16550 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY ,
PERMIT NUMBER
BU I LDING PROJECT I DENT]FICATI ON APPLICATION & PERMIT 16550
BUILDING
ADDRE
'V� BUILDING- ELECTRICAL-PLUMBING-MECHANICAL •��
OWNEXS PLAN CHECK VALI TION
NAME 2�� CITY. ELECTRIC PERMIT FEE Ck
3 PHorvE (�� 300 v a
CONTRACTORS f -�N� UTLETS-SWITCHES-RECEP 10.00!7.00
NAME J
• sec.No. LIGHTING FIXTURES 10.00/1.00
1.00RACTORs PPLIANCES-
RESIDENTIAL 4.00
ADDRESS
PHONE PANELS 10.00 DATE OF APPLICATION .
PANELS 200 AMP) 20.00 PLAN CHECK FEE 'P.C.NO.
ARCHITECT OR
EucmEER I 0 2 SIGNS TRANS. 3.00
sec.No
ARCH.OR ENy_ 5.00 PERMIT VALIDATION
` ADURESs IgE SPECIAL CIRCUIT
ZIP TEMP.METER OR POLE INS. 20.00 2-t
AwucAUT'S MOTORS SEE FEE SCH. /
ADDRESS
SERVICE CHANGE 20.00 CSI('n P 1/, (T/Q��I
IDIFI o o LICENSED CONTRACTORS DECLARATION ` v e- kr l- / K
u U I hereby affirm that I am licensed under provisions of Chapter 9 ISSUANCE DATE
sa m
o (commencing with Section 7000)of Division 3 of the Busin Ys and BLDG. ELECT. PLG. MECH.
H o a ProfessionsCodc,and my license is in full force and effect. ❑ ❑ El
a O - License Class Lic.Number w
o z H w Dam Contractor FEB 1
2 v, w BUILDINGPERMIT
E ¢ w4 OWNER-BUILDER DECLARATION INFORMATION
K
LL H I hereby affirm that I am exempt from the Cmllmetor's License MISC.- VALUATION SIFT.
w O Uw for the following reason.(Sec.7031.5.Business and Pro(cssions PERMIT ISSUANCE 10.00
Code:Any City or county which requires a Permit to consume ter.
SC a,
G O Improve,demolish,or repair any structure,prior to its h u,mCL also ELEC.CONTR. LIC.NO. ELEG I I 1 LLL /
- O u require the appfinnt for such permit to file a signed statement that TOTAL PERMIT TO
wis licensed pursuant to the provisions of the Contractor's License Ar
Fii Law(Chapter 9(commencingwith Section 7000)of Division 3 of the
a Business and Professions Code)or that he is exempt therefrom and GTY, PLUMBING PERMIT FEE U I
¢ = $ the basis for the alleged exemption,Any violation of Section 7031.5 - STORIES TYPE CONSTR.
i byany applicant for a permit subjects the applicant toa civil penalty ALTER-DRAIN&VENT-WATER'(EA.1 5.00
of not more than five hundred dollars(S500).):
❑ h as owner of the property,or my employees with wages as BACK FLOW PROTECT. DEVICE 4.00 DCC.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 docs such work FIXTURES-PER TRAP 5.00 sa FT.FLOOR AREA TOTAL ACREAGE
-Y1 himself m of rote his own employees.provided that such int building
moments art not intended or offered for vie.IL however the building GA$-EA.SVSTEM-11NC.40UTLETS 6.00 7
or improvement is sold within one year of completion,the owner- MEQUIP.
SYSTEM-OVER 4 (EA.) 2.00 BUILDING USE
builder w' ve the burden of proving that he did not build or im- RES IND CON PB Omer
Prov r purpose of sale.). IAL WASTE INTER. 30.00
I,ac owner of the property'.am exclusively'contracting with ❑ ❑ D ❑ E3
licensed contractors to construct the project(Sec. 7044.Business INKLERS- 1 INC 5 V.B. 6.00 ASSESSORS PARCEL N0.
and Professions Codc:The Contractor's License Law does not apply'
to an owner of property who builds or improves thereon,and who INKLERS-OVER 5(EA.I 1.00
Contracts for such projects with a contractons)licensed pursuant to
the Contractor's License Low. NITARY-STORM EA.200ft/10.00 TRADTNO. PARCEL No.
❑ lam a;erupt under S<e�.B.&P.C.for this EATER WJVENT 6.00
reason /Y// 1
Owner
O - YSTEM 5.00 ACC.DATE ACC.FILE NO.
WORKERS'COMPENSATION DECLARATION REATING EQUIP. 5.00
I hereby affirm that I have a certificate of consentto self-insure. ZONING ENG.SITE NO.
or a cenifiate of W'orkeri Compensation Insurance,or a certified
copy thereof(Sec.3800.Ub.C.).
Polley N Company
P e"IBed copy' hereby furnished. FIRE SPRINK ENERGYT 24
Cenifcd�C.� ��s ,�p_p�-�Ty 'm ction division.
z p Applicant_(' IN-• MISC.- REFER TO ORD. Y N Y N�
fl' N' CERTIFICATE OF EXEMPTION FROM WORKERS' PERMIT ISSUANCE 10.00 FLOODZONE A.LU.C.
ED > COMPENSATION INSURANCE PLG.CONTR. LIC.NO. PLG. Y� N� v � N�
CL O (This section recd not be completed if the permit is for one TOTAL
Z) Z hundred dollars IS 100)or IF.,)
U O 1 certify that in the perfurmavce of the work for which this per- CITY MECHANICAL PERMIT FEE FEE SUMMARY
LL F mil is issued.1 shall not employ a y ,son in any m neer so as to
U Mcop�e suy)e theWmk"s C California.
a DatJ=-6 ppliCant ALTER OR ADD TO MECH. 5.00 BUILDING
} w NOTICE TO APPLICANT: If,after making this Certificate of Ex-
Z emption,you should become subject to the Worker,Compensation APPLIANCE 5.00 PLAN CHECK
provisions of the Labor Code. you must forthwith comply with FEE
CJ ssmh provisions car this permit shall be deemed revoked. AIR HANDLING UNIT(TO 10):1000.F.M) 4.00
CONSTRUCTION LENDING AGENCY AIR HANDLING UNIT(OVER 10ODDC.F.M.) 6.00 SEISMIC FEE O 6
I hereby affirm that there is a construction lending agency for EXHAUST HOOD (WITH DUCT) 5.00
Elie performance of the work for which this permit is issued(Sec MICROFILM
3097,Civ.C.I. K HEATING UNIT(TO 100,000 B.T.U.) 8,00
Lender's Name HEATI NG UN IT(OVER 100,000 B.T.U.)9.50 ELECTRIC
Lender,Add re_._ 04tr-E-
1 certify'that I have read this application and stat,mm the above VENTILATION FAN (SINGLE) 4.00
information is correct. I agree to romply with all city and county PLUMBING
ordinances and state laws relating to building construction, and BOILER-COMP(3 H.P.or 100,000 B.T.U.1 6.00
hereby amhante vPresenta0,, of this ,,, to eine, .,on the BOILER-COMP (Oaer 100,000 BTU)SEE FEE SCH. MECHANICAL �
abovrremacr d property for inspection ompow-s.
(Wye) agree to Save, indemnify and keep harmless the City of MISC.- REFER TO ORD.
Cupertino against liabilin ,judgments. costs and expenses which CONST.TAX
my I y y accrue agvn t syd City in consequence of the PERMIT ISSUANCE 10,00
`rant 9 L MECH.CONT. LIC.NO. - MECH. _
TV a 8 9 TOTAL TOTAL
Signature of Applicant/Contmetur Date
OFFICE COPY P
POST THIS CARD NEAR FRONT OF BUILDING
PERMIT NUMBER
CITY OF CUPERTINO 16550
INSPECTION DIVISION
JOB INSPECTION RECORD
• / / // PERMIT EXPIRATION
`
JOB ADDRESS /�7Z] " llAe S� �r,TV UNIT# LOT#
PERMIT EXPIRES IF WORK
OWNER CONTRACTOR
IS NOT STARTED WITHIN
F_INSPECTION RECORD _ 1BODAYS OFPERMIT ISSU-ANCE OR 180 DAYS FROM
:�` INSPECTION-'',":,3. s .. ATEK; IPECTOR r'r;:`;'�;.;'{ •
FOUNDATION NOTE: LASTCALLED INSPECTION.
UFER ALL GRADING AND DRAINAGE SHALL BE INSTALLED
PREGUNITE TO COMPLY WITH THE APPROVED PLANS AND CITY OF PERkiLT VALIDATION
CU ERTINO STANDARDS.
GARAGE SLABS pi, C
_ y
POUR NO CONCRETE UNTWABOVE HAS BEEN.SIGNEV' A
UNDERGROUND /SLAB FEB 1 'I': ( /��/
PLUMBING p�� vi /c'N_ GC.o
ELECTRICAL City Of Cuporto ISSUANCE DATE
BLDG, ELECT] PEG M1+ECR.
MECHANICAL
� 1:1 ❑ ❑
DO NOT POUR FLOOR UNTIL ABOVE HAS BEEN SIGNED
.'v BUILDING PERMIT,.,,,,�t
.k:J:>`IN FORMATION?}'`,-.;,%p;
WOOD FLOOR VALUATION $/FT.
PLUMBING
MECHANICAL Qd�
ELECTRICAL PERMIT TO
FRAMING - C - T'
STO IES TYPE CONSTR.
INSULATION
OCC.GROUP RES.UNITS
.PLACE NO SUBFLOOR UNTIILL ABOVE HAS BEEN'SIGNED`
$O.FT.FLOOR AREA TOTAL ACREAGE
_ ROOF NOTE:NO FINAL INSP.SHALL BE MADE BEFORE
DIAPHRAGMTHE CONSTRUCTION TAX IS PAID t 3 0
BUILDING USE
• ROOF SHEATHING biD.IIA , RES IND CON PR Ow..
.APPLY NO ROOFING UNTIL ABOVE HAS BEEN SIGNED.: ` `FINALS".'» "r DATE.': .INSP. L L ❑ CD L
`� •+ ASSESSORS PARCEL NO.
ROUGH SAN.#
PLUMBING ELECT.ENERGY
TRACT NO, PARCEL NO
TUBS 8 SHOWER PAN PLUMBING ENERGY
MECHANICAL MECH.ENERGY
ELECTRICAL ACC.DATE ACC FILE NO
BUILDING ENERGY
FRAMING - ELECT,FINAL TEST ZONING ENc.SiTE NO.
INSULATION PLUMBING
GAS TEST GAS
FIRE SPRINK ENERGY I@i
MECHANICAL YE] NL Y ❑ NL
COVER NO WORK UNTIL ABOVE HAS BEEN SIGNED HEATING
EXTERIOR SHEAR ELECTRICAL RELEASE cLoou zoNE AL.0 c.
INTERIOR SHEAR FIRE DEPT. Y ❑ NL Y L N❑
SHEETROCK GRADE FEE SUMMARVit."
EXTERIOR LATH BUILDING - -
INTERIOR LATH TEMPORARY APPROVALS
BUILDING U !l0
SCRATCH COAT ELECTRIC PLAN CHECK
FEE —'
GAS
NO TAPE OR PLASTER UNTIL ABOVE HAS BEEN SIGNED JOCCUPANCY SEISMIC FEE , -
OCCUPANCY OF BUILDING IS NOT PERMITTED UNTIL BUILDING FINAL ISSIGNED BY BUILDING INSPECTOR. MICROFILM
ARRANGE FOR INSPECTION BY PHONING 252-4505, ELECTRIC
F ONE WORKING DAY BEFORE REQUIRED INSPECTION. WMECHANICAL
-
O� PLEASE GIVE JOB ADDRESS WHEN PHONING.
Z - SEE PERMIT FOR EXPIRATION DATE -
IMPORTANT!PLEASE READ REVERSE SIDE BEFORE ��
CALLING FOR FINAL INSPECTION.
OFFICE COPY