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18061W 0 z Z.P:•O' cc j L _ ao Uo LL U Oa SO U APPLICANT TO FILL IN INFORMAT101 WITHIN RED LINES — USE BALL POINT PEN ONLY BUILDING PROJECT IDENTIFICATION ��+ 7 RMITNUMBER , Simmons.APPLICATION& PERMIT '"� '-' ADD E S BUILDING — ELECTRICAL—,PLUMBING —,MECHANICAL OWNER'S PLAN CHECK VALIDATION QTY. ELECTRIC PERMIT FEE PHONE CONTRACTOR'S i NAM •. UTLETS- SWITCHES -RECEP 10.00/1.00 . - •�IFcV1/�'b h1•i _� uc. rvo. LIGHTING FIXTURES 10.00/1.00 CONTRACTORS .r - '" APPLIANCES -RESIDENTIAL 4.00 - ADDRESS /f LIQ "-{ ql1 j„l.. PHONE I / Q�1 PANELS 10.00 DATE OF APPLICATION ^ ARCM ECT PLAN CHECK FEE P.C. NO. OR PANELS (OVER 200 AMP) . 20.00 ENGINEER. r LIC. NO. SIGNS TRANS. 3.00 REOR ENG SPECIAL CIRCUIT 1:5,00 PERMIT VALIDATION " .'ZIP EMP. METER OR POLE INS. 1' 20.00 111, 0 �' `J I _ & . APPLICANTS ., MOTORS SEE FEE SCH. ADDRESS • " f SERVICE CHANGE PAI 20.00 LICENSED CONTRACTORS DECLARATION ` .I hereby. affinn,lhal, l am licensed under provisions of Chapter9I I,�•y Ej' ISSUANCE DATE (commencing with Section 7000) of Division 3 of the Business and LDG.: ELECT. PLG. - MECH. Professions Code, and my license Is in full force and effect . a - - LDaenseCless Contract., city- Date '� Contractor' - .. - - • OWNER -BUILDER DECLARATION BUILDING PERMIT MISC. — REFER TO ORD INFORMATION 1 hereby SUITOR that I am exempt from. the Contractor's License 'VALUATION. Law for the following reason, (Sec. 703 1.5, Business and Professions PERMIT ISSUANCE - 10,00 Code: Any city or county which requires a permit to construct,alter, Improve, demolish, Or Rpalr any structure, prior to its Issuance, also ELEC. CONTR. LIC.,NO.ELEC. I,i•]U requires the, applicant for such permit to file a signed, statement that1 TOTAL 2� PERMIT TO' he is licensed pursuant to the provisions of the Contractor's License - - Law (Chapter 9(Commencing with Section 7000) of Division 3 of the) e `p G Business and Professions Code) or that he is exempt therefrom and QTY. PLUMBING PERMIT FEE the basis for the alleged exemption. Any violation of Section 7031.5 - - 6TORIE$ TYPE CONSTR. by not that fora permit subjectsthe $5000.licant loscivilpenalty ALTER-DRAIN-WATER(EA.) 5.00 of not more than five hundred dollars (5500)U', . ❑ 1, as owner of the property, or my 'employees with wages as BACK FLOW PROTECT. DEVICE 4.00 OCC. GROUP RES. UNITS sole compensation, will do the work, and the structure is not intended or offered.for sale (Sea 7044, Business and Professions y DRAINS -FLOOR, ROOF, AREA, COND. 5.00 Code: The Contractor's License Law does not apply to in owner of propertywho builds or improves thereon, and who docs such work FIXTURES- PER TRAP 5.00 SO. FT. FLOOR AREA TOTAL ACREAGE himself`or, through his own employees,. provided that such improve- ments mprove- - mentsarenotintended or offered for sale. If, however, the building GAS, EA. SYSTEM -1 INC.4 OUTLETS 6.00 - or improvement is sold within'onc year of completion, the owner- GAS - EA. SYSTEM -OVER 4 (EA) _'200 builder will have the burden of proving that he did not build or im- . ,-2.00 BUILDING USE - prove for purpose ofsale .). t'1 , - RES IND, CON PB' Other ❑ 1, as owner of the property, am exclusively contracting with INDUSTRIAL WASTE INTER. 30.00 ❑ ; " ❑ El, . ❑ .❑ 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 to an owner of property who builds or improves thereon, and who LAWN SPRINKLERS - OVER 5 MAY 1.00 , contracts for such projects with a contractor(s) licensed pursuant to •. - the Contractor's License Law.. SEWER -SAN ITARV-STORM'EA. 200ft/10.00. TRACT NO. PARCEL NO. . . Ism -exempt under Sea ,BAP.E: for this WATER HEATER W/VENT' 6.00 " reason Owner - _Date 'WATER SYSTEM' 1. 5:00.. 'ACC: GATE ACC. FILE NO. ,WORKERS'COMPENSATION DECLARATION WATER TREATING'EQUIP. '5.00 1 hereby affirm'that I have a certificate ofemsent to self -insure, ; 20NING ENG. SITE N0. ora certificate of Workers' Compensation Insurance, or a certified copy thereof (Sec. 3800, Lab CJ. - PolicyNo. Company ❑ rlli¢d COpyi ereb tulnishe ' FIRE SPRINK ENERGY T-24 Certified is d th c tt�fection'division. /}�/'1♦��' MISC.- - - REFER TO ORD. pelican[` (_-[J • v ❑ N❑• v ❑ N❑ 00 E - I.C.CEFIRTIATE EXEMPTION FROM WORKERS' PERMITJSSUANC10,FLOOD ZONE A. L. , COMPENSATION INSURANCE PLG. CONTR. - -LIC. NO.' PLG. (This section need not be completed if the.permlt is for one - TOTAL ' Y ❑ N❑. Y ❑ N❑ hundred dollars ($100) or less I 1certify that in the performance of the work for which this per- OTY. MECHANICAL PERMIT FEE " FEE SUMMARY mit is issued; I shall not employ any person in any manner so as to become subject to the Workers' Compensation Laws of California. Date Applicant '. ALTER OR ADD TO MECH. 5.00 I",! '.BUILDING NOTICE TO APPLICANT: 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 j- FEE such provisions or this permit shall be deemed revoked. AIR, HANDLING UNIT (TO 10MDC.F.M.) 4.00 CONSTRUCTION LENDING AGENCY AIR HANDLING UNIT (OVER 10p00C.F.M.) 6.00 -• SEISMIC FEE I herebyaffirm 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.CJ. HEATING' UNIT (T0, 100,000 B.T.U.) 8.00 1 - Lender's NamAddress HEATING UNIT (OVER 100,OOD B.T.U.)9:50 Lender's Address ELECTRIC 1 certify that I have read this application and stats; that the above VENTILATION FAN (SINGLE) 4.00 - Information is correct. I agree to comply 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.)- 6.00 hereby authorize representatives of this 'city to enter upon the BOILER-COMP'Over 160,000 BTU) SEE FEE SCH. MECHANICAL abovelmentioned property for inspection purposes. - (We), agree to save, Indemnify. and keep harmless the°City of MISC. - `REFER TO ORD. opartino against liabilities, judgments, costs and expenses which , CON ST. TAX may In way acerue'ag cost said City in consequence of the . 'PERMIT ISSUANCE a;• a 10.00 -- ran' o Ihls Lfrm MECH: CONT. LIG NO. MECH. TOTAL .' TOTAL �.� Signa'. a of pp cant/Co tractor ate I OFFICE COPY PE OFFICE COPY POSTTHIS�C413QjGIEA FRONTOF'BUILDING,'. l'� CITY OF`CUPERTINO "• INSPECTION DIVISION JOB,INSPECTION RECORD )01 -VII y1"W JOB -ADDRESS' l I/ UI�Cf U/NI�T# _ //'�+�ALOT��#��j`� OWNER ''F--(/ ` ,CONTRACTOR , Vt.�'�� 'i ' —`•" -j :; PERMIT NUMBER 18��9 PERMIT EXPIRATION . PERMIT EXPIRES 'IF WORK IS NOT STARTED WITHIN 180 DAYS of PERMIT ISSU. ANCE•OR 180DAYS FROM - LASTCALLED INSPECTION. ' INSPECTION DATE INSPECTOR INSPECTION RECORD - FOUNDATION .. NOTE r ALL GRADING AND DRAINAGE SHALL BE INSTALLED TO COMPLY WITH THE APPROVED PLANS AND CITY OF CUPERTINO STANDARDS-. '� LIFER PREGUNITE - PERMIT VALIDATIONO - > - GARAGE.SLABS POUR NO CONCRETE UNTIL ABOVE HAS BEEN SIGNED ,�, juilil IT:r1 ("V'�•^"""I/`'1.: ISSUANCE DATE. • �' UNDERGROUND/ SLAB- PLUMBING. s ' ,� ,, OLrws-- ELECTRICAL MECHANICAL IL�or,, ELECT-, PLG, I MCCH, DO NOT POUR FLOOR UNTIL ABOVE HAS BEEN SIGNED - '.': r, BUILDING PERMIT INFORMATION ' - WOOD FLOOR VALUATION $IFT. , PLUMBING � � - - MECHANICAL ELECTRICAL; '. PER NIT TO FRAMING. INSULATION - S.TORIESJ TYPE CONSTHI OCC.GROUP ' RES.UNITS PLACE NO SUBFLOOR UNTIL ABOVE HAS BEEN SIGNED" ROOF- NOTE: NO FINAL INSP. SHALL BE MADE BEFORE -THE CONSTRUCTION TAX IS PAID" - -FINALS!" so Fr. aoow AREA TOTAL ACREAGE DIAPHRAGM : ROOF SHEATHING r BUILDING USE RES IND CON PB om,• ❑ ❑ ❑ i ❑' ❑ uAPPLY NO ROOFING UNTIL ABOVE HAS BEEN SIGNED 7 DATE '.INSP. • ROUGH - SAN,N - ASSESSORS PARCEL NO.. f 1 . .,I. K'° PLUMBING ELECT. ENERGY - NUBS&SHOWER PAN PLUMBING ENERGY .- iHACTNC: PARCELN . 3 MECHANICAL MECH. ENERGY ELECTRICAL' BUILDING ENERGY ACC DATE - ACC. FILE NO, - .FRAMING' ELECT. FINAL TEST INSULATION - � � PLUMBING .. ZONING ' - ENG.SITE NO. GAS TEST GAS MECHANICAL " .. 'FIRE SPRINK Y ❑ N❑' ENERGY T24 Y ❑ "❑ COVER NO WORK UNTIL ABOVE HAS BEEN SIGNED • HEATING EXTERIOR SHEAR ELECTRICAL RELEASE FLOOD ZONE ' Y ❑ "❑ .. A,LU.0 'Y ❑ N❑ 'INTERIOR SHEAR FIRE DEPT. SHEETROCK GRADE - FEE SUMMARY EXTERIOR .LATH - � - BUILDING BUILDING INTERIOR LATH TEMPORARY. APPROVALS SCRATCH COAT - ELECTRIC •PLAN CHECK .FEE _ - GAS - - NO TAPE OR^PLASTER UNTIL ABOVE HAS BEEN SIGNED OCCUPANCY ' - SEISMIC FEE OCCUPANCY OF BUILDING ISNOTPERMITTED. UNTILBUILDING FINAL ISSIGNED'BY•BUILDING,INSPECTOR. ` yt I MICROFILM "ARRANGE FOR INSPECTION BY PHONING 252-4505, 'h ,''ONE WORKING DAY BEFORE REQUIRED INSPECTION.,' z0 �%" '` PLEASE GIVE JOB ADDRESS WHEN PHONING. — SEE PERMIT FOR EXPIRATION. DATE — ELECTRIC. /)� PLUMBING MECHANICAL CONST. TAXA . IMPORTANT! PLEASE READ'REVERSESIDE,BtFORE " CALLING FOR.FINAL INSPECTION.- .• '' TOTAL - OFFICE COPY ---