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12820;APPLICANT TO FILL IN INFORMATION WITHIN RED LINES'- USE BALL POINT PEN ONLY BUILDING PROJECT, I DENTI FICATION APPLICATION & PERMIT :. BUILDING — ELECTRICAL— PLUMBING — MECHANICAL PERMIT NUMBER 12820 aDILOINc ADORES eon G 6 ,OWNER'S NAME PHONE OTY. ELECTRIC PERMIT FEE PLAN CHECK VALIDATION •• , CONTRACTOR NAME O/i' I T GLM U..No. ko !%- 710 7 UTLETS- SWITCHES - PIECED 10.00/1.00 LIGHTING FIXTURES10.00/1.00 CONTRACTOR'S - AOOR E(�SJlS I APPLIANCES - RESIDENTIAL 4.00 PANELS 10.00 ✓ 0,1, % e O ACPHONE C �L�I � - DATE OF APPLICATION ARCHITECT OR ENGINEER LIC. NO, PANELS (OVER ZOO AMP) 20.00' •. PLAN CHECK FEE P.C. NO. SIGNS TRANS, 3.00 ARCH. OR ENG.$DEOIAL ADDRESS CIRCUIT S.00 PERMIT VALIDATION' EMP. METER OR POLE INS.... 20.00 ZIP �J ADDRESS is - ADDRESS MOTORS SEE FEE SCH. SERVICE CHANGE 20.00 e -•' I' / I LICENSED CONTRACTORSDECLARATION 1 hereby, affirm ilial 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 a9d Viol' License lossLie. Number—_S % 'DataContractor ISSUAN E DATE BLDG. ELECT. as ❑ PLG. MECH. ❑ ❑ --15a BUILDI G PERMIT OWNER -BUILDER DECLARATION I hereby collo that I so exempt from the Contractor's License Law for the following reason: (Bac. 703L5, Business and Professions Code: Any city or County which requires a 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(commencingwith Section 7000) of Division 3 ofthe Business and Professions Code) or that he isexempt therefrom and I ATION A UA ON $/FT. PERMIT TO s MISC.— REFER TO OR tE� PERMIT ISSUANCE - - 10.00 ELEC. CONTR. LIC. NO. ELEC. TOTAL CITY. PLUMBING PERMIT FEE STORIES TYPE CONSTR. the basis far Ill. alleged exemption. Any violation of Section 703 L5 by any applicant for a permit subjects the applicant ton Civil penalty of out more five hundred dollars($500).)'. 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 BACK FLOW PROTECT. DEVICE 4.00 OCC. GROUP RES. UNITS DRAINS -FLOOR, ROOF, AR EA, COND. 5.00 intended or offered for sale (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 does such work himself' or through his own employees, provided that such improve- mentsarenotintended or offered for Sale. l f, however. the building - F IXTUR ES - PER TRAP 5.00 SO. FT. FLOOR AREA TOTAL ACREAGE GAS-EA.SYSTEM-l1NC.40UTLETS 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 or im- prove for purpose ofsale.). - ❑ I, as owner of the properly, 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 GAS - EA. SYSTEM -OVER 4 (EA.) 2.00 BUILDING USE RES IND -CON PB Other 0 El ❑ ❑ . ' ❑ INDUSTRIAL WASTE INTER. 30.00 LAWN SPRINKLERS - 1 INC 5 V.B. 6.00 - LAWN SPRINKLERS - OVER 5 (EA.) 1.00 ASSESSORS PARCEL NO. ' contracts for such projects with n uontractoos) licensed pursuant to the Contractor's License Law,' SEWER -SANITARY -STORM EA. 200ft/10.00 TRACT NO. PARCEL NO. ❑ I am exempt under See. .B.&P.C. for this reason WATER HEATER W/VENT 6.00 Owner Date WATER SYSTEM 5.00 ACC. DATE ACC. FILE NO. WATER TREATING EQUIP. 5.00 WORK F RS'COMPFNSAIION DECLARATION 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. ' copy there9(I Sgc. �yQ j.)b.CJ. Policy NOW( Y'CiiC� any RLP°7 B1i6 Af De/MN/iY FIRE SPRINK y F] No ENERGY T-24 Y [] No ❑ Certified copy is herebyfurnisled.—I CL'ertfled copy is filed with the city_ inspectiml division. Applicant MISC. - REFER TO ORD. CERTIFICATE OF EXEMPTION FROM WORKERS' PERMIT ISSUANCE 10.00 FLOOD ZONE A. L. U.C. PLG. CONTR. LIC. NO. PLG. TOTAL COMPENSATION INSURANCE ' (This section .need not be Completed, if the permit isfor ane Y ❑ No Y ❑ N CITY. MECHANICAL PERMIT FEE FEE SUMMARY hundred dollars (S I00) or less.) - I certify that in the performance of tire work for which this per mit is issued, 1 shall not employ any person in any mannerso as to became subject to the Workers' Compensation Laws of California. Date- Applicant - NOTICE TO'APPLICANT: If, after making -this Certificate oflix- emption, you should become subject to the Workers' Conlpensat ion provisions of the Labor Cade, you must forthwith comply with such provisions or this permit shall be deemed,revoked. BUILDING ALTER OR ADD TO MECH. 5.00 APPLIANCE- 5.00 PLAN CHECK FEE AIR HANDLING UNIT (TO 10MC.F.M.) 4.00 AIR HANDLING UNIT (OVER 10MC.F.M.) 6.00 SEISMICFEE CONSTRUCTION uiNDING AGENCY 1 hereby affirm that there is a construction lending agency for the performance of the work for which this permit is issued (Sec. 3097, Civ.C.). EXHAUST HOOD (WITH DUCT) 5.00 MICROFILM HEATING UNIT (TO 100,000 B.T.U.) 8.00 HEATI NG UNIT (OVER 100,0008.T.U.)9.50 ELECTRIC Lender's Name Leader's Address— 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 county ordinances and state laws relating to building construction, and PLUMBING BOILER- COMP (3 H.P. or 100,000 B.T.U.) 6.00 r BOILER -COMP (Over 100,000 BTU) SEE FEE SCH. MECHANICAL hereby authorize representatives of this city to enter upon the above-mentioned property' dor inspection purposes. _ MISC. - REFER TO ORD. - (We) agree to save, indemnify and keep harmless time City of Cupertino against liabilities, judgments, costs nnA expenses which may in any way accrue against said City in consequence of the CONST. TAX ' PERMIT ISSUANCE 10.00 - granting of this permit ,f MECH. CONT. LIC. NO. MECH. OTAL - TOTAL Slgnaure of Applicant/Contractor Date OFFICE COPY POST THIS CARD NEAR FRONT.•OF BUILDING CITY OF CUPERTINO%Q%�% PERMIT NUMBER . INSPECTION DIVISION-_. 12820 JOB INSPECTION RECORD. IT PERMIT EXPIRATION rJOB ADDRESS U' IT# L T# .•PERMIT EXPIRES IF WORK .OWNER CONTRACTOR /��j IS, NOT STARTED,WITHIN 180 DAYS OF PERMIT- ISSU. ANCE OR 180 DAYS FROM IASTCALLEDI PECTION. INSP CTION V DATE I INSPECTOR - - INMFrECTION RECORD FOUNDATION - - _ UFER PREGUNITE .' cERMrt vauon IONw 1 ISSUANCE DATE POUR NO CONCRETE UNTIL ABOVE HAS BEEN SIGNED UNDERGROUND/SLAB' PLUMBING. ELECTRICAL MECHANICAL - BLo ELECT. PLO. MECH. El .❑ 00 NOT POUR FLOOR UNTIL ABOVE HAS BEEN SIGNED " eulCowc PERMIT INFORMATION ' WOOD FLOOR .VALUATION .SIFT. ' " r' PLUMBING � _" - ,'�+�' --' MECHANICAL ELECTRICAL PERM o ; ' IMP �� •� !� I' I FRAMING ♦ - 'CONSTR. INSULATION =STORIESTYPE _ r OCC GROUP' RES. UNITS IRffCEINO SUBFLOOR UNTIL ABOVE HAS BEEN SIGNED LL ROOF - Sp. FT, FLOOR AREA TOTAL ACREAGE ' D I'AP.HRAGM. - _ - • . BUILDING USE - -'. - - 'RES IND.,. CON PB, Olnkl ❑ '❑ ' ❑ ❑ ❑' APPLY NO ROOFING UNTIL ABOVE HAS BEEN SIGNED . ROUGH - .: i, B, • ,- I' ASSESSORS PARCEL NO. PLUMBING - TRACT NO. .PARCEL NO. GAS TEST MECHANICAL ELECTRICAL "••'� P' FINALS' DATE INSP. Acc. onrE .- -Acc, PILE No, - SAN # FRAMING INSULATION. PLUMBING _ •ZONING " � ENG. SITE NO. I ;• GAS MECHANICAL FIRE SPRINK, C3-."0 ,. ENERGVT.$0 - ° [:] ""❑ y, XQVER NO WORK UNTIL ABOVE HAS BEEN�SIGNED. HEATING '.FLOODZONE• I O ..v N A.L.U.C. ❑, ❑ v ry LATH—INTERIOR Z,— — I_,❑ ELECTRICAL ,.. LATH—EXTERIOR FIREDEPTI--. .... ','t-- i-. ,• SHEETROCK - - GRADE - FEE SUMMARY SHEAR INTERIOR - BUILDING BUILDING SHEAR EXTERIOR j ", - `TEMPORARY APPROVALS ' FIREWALLS ELECTRIC-' ' PLAN CHECK. -FEE- GAS NO TAPE OR PLASTER UNTIL ABOVE HAS BEEN SIGNED OCCUPANCY SEISMIC.FEJE `• OCCUPANCYOF BUILDING ISNOTPERMITTEDUNTILB PILDING FI'AL''ISSIGNED BY BUILDING INSPECTOR. MICROFILM"• FOR INSPECTION,BY PHONA 252-4505, ELECTRIC ARRANGE Lu ONEMORKING DAY BEFORE REQUIREDINSPECTION 'P ,' PLEASE GIVE JOB ADDRESS WHEN PHO4NG, PLUMBING, MECFIANICAL Z 1 - SEE PERMIT FOR EXPIRATION DATE - CONST. TAX . IMPORTANT!. J PLEASE READ REVERSE SIDE BEFDRE TOTAL' CALLING FOR FINAL INSPECTION. " --� OFFICE COPY I