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12610 APPLICANT TO FILL IN'INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY BUILDING PROJECT I DENTI FICATION I PERMIT NUMBER aDILDING 'APPLICATION & PERMIT ^^ ^ O ADDRESS L F, / G b I /oGG �` �UILDING -ELECTRICAL—PLUMBING—MECHANICAL ..NER'a C/ lll/111 PLAN CHECK VALIDATION "AME '7,/ / OTY. ELECTRIC PERMIT FEE -I� � PHONE/,` 7,67 ,Q L �A CONTRACTORfvU.9'— 3G UTLETS-SWITCHES-RECEP 10.0011:00 > NAME a T4 � LIc,No, IGHTING FIXTURES 10.00/1.00 CONTRACTORS - APPLIANCES-RESIDENTIAL 4.00 ) ADDRESS - { (^ . �V 'D PHONE / Yl PANELS 10.00 DATE OF APPLICATION ARCHITECT - PANELS (OVER 200 AMP) 20.00 PLAN CHECK FEE P.C.NO. aR ENGINEER LIC.No. SIGNS TRANS. 3.00 ARCH.off ENG. SPECIAL'CIRCUIr VAT 5.00; �PERMIDATION ADDRESS _ }IPAM rrEMP.METER OR PQ1JhW 20.00 APPLICANT'S MOTORS kWPE$CH. ADDRESS SERVICE CHANGE01W '20.00 woo LICENSED CONIRACIORS DECLARATION < v u I hereby affirm that I am licensed under provisions of Chapter 9 uANCE DATE .. r z w ., (commencing with Section.7000)of Division 3 of the Business and PCG. CH. BLDG. ELECT. - ME'F'N i Professions Cal d q•nsy,is in full 1'orcu`ylld cf�fecL u - z 0 m — icense�Cl�es Lic.Number C 'S o u f 0 - Dale 1L!4��1._Contractor , P M s 3 T _ _ BUILDING PERMIT r a ,Ica OWNER-BUILDf;R DECLARATION INFORMATION K ;n N 1 hereby affirm that I am exempt from the Contractor's License MISC.— REFER TO ORD - w u o a Low for the following reason,(Sec.7031.5,Rusinessand Professions PERMIT ISSUANCE ,10.00 / VALUATION S/FT. r Code:Any city orcounty which requires a permit to construct,utter, ,,J .V� 5 w a' ELEC.CONTR. - LIC.NO. �'^ Q Q 40 improve,demolish,or repair any SINCIurc,prior ID its issuance,also ELEC. p y D M requires the applicant for such permit to file a signed statement that TOTAL s - PERMIT TO w 8 a he is licensed pursuant to the provisions of the Contractor's License [s I^ FZi Law(Chapter 9(commencingwith Section 7000)ofDivision3 ofthe y L./ �• y(J C Rosiness and Professions Code)or that he is exempt therefrom and, OTY. PLUMBING PERMIT FEE It H 0 the basis for the alleged exemption.Any violation of Section 7031.5 STORIES TYPE CONSTR. by any applicant for a permit subjects the applicant to acivil penalty ALTER-DRAIN -WATER (EA.) 5.00 of not more than five hundred dollars(3500).): N/tTL� ❑ 1,as owner of the property,or my employees with wages as BACK FLOW PROTECT. DEVICE 4.00 OCC.GROUP RES.UNITS 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,GOND. 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 FIXTURES-PER TRAP 5.00 SG.FT.FLOOR AREA TOTAL ACREAGE himself or through his own employees,provided that such improve- mentsamnet intended oroffered for Sale.11,however,the budding GAS-EA.SYSTEM-1 INC.4 OUTLETS 6.00 or improvement is sold within one year of completion, the owner- holder wner- GAS EASYSTEM-OVER 4 IEA) 200 i ho lder will have lire burden of proving that he did not build or ini- - . . . BUILDING USE prove focpurpose of sale:). t INDUSTRIAL WASTE INTER. 30.00 RES IND CON PB Other ❑ I,as owner of the property,am exclusively contracting with ❑ ❑ ❑ ❑ ❑ 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 Commctor's License Law does not apply to an owner of property who builds or improves thereon,and who LAWN SPRINKLERS-OVER 5 1.00 contracts for such projects with a contractors)licensed pursuant to SEWER-SAN Y-STORM Oft/1 the Contractor's Lice ase Law. TRACT NO. PARCEL NO. ❑ I am exempt under Sec. ,BAP.C.for this WATER HEATER W/VENT . 0 - reason Owner Dale WATER SYSTEM 6. ACC.DATE ACC.FILE NO. WORK Ii RS'COMPENSATION DECLARATION WATER TREATING EQUI I hereby affirm that',I.have a certificate of eousent to self'-insure. VIM ZONING or a certificate of Workers Compensation Insurance,or a certifieJ ENG.SITE NO. copy they .I 5 3 0D,Lab.C.). 1`x�/. Policy N mpanY rr�P�-as� 0 \ ❑ Certified.. erehy furnished. FIRE SPRINK ENERGY T-24Z Z ❑ e "L•d.copy is d with the city inspection division. MISC.- REFER TO ORD. Y ❑ NE] V ❑ N❑ P: PERMIT ISSUANCE -10.00 /d '— LU > CIiRTIPICCOMPENSATONI INSUR NCEr'ION FROM RKfiRS' PLG.CONTR. LIC.NO. PLG ` s` FLOOD ZONE A.L.U.0. C' O (1[Its section need not be completed if the permit is for one TOTAL S Y E] N❑' Y E] N❑ D Z hundred dollars($100)or less.) V O I certify that in the performance of the work lot which this per- OTY. MECHANICAL PERMIT FEE FEE SUMMARY IL I mit is issued,I shall not employ any person in any manner so as to 0 W become subject to the Workers' any Laws of California. a Date—Applicant ALTER OR ADD TO MECH. 5.00 BUILDING } m NOTICE TO APPLICANT': If,after making this Certificate of Ex- Z emption,you should become subject to the Workers'Compensation APPLIANCE 5.00 PLAN CHECK provisions of the Labor Code, you mesPforthwilh comply with FEE L) such provisions or this permit shall be deemed revoked. AIR HANDLING UNIT(TO 1Q000 4.0 OOO CONSTRUCTION LENDING AGENCY AIR HANDLING UNIT(OVER IOC. I SEISMIC FEE , I hereby affirm that there is a construction lending agency for EXHAUST,HOOD (WITH D 5.00 the performance of the work(or,which this permit is issued(See. MICROFILM - 3097,Civ.C.L ! HEATING UNIT(TO 100,000 B.T.U. Lender's Name 0 UNIT(OVER 10 ,0 .19.50 Lender's Address HEATING ELECTRIC I certify that I have read this application and state 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 r hereby authorize representatives of this city to enter upon the of above-mentioned property for inspection purposes. ' BAILER-COMP (Offer 100.000 BTU)SEE FEE SCH. MECHANICAL Q f�J"'L (We) agree to save, indemnify and keep harmless the City of MISC.- REFER TO ORD. /, , Cupertino against liabilities,judgments, costs and expenses which .PERMIT ISSUANCE 90.00 Q CONST.TAX may in any way accrue against said City in consequence of the ting'OCthL9- Imt ECH.CONT. ' LIC.NO. MECH. ^ + TOTAL �' f f't TOTAL J-'3 Signature of Applicant/Contractor D to - - ,\ I OFFICE COPY POSTTHIS.CARD.NEAR FRONTOF'BUILDING ' PFHM1VT NUMBER' r CITY OF CUPERTINO 12610 INSPECTION'DIVISION 9 JOB INSPECTION RECORD \ 1 4 + PERMIT EXPIRATION JOB ADDRESS, 20866 Jolly an Lane 'UNIT ft LOT# PERMIT EXPIRES IF WORK OWNER ReX Tsou CONTRACTOR T !& F CoLIStTUCtlon IS NOT STARTED WITHIN _ L, INSPECTION DATE INSPECTOR INSPECTION RECORD 180 DAYS OF PERMIT ISSU• ' FOUNDATION - ANCE OR, 180 DAYS FROM LASTCALLED INSPECTION. r UFER PREGUNITE (.�^�� - PERMIT VALIDATION: •- POUR NO CONCRETE UNTIL ABOVE HAS BEEN SIGNED i UNDERGROUND /SLAB PLUMBING -$ - l��? ELECTRICAL IJ ISSUANCE DATE. MECHANICAL ELECT. PLG. MECH. . DO NOT POUR FLOOR UNTIL ABOVE HAS BEEN SIGNED - BUILDING PERMIT WOOD FLOOR I INFORMATION, " VALUATION S/FT. -" PLUMBING p MECHANICAL- ELECTRIC /'' PERMIT TO,'']`� AL' - FRAMING �' - `' - - STORIES rYPE CONSTR. INSULATION OCC.GROUP RES,UNITS lPVACE;NO SUBFLOOR UNTIL ABOVE HAS BEEN SIGNED R00 SO FT,FLOOR,AREA TOTAL ACREAGE , DIAPHRAGM - I BUI LEINC USE • _ _ _ R[5 IND CON PB ONer B(APPLY NO ROOFING UNTIL ABOVE HAS BEEN SIGNED C] ❑ E] E3. CD ASSESSORS PARCEL NO. ROUGH PLUMBING - . TRACT NO. PARCEL NO, GAS TEST MECHANICAL - NPLUMBING ACC,DATE ACC,FILE NO. I, ELECTRICAL ' - DATE INSP, FRAMING - - ZONING. ENG.SITE NO. INSULATION ��-_� FIRE SPRINK ENERGY T-24 'COVER NO'WORK UNTIL ABOVE HAS BEEN SIGNED ❑ "❑ ❑. "❑ FLOOD ZONE A!L;U.C. .LATH-INTERIOR - Q- LATH-EXTERIORI _ FIRE DEPT, - °❑ "❑ v ❑ "❑ SHEETROCK • - - GRADE - FEE SUMMARY SHEAR INTERIOR'. - BUILDING 00 SHEAR EXTERIOR. : . BUILDING � TE PORARY APPROVALS - • .; = FIREWALLS - ELECTRIC .PLAN CHECK- . - GAS FEE (NO TAPE OR PLASTER UNTIL ABOVE HAS BEEN SIGNED OCCUPANCY SEISMIC FEE y^ OCCUPANCY OF BUILDING IS NOTPERMITTED UN I ILBUILDING FINALISSIGNED BY BUILDING INSPECTOR; MICROFILM . ARRANGE FOR INSPECTION BY PHONING'252-4505 %LECTRIC w ONE WORKING DAY BEFORE REQUIRED INSPECTION. Fs' PLUMBING O� PLEASE GIVE JOB�ADDRESSWHEN PHONING. r — SEE PERMIT FOR EXPIRlz ATION DATE — MECHANICAL IMPORTANT! CONST.TAX PLEASE READ REVERSE SIDE BEFORE TOTAL CALLING FOR FINAL INSPECTION:' 1-. OFFICE COPY