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8972APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY - BUILDING PROJECT I DENTI F ION ' APPLICATION & IT BUILDING -ELECTRICAL- PLUMBING -MECHANICAL _ PRMIT NUMBER ^ 97G BUILDING ADDRESS17D�� t OWNER'S N AMC -c, rr�� 2SS'46gs �r�MGS S IG PHONE - OTY. ELECTRIC PERMIT FEE PLA CHECK VALIDATION NAME Across SAML LIC. No, UTLETS-SWITCHES -RECEP 10.00/1.00 W IGHTING FIXTURES 10.00/1.00 CONTRACTORS ADcrons DRESs PPLIANCES- RESIDENTIAL 4.00 vHONE ��rr PANELS 10.EI0 p`b DATE OF APPLICATION AARRCHITECr ENGINEER No. PANELS (OVER 200 AMP) 20.00 PLAN CHECK FEE P.C. NO. SIGNS TRANS. 3.00 _LIC. ARCH, ENG. - SPECIAL CIRCUIT - 5.00 PERMIT VALIDATION ' TEMP.METER OR POLE INS. 020'.00 ZIP APPLICA 10041 ,V IC, BLVD. ADDRE rvrs .1 q] MOTORS E FEE SCH. 3 ijlO] SERVICE CHANGEot cup Lt D - LICENSED CONTRACTORS DECLARATION TEMP. POLE 30.00- I hereby affirm that I am licensed under provisions of Chapter 9 (commencing with Section 7000) of Division 3 of the Business and Professions Code, and my license is in full force and effect Proem Class Lia Number IWAINI ANTAD(S 7 BLDG. ELECT. PLG. MECH. (L� Dale Contractor OWNER -BUILDER DECLARATION I hereby affirm that I am exempt from the Contractor's License Law forthe following reason. (See. 7031.5, Business and Professions Cade: Any city or county which requiresa permit to construct, alter. improve, demolish, or repair any structure, prior to its issuance, also requires the applicant for such permit to file a signed statement that he is licensed pursuant to the provisions of the Contractor's License Law (Chapter 9 (commencing with Section 7000) of Division 3 of the Business and Professions Code) u that he is exempt therefrom and BUILDING PERMIT INFORMATION MISC. - REFER TO ORD VALUATION / S/FT. PERMIT ISSUANCE 10.00 Lr ELEC. CONTR. LIC. NO. \ ELEC. r TOTAL 11dyZPERMIT TO ��H /5sorpw OTY. PLUMBING PERMIT FEE STORIES TY/rPE CONSTR. thebasis for the alleged exemption. Any violation of Section 7031.5 by any applicant for a permit subjects the applicanto a civil penalty of not more than five hundred dollms (S5001.): y - J �/ aPEC� ALTER-DRAIN&VENT_-_WATER(EA.) 5.00 ❑ 1, as owner of the property or my employees with wages as their sole compensation, will do the work, and the structure is not intended or offered for sale (Sec. 7044, Business and Professions Code: The Contmclor's License Law does not apply to an owner of property who builds or improves thereon, and who docs such work himself or through his own employees, provided that such improve- meats are not intended or offered for sale. If, however, the building BACK FLOW 'PROTECT?DEVIC 4.00 DOD. GROUP RES. UNITS DRAINS-F,LOOR,;ROOF, AFVATMD. 5.00 FIXTURES - PER TRAP ;,,t5: D SO. FT. FLOOR AREA TOTALACREAGE _ GAS - EA. SYSTEM - 1 I L 6.00 or improvement is sold within one year of completion, the owner- builder will have the burden of proving that he did not build orun. p ve for purpose of sale.). 1, as Owner of the property, am exclusively contracting with GAS - EA, SYSTEM - OVER 4 IE I BUILDING USE RES IND CON PB Ome. ❑ INDUSTRIAL WASTE IN 30.00 LAWN SPRINKLERS- 1 INC 5 V.B. 6.00 LAWN SPRINKLERS - OVER 5 (EA.) 1.00 MRSORSP❑ ARCELN❑ O. rt / V b -.3dML licensed contractors to construct the project (Sec. 7044, Business and Professions Code: The Contractor's License Law does not apply to an owner of property who builds or improves thereon. and who contracts for such projects with a contractors) licensed pursuant 0 the Contractor's License Law. TRACT NO. PARCEL NO. SEWER -SANITARY -STORM EA. 200ft/10.00 Q ❑ l am exempt under Sec. ,B.&P.C. for this re-�� ���{�q.�pJ� ACC. DATE ACC. FILE NO. WATER HEATER W/VENT 6.00 Ow yyk, `fes Datt WATER SYSTEM 5.00 " WATER TREATING EQUIP. 5.00 WORKERS'COMPENSATION DECLARATION I hereby affirm that I have a certificate ofconsent to self -insure. or a certificate of Workers' Compensation Insurance, or a certified ZONING ENG. SITE NO. copy thereof (Sec. 3800, LatEC.). Policy No. Company ❑ Certified Copy is hereby furnished. ❑ Certified copy is riled with the city inspection division. Applicant FIRE SPRINK Y ❑ N❑ ENERGY T-24 Y ❑ N❑ MISC. - REFE TO ORD. CERTIFICATE: OF EXEMPTION FROM WORKERS' PERMIT ISSUANCE 10.00 Q FLOOD ZONE A.L.U.C. PLG. CONTR. LIC. NO. .f \. PLG. r TOTAL COMPENSATION INSURANCE: (This section need not be completed if the permit is for one Y ❑ N ❑ Y ❑ N❑ hundred dollars (S 100) or less.) I certify that in the performance of the work for which this per-OTY mit is issued, I shall not employ any person in any manner so as to become subject to the Workers' Compensation Laws of Califomia. Date Applicant MECHANICAL PE 0' FEE - IY FEE SUMMARY BUILDING 0 ALTER OR ADD TO MECH. fa. 0 NOTICE: TO APPLICAN'O If, after making this Certificate of Ex- emption, you should become subject to the Workers' Compensation APPLIANCE 5.00 PLAN CHECK Provisions of the Labor Code, you must forthwith comply with such provisions or this permit shall be deemed revoked. CONST RUCTION LENDING AGENCY FEE AIR HANDLING UNIT ITO 1 ,00DC.F. AIR HANDLING UNIT (OVER 1 6.00 .. SEISMIC FEE EXHAUST HOOD (WITH DUCT) 5.00 AS- S I hereby affirm that there is a construction lending agency for the �h097, Civ C )ace of the work for which this permit is issued (Sec. MICROFILM HEATING UNIT (TO 100,000 B.T.U.) 8.00 HEATI NG UN IT ER 100,000 B.T.U.) 90 .5 ELECTRIC Lender's Name Lender's Address I certify that I have read this application and state that the above information is correct. I agree to comply with all city and County ordinances and state laws relating to building construction, and hereby authorize representatives of this city to enter upon the above-mentioned properly for inspection purposes. VENTILATION FAN (SINGLE) 4.00 PLUMBING �� BOILER -COMP 13 H.P. or 100,000 B.T.U.) 6.00 BOILER -COMP (Over 100,000 BTU) SEE FEE SCH. MECHANICAL MISC. - REFER TO ORD. CONST. TAX (we) agree to save, indemnify and keep harmless the City of Cupertino against liabilities, judgments, costs and expenses which may in any way accrue against said City in consequence of the - PERMIT -ISSUANCE 10.00 is MECH. CONT. LIC. NO. - MECH. TOTAL t - TOTAL o c,;, granting of this permit. ignalure of Applicant/Contractor Data OFFICE COPY .0 POST THIJIWARD NEAR FRONT OF BUILDING — PERMIT NUMBER CIW OF CUPERTINO% 8972 a INSPECTION DIVISION ..,.• JOB -INSPECTION RECORD �,1y- ' • - �. /_Babb� ��),� PERMIT EXPIRATION JOB ADDRESS Lab✓ 'SAI UNIT# LOT#t - - • •Y--... PERMIT EXPIRES IF WORK OWNER 1 F CONTRACTOR IS NOT STARTED WITHIN - 180 DAYS OF PERMIT ISSU- ANCE OR 180 DAYS FROM LAST CALLED INSPECTION. INSPECTIONDATE INSPECTOR INSPECTION INSPECTION RECORD FOUNDATION UFER PREGUNITE tiJT SE. fC 1 - PERMIT VAU DATION —" - ISSUANCE DATE 5 —� POUR NO CONCRETE UNTIL ABOVE HAS BEE SIGNED UNDERGROUND/SLAB PLUMBING ELECTRICAL MECHANICAL BLDG.ELECT: PLG, NECK DO NOT POUR FLOOR UNTIL ABOVE HAS BEEN SIGNEDILDING PERMIT r INFORMATION WOOD FLOOR VALUATION $/FT. PLUMBING - '947 p MECHANICAL ELECTRICAL /B ro, .•1PERmlr SFDtlll% ',. f FRAMING X(/`/ INSULATIONEC oNsrR. ., OCCIGROOF RES,UNIT$ - 'ACREAGE. PLACE NO SUBFLOOR UNTIL ABOVE HAS BEEN SIGNED ROOF SO, FT. FLOOR A AEA TOTAL "DIAPHRAGM BUILDING USE HES IND CONI PB P OIM1ei APPLY NO ROOFING UNTIL ABOVE HAS BEEN SIGNED ASSESSORS PARCEL NO. . ROUGH PLUMBING A0, GAS TEST - TRACT NO. PARCEL NO MECHANICAL 2 ELECTRICAL, FINALS. DATE INSP. ACC . DATE ACG FILE NO. , FRAMING SAN * 1 INSULATION PLU I G Z 20NING ,ENG. SITE NO. GA ME HANICAL. 2 av 8 FIRE SPRINK ENERGY TQC ;• v � No r [] N[] COVER NO WORK UNTIL ABOVE HAS BEEN SIGNED HE TING - LATH -INTERIOR EL CTRIC FLooD zoNE y0 N[] A. L. u.c. .y❑ No - LATH -EXTERIOR I FIR SHEETROCK. - (f GRADE - �(/ FEESUMMARY SHEAR INTERIOR .{ 6 BUILDING' BUILDING SHEAR EXTERIOR Q v TEMPORARY APPR VALS '' FIREWALLS ELECTRIC 'PLAN CHECK,.' FEE GAS NO TAPE 0R PLASTER UNTIL ABOVE HAS BEEN SIGNED OCCUPANCY SEISMIC FEE OCCUPANCYOF BUILDING IS NOT PERMITTED UNTIL BUILDING FINAL IS SIGNED BY BUILDING INSPECTOR. ' MICROFILM ARRANGE FOR INSPECTION BY PHONING 252-4505, ELECTRIC LEI ONE WORKING DAY BEFORE REQUIIRED INSPECTION. PLEASE GIVE JOB ADDRESS WHEN PHONING. , PLUMBING ' — SEE PERMIT'FOR EXPIRATION DATE — MECHANICAL CONST. TAX IMPORTANT! PLEASE READ REVERSE SIDE BEFORE NOTAL CALLING FOR FINAL INSPECTION. . I • . OFFICE COPY'