12656 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USF BALL POINT PEN ONLY
• BU I LD)NG PROJECT I DENTIFICATI ON PERMIT NUMBER
n
o'nnEs,{ APPLICATION & PERMIT'
104 0 �i BUILDING -ELECTRICAL-PLUMBING-MECHANICAL 12656
S H' ml.I'tp t...Ca 'yjem•''AGA•1•'m. h it•1�f}'�A��rN� I'„'•.ySLZ4 I PLAN'CHECK VALIDATION
QTY. ,-.� ELECTRIC PERMIT ,F.EE
DN 46-1913 •
flame Ac Hs 99. UTLETS-SWITCHES-RECEP 10.00/1.00
Deb Cor Corporation Luz,No. 385712 LIGHTING FIXTURES 10.00/1.00 -
ADDRESST0R 521625 Stevens Creek -Blvd , APPLIANCES-RESIDENTIAL 4.00 �-
Cupertino, 95014 PHONE446-1913 I PANELS 10.00 DATE OF APPLICATION
ARCHITECT Seals & Assoc. C-15162 PANELS (OVER 200 AMP) 26,60 PLAN CHECK FEEP.C.NO.
ENGINEER
Stephen Clark mc.Noc-6382 SIGNS TRANS. 3.00
ARCH.OR ENG. PERMIT VALIDATION
ADDRESS Seals, Oakland, CA SPECIAL CIRCUIT 5.00 _
Clark Saratoga, CAzIP EMP.METER OR POLE INS. 20.00
ADDDREDRESSS S
A - MOTORS SEE FEE SCH, i
�
21625 Stevens Creek Blvd, Cuipt SERVICE CHANGE -- • 20.00 ( ^
o 0 i
F O o LICENSED CONTRACTORS DECLARATION
< u u I hereby affirm that I am licensed under provisions of Chapter 9 - +"."'!1 SUANLEOATE'
v, <n (commencing ith Section'7000)of Division 3 of the Business and BLDG. ELECT. PLG. MECH.
r N i Professions Code, d my license is in full fore y
>: O L Licen C Lic.Number q /y'L�I-'
0 H w Date�Can[mctor_j�l? � •+ ^,:? ;:L.:6
r w - !:] --
< x s ti"v+';:�BUIL'DING;PERMIT ['`P'q
rt o:w OWNER-BUILDER DECLARATION '0.r,Fy'e'�;`2i°I N FO RMATI ONt fit$ fie€
A. ;°'> I hereby affirm that 1 am exempt from rhe Contractor's License MISC.- REFER TO ORD
w a-o Law for the followin reason.(Sec.7031.5,Business and Professions VALUATION
1-- - g PERMIT ISSUANCE 10.00 i -
Code:Any city-county which requiresa permit to construct,alter,
Q C 4 p improve,demolish,or repair any structure,prior to its issuance,also ELEC.CONTR. LIC.NO. - g
ELEC.
y C 0 u requires the applicant for such permit to file a signed statement that TOTAL / Q PERMIT TO
w m m he is licensed pursuant to the provisions of the Contractor's License _ }
r z > Law(Chapter9(commencing with Section 7000)o(Division 3 of the g C S R ? `�1 , y
4 o Business and Profeaions Code)or that he is exempt therefrom and DTY' ".p,-'f�'7�5 PLUMBING PERMIT Vt r�s+7 3FEEe' W L.-
H the basis for the alleged exemption.Any violation of Section 7031.5 J .5 r? �.\",fFfea, {�L{x1}G'3,v4'Ms >`# -'IN.3;i4.; +�AA..oS�. -STORIES TYPE CONSTR. .
e, by any applicant forapermit sobjects the applicant loo civil penalty ALTER-DRAIN 5.00
of not more than five hundred dollars(55001.):
O I,as owner of the property,or my employees with wages as BACK FLOW PROTECT.DEVICE 4.00 OCC. ROUP RES. NITS
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 does such work I'3 FIXTURES-PER TRAP 5.60 = SO.FT.FLOOR AREA TOTAL ACREAGE .
himself or through his own employees,provided that such improve.
mems are not intended proffered for sale.If,however,the building GAS-EA.SVSTEM•11NC.40UTLETS 6.00 8�
or improvement is sold within one year of completion,the owner- GAS-EA.SYSTEM-OVER 4 (EA.) 2.00 O
builder will have the burden of proving that he did nor build or im- BUILDING USE ^'IV1,
prove for purpose ofsals.). INDUSTRIAL WASTE INTER. 30.00 'RES IND CON _ PB 4r Om.,O .,
❑ I,as owner of the property,am exclusively contracting with
licensed contractors to construct the project(Sec.7044,Business LAWN SPRINKLERS-1 jNC.S V.B. 6.00 ASSESSORS PARCEL N0 '.-;I,y:iv
and Professions Code:The Contractors License Law does not apply . c.1. .
to an owner of property who builds or improves thereon,and who LAWN SPR IN KLERSi'OVER'5 IEA.) 1.00 e�j •= i
contracts for such projects with a conloactor(s)licensed pursuant to +6?,`
the Contractors License Law. SEWER-SANITARY-STORM EA.200ft/10.00 TRACT NO, PARCEL NO.,:
❑ lam exempt under SSC..B.&P.C.for thisAl�.`r;3 u
reason WATER HEATEIRWIVENT' 6.00 - n
Owner1t.
Dare WATER SYSTEM 5.00 ACC.DATE ACC.FILE NO.
WORKERS'COMPENSATION DECLARATION WATER TREATING_;EDUIP;L "' 5.00 '�''•'
I hereby affirm that 1 have a certificate of consent to self-insure,
or a certificate of Workers'Compensation Insurance,or a certified ZONING. ENG.SITE NO.r
copy thereof(Sec.3800,Lab.C.). USF & Ca S s
Policy No. Company
o ❑ Certified copy is hereby furnished. FIRE SPR INK ENERGY T-24 :•
Z Z ® Certif d o f with the city inspection division.
0 Applicant 15eLkgrp MISC.• REFER TO ORD. Y 0 N Y [3 NC:]
T CERTIFICATE OF EXEMPTION FROM WORKERS' PERMIT ISSUANCE 10.00 FL000 ZONE A.L.U.C.
LU 2! COMPENSATION INSURANCE PLG.CONTR. LIC.NO. PLG.
1 O (Thu section need not be completed if the permit is for one TOTAL Y N� Y❑ No
Z hundred dollars(E100)or less.) d eR, '� -L 4,+ sky. �1- zs `sJ ' `rs.r t"A{I r L peP^'•^ •;
U 0 1 certify that in the performance of the work for which this per. ' t s' EE SUMMARYt 1"
CITY. �i "> MECHANICAL PERMIT ,9 )"`FEE x�-3'*!F
LL 1- mit is issued,1 shall not employ any person in any manner so as to Fps d„.+I• S E3.T Ry Rl a +f ' ,tiF qe.
Wbecome subject to the Workers'Compensation Laws of California. ^-�'• -�'�'••-� �"•.'
Q. Dare ApplicantALTER OR ADD TO MECH. 5.00
BUILDING 3 30
} N NOTICE TO APPLICANT: If,after making this Certificate of Ex- .
I- ? emprion,you should become subject to the Workers Compensation APPLIANCE 5.00 PLAN CHECK
provisions of the Labor Cade, you must forthwith comply with + FEE
CJ such provisions or this permit shall he deemed revoked. AIR HANDLING UNIT•(TO I0=C.FAt) 4.00
CONSTRUCTION LENDING AGENCY AIR HANDLING UNIT(OVER 10,000CEM:) 6.00 7 SEISMIC FEE 33
I hereby affirm that there is a construction lending agency for EXHAUST HOOD (WITHDUCT) 5.00 Ste,
the performance of the work for which this permit is issued ISec. MICROFILM
3097,Civ.C.). HEATING UNIT ITO 100,000 B.T.U.) 8.00
Lender's Name t azo Bank
Lender's Address�J a en k3lz7d9521 HEATING UNIT(OVER 100,000 B.T.U.)9.50 ELECTRIC
-1• I certify that I have read this application and slate that the above VENTILATION FAN (SINGLE) 4.00 -
information is correct. I agree to comply with all city and countyPLUMBING
ordinances and state laws relating to building construction, and BOILER-COW(3 H.P.or 100,000B.T.U5 6.00
herebhereby authorize representatives of this city es enter upon theaboveBOILER-COMP (Over 100,000 BTU)SEE FEE SCH. MECHANICAL
y
authorize
property representative,
o thion purposes. 3J
(We) agree to save, indemnify and keep harmless the City of MISC.• REFER TO ORD.
Q
Cupertino against liabilities,judgments, costs and expenses which CONST.TAX r�uQ�
may in any way accrue against said City in consequencePERMIT ISSUANCE 10.00 of the �s
granting of this))per. MECH.CONT. LIC.NO. MECH.
l LL h TOTAL
�L 41nFs�87 ?
Iglsalure of pphcam/Convector Dalc LJ�- 'FTOTAL.' n div D9
OFF1C'S COPY
POST THIS CARD NEAR FRONT OF BUILDING
CITY OF CUPERTINO R1,IT NUMBER
INSPECTION DIVISION 12656
JOB INSPECTION RECORD
,, �J PERMIT EXPIRATION
-' JOB ADDRESS �DyoD IMOf,-7,i.Y UNIT# LOT#
—I-- -T PERMIT EXPIRES IF WORK
OWNER .h CONTRACTOR (-' COC4 IS NOT STARTED WITHIN
INSPECTION ' DATE ad INSPECTOR' 4,,:3% "s?,:;`vINSPECTION RECORD `= z. 180 DAYS OF PERMIT ISSU-
FOUNDATION ANC. OR 180 DAYS FROM
LIFER
LASTCALLED INSPECTION.',
PREGUNITE
PERMIT VALIDATION
T +�
UR 0 CONCRETE"UNTIL A OV HAS BEEN SIGN E01
UNDERGROUND /SLAB
PLUMBING '•. (x 4 -I
ELECTRICAL - +y d CIvsau�cEDATE
MECHANICAL 8 DG. EL�E'CyT. PpLG7. MECH.•
M,NOTtPOUR',F.LOOR UNTIL"ABOVE HAS.BEEN,SIGNED' ,° SIN O_R.MAT ONA�,jT,
WOOD FLOOR —
PLUMBING - VALUATION S/FT.'�F
MECHANICAL
ELECTRICAL ERMITTO
FRAMING Ly $�
INS LATION - STORIES TYPE CONSTR.�=
z 0 J�
A7—
OCC.GROUP GROUP RES.UNITS
AM6 . LACEiNO?SUB , ORiUNTIL^IA OVE'HAS B
zPEENISIGNED5/ 1S
p00F SO.FT,FLOOR AREA TOTAL ACREAGE.
-> DIAPHRAGM
BUILDING USE .>I•I'�'ipjal•
"RES .' IND CON PB ,=TOtFar�zw• .>
_LAPP.LYtN01R00FING;UNTILKABOVEiHAS'BEEN;SIGNEO '`El El'°r
ROUGH _ ASSESSORS PARCEL NO. 1,i;1j d-
1 � �iA^�.3
PLUMBING
GAS TEST TRACT NO. .PARCEL NO„-
MECHANICAL 0� 3,
ELECTRICAL x a ACC.DATE ACO FI LENO.,1±:
D / –Fl FINALS DATE IN§P,.
FRAMING 0_(� SAN #' f� �"��
INSULATION 0. ('.� PLUMBING _ _ ry zoNlNc Erva 517E No.1?
7u-v OfGAS
•I- ' MECHANICAL _ FIRESPRINK ENERGYT]A
COVER;NO,WOMU TI VABO,VE;HASIBEEN-ASI HEATING Y "� O .
LATH-INTERIOR ELECTRICAL _�� , FL000 LONE _ A.LU.C. -
LATH-EXTERIOR FI RE DEPT. Y[3 N[j _Y
SHEETROCK 7 GRADE t "i 'F EISUMMARV
SHEAR INTERIOR 0 BUILDING ,� , x
'I SHEAR EXTERIOR __F17 TEMPORARY APPROVALS V BUILDING
FIREWALLS - ELECTRIC PLAN CHECK
x GAS
dNO;TAPE:OR?L'ASTER;UNTIGABOVE HAS,BEEWSIGNEO} OCCUPANCY SEISMIC FEE SV-,�
-° OCCUPANCYOF BUILDING IS NOT PERMITTED UNTIL BUILDING FINAL IS SIGNED BY BUILDING INSPECTOR. MICROFILM
• L ARRANGE FOR INSPECTION BY PHONING 252-4505, ELECTRIC
-� ONE WORKING DAY BEFORE REQUIRED INSPECTION. PLUMBING =`
PLEASE GIVE JOB ADDRESS WHEN PHONING.
d — SEE PERMIT FOR EXPIRATION DATE — MECHANICAL �3
CONST.TAX
IMPORTANTIGC�—
PLEASE READ REVERSE SIDE BEFORE . -TOTAL
CALLING FOR FINAL INSPECTION.
CFFICZ CUlf