00
reason
Owner Dare WATER SYSTEM 5.00 ACC.OATE IIACC.FILE NO.
WORK E RS'COMP1!NSATION DECLARATION WATER TREATING EQUIP. 5.00
I hereby uffinn that I hove a cendicme of amsrnI to self insure. ZONING ENG.SITE NO.
or a certificate of Workers'Compensation Insurance,or a certified
r copy there fSe� 3 0 Iy ). .i
PolicyNo n
Q Cl❑ Ccr op Tetchy furnished. FIRE SPRINK ENERGY T 24
Z Z •CI'^Ceitifed copy is filed with the city inspection division.
pj Applicant MISC.- REFER TO ORD. Y ❑ N❑ Y ❑ No
c m \�Cf RTIFICA'rE OP EXEMPTION PROM WORKERSPERMIT ISSUANCE 10.00 FLOOD ZONE A.L.U.C.
LU COMPENSATION INSURANCE PLG.CONTR. LIC.NO. PLGCL , v❑ N❑ v E] N❑
Z (This section need not be completed if the permit is or one TOTAL
hundred dollars(S100)orlesO
U O 1 certify that in the performance of the work for which this per, QTY. MECHANICAL PERMIT FEE FEE SUMMARY
LL 1- mit is issued,I shall not cnhploy any person in any rammer so as to
O beconm subject to the Workers'Compenml ion Laws of California.
W Date Applicant ALTER OR ADD TO MECH. 5.00 BUILDING PI
} W NOTICE TO APPLICANT': IL ager 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 nnhsl forthwith comply with FEE
U such provisions or this permit slhall be deemed revoked. AIR HANDLING UNIT(TO 10=1 F.M.) 4,00
CONSTRUCTION LENDING AGENCY AIR HANDLING UNIT(OVER 10A00C.EM.) 6.00 SEISMIC FEE a J'
I hereby uffinn that there is a construction lending agency for EXHAUST HOOD(WITH DUCT) 5.00
3097,Civ,G)nce of the work for which this permit is issued(Sc,. HEATING UNIT(TO 100,000 B.T.U.) 8.00 MICROFILM
Lender's Name HEATING UNIT(OVER 100,000 B.T.U.0.50
Lendeis Address ELECTRIC U
I certify that I have read this application and state that the above VENTILATION FAN (SINGLE) 4.00
into nu anion is correct. I agree to comply with all city and county' PLUMBING
ordinances and state laws relating to building construction, and BOILER-COMPI3 H.P.Or 100,000 B.T.U.1 6.00
,vcby authorize representatives of this city Waver upon the BOILER-COMP (Over 100,000BTUISEE FEE SCM. MECHANICAL / w
above-mentioned property for inspection purposes.
(I agree to save, indemnify and keep harmless the City of MISC.- REFER TO ORD.
Cupertino against liabilities,judgments, costs and expenses which PERMIT ISSUANCE 10.00 CONST.TAX
may m r� wagfac a•ainSt said ity in consequence o 'the
n g oq this' MECH.CONT. LIC.NO. MECH.� TOTAL / TOTAL
ig atureofAp / o re or Date
L' INSPECTOR COPY
POST THIS CARD NEAR FRONT OF BUILDING RAaT Nin+RER
CIT*F CUPERTINO 9
'INSPECTION DIVISION 9236
JOB INSPECTION RECORD
•�^ y PERMIT EXPIRATION
JOB ADDRESS 006 �•' SG -&a LAS UNIT# LOT# • PERMIT EXPIRES IF WORK
OWNER CONTRACTOR IS NOT STARTED WITHIN
INSPE ION DATE INSPECTOR INSPECTION RECOR 180DAYS OFPERMIT ISSu-
FOUNDATION c�-yr; •� u 5�� ANCE OR 160 DAYS FROM ,
UFER
LAST CALLED INSPECTION.
PREGUNITEQM -��L PERMIT vnuonnoN
�o �� PAI®
POUR NO CONCRETE UNTIL ABOVE HAS BEEN SIGNED .
UNDERGROUND /SLAB AUG mi ��fd•,
PLUMBING {s{{.�
ELECTRICAL CItySQBAC.VRRW00
MECHANICAL BLDG. ELECT. PLG. mEc .
DO NOT POUR FLOOR UNTIL ABOVE HAS BEEN SIGNED 'BUILDING ERMI
WOOD.F LOOR INFORMATION'
VALUATION $/FT.
PLUMBING 10 f—' -.
MECHANICAL
ELECTRICAL PERMIT TO
FRAMING
INSULATION STORIES - TYPE CONSTR.
OCC.GROUP RES.UNITS
PLACE NO SUBFLOOR UNTIL ABOVE HAS BEEN SIGNED
ROOF SQFT.FLOODAVEA TOTALACREAGE
DIAPHRAGM •.'
BUILDING USE
i RES IND CON PB Ume,
APPLY NO ROOFING UNTIL ABOVE HAS BEEN SIGNED - ❑ ❑ ❑ ❑
ROUGH ASSESSORS PARCEL NO.
NNORK
TRACT No. PARCEL No.
AL
L —( FINALS DATE INSP. ' ACC.DATE ACC,FILENO.
• SAN #
N PLUMBING ZONING ENG.SITE NO.
GAS
MECHANICAL FIRE SPRINK - ENERGY Th 24
NO WORK UNTIL ABOVE HAS BEEN SIGNED HEATINGY ❑ "❑ Y ❑ N❑ERIOR ELECTRICAL ^o27 PJ Q FLOOD ZONE A.c.0 c,
LATH—EXTERIOR Q_ FIRE DEPT. ,.Y❑ N❑ Y ❑ N❑
SHEETROCK - ' GRADE
SHEAR INTERIOR FEE SUMMARY
(P
BUILDINGOp V
SHEAR EXTERIOR TEMPORARY APPROVALS 'BUILDING
FIREWALLS 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 IS SIGNED BY BUILDING INSPECTOR.
JR
ARRANGE FOR INSPECTION BY PHONING 252-4505,
o� ONE WORKING DAY BEFORE REQUIRED INSPECTION.
z
PLEASE GIVE JOB ADDRESS WHEN PHONING.
- SEE PERMIT FOR EXPIRATION DATE —IMPORTANT!-..PLEASE READ REVERSE SIDE BEFORECALLING.FOR FINAL INSPECTION.
�^ r OFFICE COPY
POST THIS CARD NEAR FRONT OF BUILDING RAaT Nin+RER
CIT*F CUPERTINO 9
'INSPECTION DIVISION 9236
JOB INSPECTION RECORD
•�^ y PERMIT EXPIRATION
JOB ADDRESS 006 �•' SG -&a LAS UNIT# LOT# • PERMIT EXPIRES IF WORK
OWNER CONTRACTOR IS NOT STARTED WITHIN
INSPE ION DATE INSPECTOR INSPECTION RECOR 180DAYS OFPERMIT ISSu-
FOUNDATION c�-yr; •� u 5�� ANCE OR 160 DAYS FROM ,
UFER
LAST CALLED INSPECTION.
PREGUNITEQM -��L PERMIT vnuonnoN
�o �� PAI®
POUR NO CONCRETE UNTIL ABOVE HAS BEEN SIGNED .
UNDERGROUND /SLAB AUG mi ��fd•,
PLUMBING {s{{.�
ELECTRICAL CItySQBAC.VRRW00
MECHANICAL BLDG. ELECT. PLG. mEc .
DO NOT POUR FLOOR UNTIL ABOVE HAS BEEN SIGNED 'BUILDING ERMI
WOOD.F LOOR INFORMATION'
VALUATION $/FT.
PLUMBING 10 f—' -.
MECHANICAL
ELECTRICAL PERMIT TO
FRAMING
INSULATION STORIES - TYPE CONSTR.
OCC.GROUP RES.UNITS
PLACE NO SUBFLOOR UNTIL ABOVE HAS BEEN SIGNED
ROOF SQFT.FLOODAVEA TOTALACREAGE
DIAPHRAGM •.'
BUILDING USE
i RES IND CON PB Ume,
APPLY NO ROOFING UNTIL ABOVE HAS BEEN SIGNED - ❑ ❑ ❑ ❑
ROUGH ASSESSORS PARCEL NO.
NNORK
TRACT No. PARCEL No.
AL
L —( FINALS DATE INSP. ' ACC.DATE ACC,FILENO.
• SAN #
N PLUMBING ZONING ENG.SITE NO.
GAS
MECHANICAL FIRE SPRINK - ENERGY Th 24
NO WORK UNTIL ABOVE HAS BEEN SIGNED HEATINGY ❑ "❑ Y ❑ N❑ERIOR ELECTRICAL ^o27 PJ Q FLOOD ZONE A.c.0 c,
LATH—EXTERIOR Q_ FIRE DEPT. ,.Y❑ N❑ Y ❑ N❑
SHEETROCK - ' GRADE
SHEAR INTERIOR FEE SUMMARY
(P
BUILDINGOp V
SHEAR EXTERIOR TEMPORARY APPROVALS 'BUILDING
FIREWALLS 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 IS SIGNED BY BUILDING INSPECTOR.
JR
ARRANGE FOR INSPECTION BY PHONING 252-4505,
o� ONE WORKING DAY BEFORE REQUIRED INSPECTION.
z
PLEASE GIVE JOB ADDRESS WHEN PHONING.
- SEE PERMIT FOR EXPIRATION DATE —IMPORTANT!-..PLEASE READ REVERSE SIDE BEFORECALLING.FOR FINAL INSPECTION.
�^ r OFFICE COPY