15631 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
BUILDING PROJECT IDENTIFICATION PERMITNUMBER
-
IDILDING APPLICATION & PERMIT .
ao�gE-s� . �� BUILDING - ELECTRICAL-PLUMBING-MECHANICAL 15 6
Y
OWNER'S ��, //A�Ir(,0 PLAN CHECK VALI ATION
"AME 'lr� - T ELECTRIC PERMIT - FEE
6�hr PHONE aS3-� �3 ao�
coNT ACT Rs 2: UTLETS-SWITCHES-RECEP 10:OBF7.00 S�
NpM ((� //n` fI /�F 1J ��p
,�C1 911) FV/�c.No.%3�I 0 S LIGHTING FIXTURES 1 �129TD
CONTRACTOR'S APPLIANCES-RESIDENTIAL 4.00 -
'
ADD RE (/ �y/� / y
` J /�0 6 PHONE �/// PANELS _ 10.00 DATE OF APPLICATION'
ARCHITECT. - PLAN CHECK FEE P.C�NO.
- OR PANELS (OVER 200 AMP) 20.00 '
ENGINEER
LIC.No. SIGNS TRANS. 3.00
I ARCH.OR ENG. - PERMIT VALIDATION
ADORES, SPECIAL�CIRCUIT 5.00 - ^
I - ZIP TEMP.METER OR POLE INS. 20.00 11-.-
APPLICANTS MOTORS SEE FEE SCH.
AD REss /��7-W,.�/
61D /� - SERVICECHANGE 20.00 V � S�/Jp!
wO o . LICENSED CONTRACTORS DECLARATION / / 0._-0
U o 1 hereby affirm than I min licensed under provisions ol'Chapter'J• ISSUANCE DATE
w rt d (commencing with Section 7000)of Division 3 of the Business anJ - - G. ELECT. PLG. MECH.
F y z' Professions Code and my license is in full for d P
Z O•h - Eicenxe Class - Lic.Numher
'0 = F Date Contractor
¢ x ¢ a
OWNER-BUILDER uBCLARA'rlON& - - 4'R DING PERMIT
Ix w U - INFORMATION
o MISC.— REFER TO ORD
w 3 H I hereby all ret that I am ex mph from lheC Contractor's License ecce N S/FT.
F 0 j Law for the fol, w ng reason.(See 7031.5,B ism ,sand Professions PERMIT ISSUANCEw�`•-;1''L'�-
w Code.Any city or county which requires a permit to construct,alter,
2 m < improve,demolish or repair any structure,prior to Its issuance,also ELEC.CONTR. LIC.NO. ELEC. _ q//
D ii�0 requires the applicant for such permit to file a signed statement that ' . TOTAL Cies �,'— PERMIT TO
'K oN'u -' he,s licensed pursuant to the pr, ''ions of the Contractor's License ' _ / P'
r z i
Law(Chapter 9(commencing with S Section 7000) fD'visiol 3 oftle /��46 V
a Business and Professions Code)or that he is exempt therefrom and 0 WY. PLUMBING PERMIT FEE
K F o Ihe'busis for the aICF,d exemption.Any violation of Section 7031.$ -STORIES TYPE CONSTR.
u ;m by any applicant for a permit subjects the applicant to a civil penalty ALTER-DRAIN -WATER IEA.1-5:00
Of not more than five hundred dollars(5500)): -
❑ 1,as owner of fh,property,or my employees with wages us BACK FLOW PROTECT. DEVICE 4.00
their sol,coin peasmion,will do the work.and the structure is not OCC.GROUP RES.UNITS
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 all owner of
property who buildS m improves thereon,and who do,,such work FIXTURE$-.PER TRAP SDO a0.FT.FLOOR AREA TOTAL ACREAGE
himself or through his own employees,provided that such improve-
ments GASI are not intended tar offered for sale.If,however,the building - .
or improvement is sold within one year of completion,the owner- GAS-EA.SYSTEM-OVER 4 IEA.) 2.00 -
builder will have the burden of prow g t),a,he did not build or ice- BUILDING USE
prove for purpose ofsalef, INDUSTRIAL WASTE INTERRES IND .CON PB Diner
❑ I,ns owner of the property, li exclusively contracting with INDUSTRIAL 30.00 ❑ ❑ ❑ ❑ ❑
lice
ors
used comctoto construct the project(See 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 on owner of property who builds or improves thereon,and who LAWN SPRINKLERS-OVER 5(EA.) 1.00
contracts for such projects with u c.ntrucl.O,)licensed pursuant to
the Contractor's License Law. SEWER-SAN ITARY-STORM EA.200ft/,10.00 TRACT NO. PARCEL NO.
❑ I am exempt under Sec. ,B.&P.C.for this WATER HEATERW/VENT ' 6.00
reason
Owner Date WATER SYSTEM '5.00 ' ACC.DATE ACC.FILE NO.
wORKHRS'COMPENSA'IION DECLARATION WATER TREATING EQUIP. 5.00 '
I hereby atfirm that I have a certificate of consent to self-insure. .ZONING ENG.SITE NO,
or a uc,ificatc of Workers'Compensation Insumnce,or a cculficd
ropy thereof(Sec.3800,Lab.C.1. -
Policy No. Company
0 ❑ Certified copy is h,r,by furnished. FIRE SPRINK ENERGY T.24
z13Certified copy is filed with tio
he city inspection divisn. MISC- REFER TO ORD.
-'O Applicant .Y E) NE] Y [JNE]
m CERT'IFICAT'E OF EXEMPP
" ION FROM WORKERS' , 'PERMIT ISSUANCE FLOOD ZONE A.L.0 c.
LLQ COMPENSATION INSURANCE PLG.CONTH. LIC.NO. _ PLG.` •T', Y❑ 'N❑ "V❑• N❑
d (This section need nal he completed it the permit is' for one TOTAL k
::) Z hundred dollars IS 100)or less.)
0 0 1 certify that in the performance he worejpppnr wiy',h Ids per- GT MECHANICAL PERMIT FEE FEE SUMMARY
LL mit is issued,1 shall not,nlploy nr�u n'rlLdnY Qnner so us o -
becom• o mWorkeri air L, of California.
0 a Dat APplicamt Ay - ALTER OR ADD TO MECH. 5.00 BUILDING
>_ m NO PPI.ICAN'I': I ,after nwking Ili' C rlificate of pix-
Z emption,you should become subjcn o the wo Compensation APPLIANCE 5.00 PLAN CHECK
provisions of the Labor Code, you mast forthwith comply with - FEE
U ,such provisions or this permit shell be deemed revoked. AIR HANDLING UNIT(TO 10)000CF.M.) 4.00 -• G.
CONSTRUCTION LENDING,AGENCY AIR HANDLING UNIT(OVER I0WOCBM.).6.00 SEISMIC FEE -2
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,Civ.C.). HEATING UNIT(TO tOQ000 B.T.U.) '8.00
-- - �
Leader's Nd
Lender's Address
HEATI NG UNIT(OVER 100,000 B.T.U.)9.50 ELECTRIC 6 —
I certify that I have read this application and state that the above VENTILATION FAN (SINGLE)
information i,correct. I agree to comply with all city and county PLUMBING p�
ordinances and state laws relating to building construction. and BOILER-COMP(3 H.P.Or 100,000 B:T.U) 6.00
hereby aWhnrizc representatives of this city to enter upon the BOILER-COMP (Over 100,000BTU1SEE FEESCH. MECHANICAL
above-men NonW'praperly for inspection purpose..
'(We) agree to save, indemnify and keep [,armless the City of MISC.- REFER TO ORD.
Cupertino ag'jnst liabilities,j�gments, msts and expenus which l CONST.TAX
2 PERMITASSUANCE
'may i an v ay accuse og t coir Ely in COI equc tae If the /
mou go B' eFlnil. MECH.CONT. LIG NO. MECH.
Jk MECH. TOTAL
Sig u eof PPlical t/ ontra -'/Date
OFFICE COPY
POST THIS CARD NEAR FRONT OF BUILDING
PERMIT NUMBER
y CITY OF CUPERTINO.( 1563,1
i.. 'INSPECTION DIVISION -
JOB INSPECTION RECORD
PERMIT EXPIRATION
90BADDRESS /('�'O`0 `�-/�-1 i4/ �-T UNIT# _LOT# -
' --��- PERMIT EXPIRES IF WORK
'owNER L• CONTRACTOR 'V/pF-/r/' /�' (�p IS NOT STARTED WITHIN
� INSPECTION DATE INSPECTOR NSPECTION RECORD
180 DAYS OF PERMIT ISSU
ANCE OR 180 DAYS FROM
�FOUNDATION NOTE:
LASTCALLED INSPECTION..,
T �UFER - ALL GRADING AND DRAINAGE SHALL BE INSTALLED
PR EGUNITE• TO COMPLY.WITH THE APPROVED PLANS AND CITY OF PERMIT VALIDATION
OUPERTINO STANDARDS.
GARAGE SLABS
POUR NO CONCRETE UNTIL ABOVE HAS BEEN SIGNED _
UNDERGROUND /SLAB - -
PLUMBING -
ELECTRICAL ' ISSUANCE DATE
MECHANICAL
BLDG ELECT PLC,
c. MECH.
E El Fl: 23
DO NOT POUR FLOOR UNTIL ABOVE HAS BEEN SIGNED Q BUILDING PERMIT
INFORMATION
' WOOD FLOOR wanoN slFr.
PLUMBING
MECHANICAL J -a
PERMIT To
- ELECTRICAL J1
.. .FRAMING - �tY J/ /1&VI
INSULATION STORIES TYPE CONSTR.
N - OCC.GROUP RE.S.UNITS
PLACE NO SUBFLOOR UNTIL ABOVE HAS BEEN SIGNED -
SO,FT.FLOOR AREA TOTAL A[REACE'
ROOF NOTE:NO FINAL INSP.SHALL BE MADE BEFORE
DIAPHRAGM THE CONSTRUCTION TAX IS PAID
BUILDING USLP
ROOF SHEATHING • ,. tics IND CON PB 6111,
APPLY NO ROOFING UNTIL A OVE HAS BE IGNEO .� FINALS DATE INSP. 0 ❑ � � ❑.
ASSESSORS PARCEL NO,
RI SAN.p. _
PLUMBING — p.- ELECT.ENERGY - -
TUBS&SHOWER PA PLUMBING ENERGY TRACT No, , PARCELED
MECHANICAL. , MECH.ENERGY - '
ELECTRICAL- - ncc DATE . Acc.EILE,No.
L7 BUILDING ENERGY
FRAMING — - ELECT.FINAL TEST - 0-
FRAMING
ENG,SITENO.
INSU LATIONBR PLUMBING 7p. I
GAS TEST GAS .
' +Q MECHANICAL FIRE SPRINK ENERGY-T-74
COVER NO WORK UNTIL ABOVE HAS BEEN SIGNED HEATING Y ❑• N❑ Y � ' N❑
FL0002UNE - A.L V;C.
- EXTERIOR SHEAR [, ELECTRICAL RELEASE �� c➢- '
INTERIOR SHEAR - FIRE DEPT. Y❑ NEIY L N,El
SHEETROCK GRADE FEE SUMMARY
EXTERIOR LATH BUILDING J" - - 4
BUILDING
INTERIOR LATH TEMPORARY APPROVALS /-
SCRATCH COAT ELECTRIC PLAN CHECK
'FEE
GAS
,NO-TAPE OR PLASTER UNTIL ABOVE HAS BEEN SIGNED OCCUPANCY SEISMIC FEE 2, D
OCCUPANCY OF BUILDING IS NOT PERMITTED UNTI L BUI LDMG FINAL IS SIGNED BY BUILDING INSPECTOR. MICROFILM
ARRANGE FOR INSPECTION BY PHONING 252-4505, ELECTRIC 6
LU
UONE WORKING DAY BEFORE REQUIRED INSPECTION. PLUMBING •
Z PLEASE GIVE,JO,B ADDRESS WHEN PHONING.
- SEE PERMIT FOR EXPIRATION DATE - MECHANICAL S
IMPORTANT! CONST.TAX
.PLEASE READ REVERSE SIDE BEFORE - TOTAL
CALLING FOR FINAL INSPECTION. .
OFFICE COPY