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11876POST THIS CARD NEAR FRONT OF BUILDING CITY OF CUPERTINOINSPECTION DIVISIONJOB INSPECTION RECORD / JOB ADDRESS /lo `✓ / UNIT# LOT# OWNER CONTRACTOR T71 XPIRATION PERMIT EXPIRES IF WORK IS NOT STARTED WITHIN 180 DAYS OF PERMIT ISSU- ANCE OR 180 DAYS FROM LAST CALLED INSPECTION. INSPECTIO DATE INSPECTOR INSPECTION RECORD FOUNDATION UFER PREGUNITE - PERMIT VALIDATION oZ� - ISSUANCE DATE POUR NO CONCRETE UNTIL ABOVE HAS BEEN SIGNED UNDERGROUND/SLAB PLUMBING - ELECTRICAL MECHANICAL BLDG, El ELECT. 1:1 PLG. ❑ MEER. ❑ , DO NOT POUR FLOOR UNTIL ABOVE HAS BEEN SIGNED BUILDING PERMIT INFORMATION WOOD FLOOR PLUMBING VALUATION .-- SIFT. MECHANICAL ELECTRICAL PERMIT TO FRAMING INSULATION S STORIES - TY CONSTR. - OCC GROUP RES. UNITS PLACE NO SUBFLOOR UNTIL ABOVE HAS BEEN SIGNED ROOF OFT. FLOOR AREA TOTAL PLREAGE DIAPHRAGM BUILDING USE RES IND CON PB 011ie, ❑ ❑ ❑ ❑ ❑ APPLY NO ROOFING UNTIL ABOVE HAS BEEN SIGNED ROUGH ' ASSESSORS PARCEL NO. TRACT NO. PARCEL NO, PLUMBING GAS TEST MECHANICAL ELECTRICAL FINALS DATE INSP, ACC.DATE ACC. FILE NO. FRAMING SAN # INSULATION - PLUMBING ZONING FIRESPRINK Y ❑ N FLOOD ZONE Y ❑ Nol ENG. SITE NO. ENERGY T 24 Y ❑ N❑ A. L.uc. Y ❑ No GAS ' MECHANICAL COVER NO WORK UNTIL ABOVE HAS BEEN SIGNED HEATING LATH -INTERIOR ELECTRICAL LATH -EXTERIOR FIRE DEPT. SHEETROCK GRADE FEE SUMMARY SHEAR INTERIOR BUILDING BUILDING SHEAR EXTERIOR TEMPORARY A PR VALS FIREWALLS ELECTRIC PLAN CHECK FEE GAS NO TAPE OR PLASTER UNTIL ABOVE HAS BEEN SIGNED OCCUPANCY SEISMIC FEE OCCUPANCYOF BUILDING IS NOT PERMITTED UNTIL BUILDING FINALISSIGNED BY BUILDING INSPECTOR. MICROFILM LU ARRANGE FOR INSPECTION BY PHONING 252-4505, � ONE WORKING DAY BEFORE REQUIRED INSPECTION. Z PLEASE GIVE JOB ADDRESS WHEN PHONING. - SEE PERMIT FOR EXPIRATION DATE - ELECTRIC PLUMBING MECHANICAL CONST. TAX IMPORTANT! PLEASE READ REVERSE SIDE BEFORE CALLING FOR FINAL INSPECTION. TOTAL OFFICE COPY O Z Z N CC - Lu > ao z Uo LL U Ow } N A APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY BU LDING PROJECT IDENTIFICATION APPLICATION & PERMIT BUILDING -ELECTRICAL -PLUMBING -MECHANICAL PERMIT NUMBER 118 7 6 BUILDING , AooREss • 04 ./�(a� �Qey DINNER'S NAME //�� ++�� I �) _/11If y1 7 -Ar/ PRONE TY. ELECTRIC PERMIT FEE PLAN CHECK VALIDATION DATE OF APPLICATION NAIERncroRs LIC, NO. OUTLETS - SWITCHES -RFCEP 10.00/1.00 LIGHTING FIXTURES 10.00/1.00 ADDRESS ooREsgsj fl'r,;� y As �S9 PHONE- PPLIANCES- RESIDENTIAL 4.00 PANELS 10.00 ARRCHITECi ENGINEER LIC. No. PAN ELS (OVER 200 AMP) 20,00 PLAN CHECK FEE P.C. NO. SIGNS TRANS. 3.00 ARCH. 8 ENG. ADDRAZIP SPECIAL CIRCUIT S.OD PERMIT VALIDATION COY ISSUANCE DATE - ELECT. PLG. MECH. BLDG ❑ L1 ❑ ❑ EMP. METER OR POLE INS. 20.00 APPLICANT ADORE DRE MOTORS SEE FEE SCH. SERVICE CHANGE 20.00 LICENSED CONTRACTORS DECLARATION I hereby affirm that 1 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. License Class Lia Number Dale Contactor OWNER -BUILDER DECLARATION 1 hereby affirm that I am exempt from the Contractor's License Law for the following reason. (Sec. 7031.5, Business and Professions Code: Any city or county which requires a permit o 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 ofthe Business and Professions Code) or that he is exempt therefrom and the basis for the alleged exemption. Any violation of Section 7031.5 by any applicant for a permit subjects the applicant to a civil penalty of not more than five hundred dollars (S500).) ,C 1, as owner of the properly, 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 ProfessionsDRAINS-FLOOR, Code: The Contractor's License Law does not apply to an owner of property who builds or improves thereon, and who does such work himself or through his own employees, provided that such improve- ments are not intended or offered for sale. If, however, the building or improvement is sold within one year of completion, the owner- builder will have the burden of proving that he did not build or im. prove for purpose of sale.). ❑ I, as owner of the property, am exclusively contracting with 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 to the Contractor's Licen ❑ 1 a under Se . ,B.&P.C. for this BUILDING PERMIT INFORMATION MISC. - REFER TO ORD PERMIT ISSUANCEVALUATION 10.00 $/FT. ELEC. CONTR. - LIC. NO, ELEC. TOTAL PERMIT TO �� / L 'O 7 - CITY. PLUMBING PERMIT FEE 1 STORIE TYPE CONSTR. ALTER -DRAIN& VENT -WATER (EA.) 5.00 BACK FLOW PROTECTDEVICE 400 . . OCC. GROUP RES. UNITS ROOF, AR EA,CON D. 5.00 FIXTURES - PER TRAP 5.00 GAS-EA.SYSTEM-11NC.4OUTLETS 6.00 SO, FT. FLOOR AREA TOTALACREAGE GAS - EA. SYSTEM - OVER 4 (EA.) 2.00 BUILDING USE RES IND CON PB Other El El El El INDUSTRIAL WASTE INTER. 30.00 LAWN SPRINKLERS- 1 INC 5 V.g. 6.00 ASSESSORS PARCEL NO. LAWN SPRINKLERS - OVER 5 (EA.) 1.00 SEWER -SANITARY -STORM EA. 200ft/10.00 WATER HEATER W/VENT 6.00 TRACT NO. PARCEL NO. Own e Date WATER SYSTEM 5.00 WORKER COMPIiNSATION DECLARATION I hereby affirm that I have a certificate of consent W sell'MlLue, or u certificate of Workers' Compensation Insurance, or a certified copy thereof(Sce. 3800, Lab.C. 1. Policy No.Company ACG DATE ACC FILE NO. WATER TREATING EQUIP. 5.00 ZONING ENG. SITE NO ❑ Certifiedcopy is hereby furnished. ❑ Certified 'capy is fled with the city inspection division. Applicant MISC.- REFER TO ORD. FIRESPRINK rE] N� ENERGY T-24 v[3 N[3 CERTIFICATE OF EXEMPTION FROM WORKERS' COMPENSATION INSURANCE (This section need not be completed if the permit is for one hundred dollars (S 100) or IvR.) 1 certify that in the performance of the work for which this Per - .It is issued, 1 shall not employ any person in any manner so as to become subject to the Workers' Compensation Laws of Califontia. Date I Applicant PERMIT ISSUANCE 10,00 FLOOD ZONE Y ❑ IN A.LU.C. Y [] IN PLG. CONTR. LIC. NO. FLU. TOTAL FEE SUMMARY BUILDING /Q R OR ADD TO MECH. 5.00 NOTIC17 TO APPLICANT: If, alter making this Certificate of Ex- emption, you should become subject to the Workers' CompensationANCE provisions of the Labor Code, you must forthwith comply with such Provisions or this permit shall be deemed revoked. COMIROCDOIJ LENDING AGENCY hereby affiim that there 's a construction Icntling agency furUST the performance of the work for which this permit is issued (Sec. 7097, Civ.CJ. I Lender's Name Lender's Address 1 certify that I have read this application and state that the above ordinances n e'star, . I agree to comply with all city and county ordinance and 'state laws relating to building construction,ityndco and hereby autlrorize representatives of this city to enter upon the above-mentioned property for inspection purposes. (We) agree to save, indemnify and keep harmless the City of Cupertino against liabilities, judgments, costs and expenses which may in any wa RKtyid City in consequence of the graph ty permit 4 5.00 PLAN CHECK FEE ANDLING UNIT (TO iQ000C.F.K) 4.00 NDLING UNIT(OVER 10= C. EM.) 6.00 SEISMIC FEEI HOOD (WITH DUCT) 5.00 MICROFILM HEATING UNIT (TO 100,000 B.T.U.) 8.00 HEATING UNIT (OVER 100,000 B.T.U.)9.50 ELECTRIC VENTILATION FAN (SINGLET 4.00 BOILER- COMB (3 H.P. or 100,000 B.T.U.) 6.00 PLUMBING BOILER-COMP(Over100,000 BTU) SEE FEESCH. MECHANICAL MISC. - REFER TO ORD. PERMIT ISSUANCE 10.00 CONST. TAX MECH. CONT. . LIC. NO. MECH. roTAL COPY TOTAL /7 •� Signa re of A jean /Contractor Date OFFICE