16777 APPLICANT'TO FILL IN INFORMATION WITHIN RED LINES - USE BALLPOINT PEN ONLY +'
BUILDING PROJECT. IDENTIFICATION - - 'PERMIT Numeea
„GILDING APPLICATION & PERMIT
ADDRESS 16777 1 6 7 7 7
BUILDING-ELECTRICAL_PLUMBING-MECHANICAL
OWNER'S �-7 '
NAME
/ 4'6 OTY. "ELECTRIC PERMIT FEE PLAN CHECK VALIDATION
Y PHONE
NAME ACT Rs �sv OUTLETS-SWITCHES-RECEP 10.00/1.00
LIC NO. LIGHTING FIXTURES 10.00/1.00
ADDRESSTOas -APPLIANCES-RESIDENTIAL 4.00
e' 'PHONE ' PANELS 10.00 DATE OF APPLICATIO P.CC-
PLAN CHECK FEE RCHITECT .N
OO.
OR - - . PANELS (OVER 200 AMP) 20.00
-
• ENGINEER
LIC.NO. SIGNS TRANS. 3.00ARCH OR '
ADDRESS ErvG.. SPECIAL DIRCU IT ,I 5.00 PERMIT VALIDATION
ZIP EMP-METER OR POLEINS.+ 20.00
APPLICANTS ). MOTORS': SEE FEE SCH.
ADDRESS -
SERVICE CHANGE PA!d0.00ILCLC�
t00 LICENSED CONTRACTORS DECLARATION
u I hereby affirm that I am licensed under provisions of Chapter 9 ISSUANCE DATE
(commencing with Section 7000)of Division 3 of the Business end n a n „ _ BLDG. ,ELECT. PLG. MECH.
Hoz Professions Code,and my license is in full force and effect. 'I - ❑
z o y- License Class Lic.Number ,r� ❑. ❑ R I
F w H o Dale Contractor. - x Ci y, Cupertino 111"""""""'
a x BUILDING PERMIT
¢ ¢ a OWNER-BUILDER DECLARATION~ -
¢ w o INFORMATION
K e- I- 1 hereby affirm that.I am exempt from the Contractor's License MISC.'- 'REFER TO ORD
w '/+ - VALUATION SIFT.
LLoa Law forthe following reason.(Sec.7031.5,Businessand Professions PERMIT ISSUANCE 10.00
' Nye Code:Anycityorcounty which requires a permit m construct,alter, -
¢ ¢< improve,demolish,or repair any structure,prior to its issuance,also ELEC.CONTR. LIC.NO. - ELEC. _
n w m LL requires the applicant for such permit to file a signed statement that - - .TOTAL PERMIT TO' -
he is licensed pursuant to the provisions of the Contractor's License -
t z i Law(Chapter 9(cammencingwltli Section 7000)of Division 3 of the
4 o Business and Professions Code)or that he is exempt therefrom and QTY. PLUMBING PERMIT FEE 1 ,
¢ H$ the basis for the alleged exemption.Any violation of Section 7031.5 STORIES TYPE CONSTR.
by anyapplicaut for a permit subjects the applicant to a civil penalty ALTER-DRAIN&.VENT-WATER'(EA.) 5.00 "
of not more than five hundred dollars($500).1: n - -
❑ 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.lhe work,and the structure is not
intended or offered for sale (See, 7044,.Business and:Professions - DRAINS-FLOOR,ROOF,AREA,COND."5,00 . .
Cade:The Contractor's License Law does not apply to an owner of
property who.builds or improves thereon,and who does such work. F IXTUR ES-PER TRAP , (' 5.00 SQ.FT.FLOOR AREA TOTAL ACREAGE
himself re through his own employees,Provided that such improve-
map"
mprove- - ' ' • " .
mmself a through
or offered Res,or prov,however,ided
that such
building GAS-EA:SVSTEM-11NC.40UTLETS 6.00
or improvement is sold within one year of completion,the owner- GAS-EA:.SV STEM--OVER 4 (EA.) 2.00 BUILDING USE
builder will have the burden of proving that he did not build or im- -RES" IND CON - PB Other'
as owner of the property,am exclusively contracting with ❑ ❑
pave for purpose of sale.). INDUSTRIALWASTE INTERN 30.00 '
r `�^1, 1:1 - ❑ ❑
Ii n d contractors to construct the project(Sec.7044,Business LAWN SPRINKLERS- 1 INC 5 V.B.- 6.00 - 7 ASSESSORS PARCEL NO.
and Professions Code:The Contractor's License Lawdoes not apply
to an owner of property who buildsorimproves thereon.and who LAWN SPRINKLERS-OVER 5(EA,) 1.00 -
contracts for suchprojects with a contractor(sl licensed pursuant to - -' -
theContractor'sLicenseLaw. - SEWER-SANITARY-STORMEA.200ft/10.00 TRyACTAO. „ PARCEL NO.
reason❑ l um exempt under Sec. ,BAP.C.for this - WATER HEATER W(VENT 6.00
Owner Date - WATER SYSTEM'- 5.00 -
ACC.DATE ACG FILE N0.
.. WORK ERS'COMPENSATIo ECLANATION WATER TR EATING EQUIP. . 5.00
I hereby affirm that I have a certificate of consent tri self-insure, -
• or a certificate o(,Workers'ComZONING
pensation Insurance,or a certified "' I ENG.SITE NO. .
copy thereof(Sec.3800;Lib.CJ.
Policy No. Company _ -
❑ Certified copy is hereby furnished. FIRE SPRINK ENERGY T-24'
Z Z - ❑ Certified copy is Fled with the city inspection division. MISC.- 'REFER TO ORD.
O Applicant V❑ IN V ❑ N❑
SN
CERTIFICATE OF EXEMPTION FROM WORKERS' PERMIT ISSUANCE 10.00 FLOOD ZONE -A.L.U.C, -
LU > COMPENSATION INSURANCE PLG.CONTR. , LIC.NO. PLG.
G. O (This section need not be completed X11'thepermit is for one TOTAL Y❑ N❑. : Y ❑ . N❑
0 Z hundred dollars($100)or less.)
U O 1 certify that in the performance of the work for which this per- 'QTY MECHANICAL PERMIT FEE FEE SUMMARY
LL 1- mit is issued;I shall not employ any person in any manner so as to .. -
U become subject to the Workers'Compensation Laws of California:
00. Date 'Applicant ALTERORADDTOMECH. 5:00 'BUILDING
.} m NOTICE TO APPLICANT: If,after making this Certificate of Ex- - -
? emption,you should become subject to the Workers'Compensation APPLIANCErl G on S ,00 N 6 s D' PLACHECK
provisions of the Labor Code, you must forthwith comply with FEE
U - such provisions or this permit shall be deemed revoked. AIR HANDLING UNIT( O 10MOCF.M.) 4.00
CONSTRUCTION LENDING AGENCY AIRHANDLING UNIT(OVER 10, 00C.F.M.) 6.00 SEISMIC FEE
I hereby affirm that there is a constr'uction.[ending agency4or EXHAUST HOOD(WITH DUCT) 5.00
" the performan.ce of the work forlwhich'this permit is issued(Sec. MICROFILM
3097,CRCJ." - .HEATING UNIT(70'100,000 B.T.U.) 6.00 '
.._. Lender's Name HEATING UNIT 100,000 B.T.U.)9.50
Lender's Address ELECTRIC.
Y Icertify that lhaveread thisappllatlon aad''tate.that the above VENTILATION FAN (SINGLE) _ 4.00 -
r�l Information is,correct I agree to comply with all city and county PLUMBING
ordinances and stale haws'relating:to building construe Don,landBOILER-COMPO H.P.of 100,000 B.T.U.) 6.00
hereby authorize representatives of this city W enter upon the BOILER-COMP(Over[00,000 BTU)SEE FEE SCH. MECHANICAL- 8
above-mentioned property for inspection purposes. - t
_
(Wed-agree to save, indemnify and keep harmless the City of MISC.- ,'s- - REFER TO ORD. .
Cupertino against liabilities;judgments, costs and expenses which 'f of CONST:TAX
may in any way.accme against said City in consequence of the . .PERMIT ISSUANCE 10.00 /w
ranting gLthis permit., MECH'.CONT. LIC.NO. MECH. . '
_ _ TOTAL / ` `�//1 TOTAL
Signature of Applicant/Contactor [)are
I� f POST THIS CARD NEAR FRONT OF BUILDING
PERMIT NUMBER
CITY OF CUPERTINO .16777
INSPECTION DIVISION
JOB INSPECTION RECORD
PERMIT EXPIRATION
JOB ADDRESSvceUNIT# _LOT# Al fTEXPIRIE I F WORK
OWNER ( 'CONTRACTOR IS NOT STARTED WITHIN,,
INSPECT ON DATE INSPECTOR INSPECTION RECORD 180 DAYS OF PERMIT ISSU-
FOUNDATION - ANCE OR 180 DAYS FROM -
NOTE: LASTCALLED INSPECTION.:
LIFER ALL GRADING AND DRAINAGE SHALL BE INSTALLED
PREGUNITE - - TO COMPLY WITH THE APPROVED PLANS AND CITY OF PERMIT VALIDATION
.CUPERTINO STANDARDS.
GARAGESLABS '
POUR NO CONCRETE UNTIL ABOVE HAS BEEN SIGNED
UNDERGROUND /SLAB. - ),e
PLUMBING
ELECTRICAL 55uANCE uNrE
. 1
MECHANICAL ' _ _ BLDG ELECT I PLO. . -MECH. .
❑ 1 ❑ ❑ A
DO NOT POUR FLOOR UNTIL ABOVE HAS BEEN SIGNED - BUILDING PERMIT
WOOD FLOOR - - INFORMATION
PLUMBING p H�Ou iG✓ Y VALUATION. SIFT.
ONS
MECHANICAL - // 3 91-
ELECTRICAL - - PEMI
FRAMING PMD
INSULATION --- IES TYPE CONSTR.
NOV 81988
- . - OCC.GROUP RES UNITS
PLACE NO SUBFLOOR UNTIL ABOVE HAS BEEN SIGNED City Dt Cupertino
SO.FT.FLGOR AREA TOTAL ACREAGE
ROOF NOTE:NO FINAL INSP.SHALL BE MADE BEFORE
DIAPHRAGM THE CONSTRUCTION TAX IS PAID
BUILDING USE
ROOF SHEATHING _ RES IND CON i-PB Oor'
APPLY NO ROOFING•UNTIL ABOVE HAS BEEN SIGNED FINALS DATE INSP. ❑ ❑ ❑ ❑ ❑
'ROUGH SAN.p ASSESSORS PARCEL NO.
PLUMBING .ELECT.ENERGY
TUBS 8 SHOWER PAN PLUMBING ENERGY TRACT NO. PARCEL NO,
MECHANICAL MECH.ENERGY
ELECTRICAL BUILDING ENERGY - ACC DATE ACC.FILE NO.
FRAMING ELECT,FINAL TEST '
ZONING ENG.SITE NO.
INSULATION IPLUMBING -
GAS TEST - - GAS `
MECHANICAL -PIPE SPRINK ENERGY T-24
COVER NO WORK UNTIL ABOVE HAS BEEN SIGNED HEATING e Y❑'. N❑ ❑ ]rN❑'
ZONE, A.LU,L,
�rt
EXTERIOR SHEAR ELECTRICAL RELEASE
FLOOD
INTERIOR SHEAR - - FIRE DEPT. 'Y E_ "❑ Y ❑ "❑
SHEETROCK GRADE FEE SUMMARY
EXTERIOR. LATH BUILDING
INTERIOR LATH. TEMPORARY APPROVALS BUILDING
SCRATCH COAT ELECTRIC PLAN CHECK '
GAS FEE
NO TAPE OR PLASTER UNTIL ABOVE HAS BEEN SIGNED OCCUPANCY SEISMIC FEE
- OCCUPANCY OF BUILDING IS NOTPERMITTED UNTIL BUILDING FINAL ISSIGNED BY BUILDING INSPECTOR. MICROFILM.
ARRANGE FOR INSPECTION BY PHONING 252-4505; ELECTRIC
F. ONE WORKING DAY BEFORE REQUIRED INSPECTION. ' PLUMBING
O' PLEASE GIVE JOB ADDRESS WHEN PHONING.
Z. MECHANICAL fS�.
— SEE PERMIT FOR EXPIRATION DATE .—
IMPORTANT! coNs7.TAX
PLEASE READ REVERSE SIDE BEFORE; TOTAL
CALLING FOR FINAL INSPECTION.
OFFICE COPY
Wornock Hersey Inter notional Inc.
P.O. Box 1078. Antloch,Callfornla 94509 - 0107
J es - 2LOMM
*;
(415)432-7344— Telex 33.7797 1
June 15, 1984
Mr. Lee Adams , Technical Director
The Earth Stove , Inc.
Building B-22
S.W. Commerce Circle
Wilsonville, OR 97070
' r
Dear Mr. Adams ,
We are writing this letter to provide information that will be
helpful to your company in enlightening your California customers
who may need further information about Warnock Hersey .
Warnock Hersey International, Inc. is,an independant testing
laboratory and inspection service recognized through out the
• Unites States and Canada.
We have a Solid Fuel Burning Appliance test facility in Middleton ,
Wisconsin and Coquitlam, British Columbia.
All tests are conducted to appropiate UL or ULC standards for the
type of unit to be tested including UL 127 , UL 737 , UL 907.`:?OT� 6L
1482 for SEBA tested for the United SASMRtGnVE1Dt and ULC S¢'10,
ULC 561,1 , ULC S627 or ULC_ 5628 folicA¢p0 WACEtWITPr%ESd4S, in CanaQa.
CUPERTINO CODES AND ORDINANCES
We have• NAVLAP approval ( Lab Code 02 ) a��d�� ��c�, listed in
; .`.' current ..Building Standards fromD� nQuality Control
Agencies and Testing Labor ator i9196 N 1 r H YS has
written. acceptance from the Ca11iti,kggq n nu ci„ pp,, Office
Y and thev'California Department off pN®RIA93� q �?�, tim���ny�KX`ty Development
as well as major cities in Ca1il&utrbirftyeany changes or ai:eia:i in
on same witkw written }�e mssim It'll,
We trust that this information t4tibli�linpro.v ;ilshp��) E}� to your company:
The stamping of this Pan.nal specifications
SHALL NOf bel,e;d to pu.mit or to be an
approval of the violation of any provisions
of any City Ordinance or State Law.
Yours Truly ,
`• R. Provine C
( j��//Manager, Western Region �lr \ICRP/d1 IJ IJ
cc: George E.__Meyer : _