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12786 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY BUILDING PROJECT IDENTIFICATION PERMIT NUMBER 9, BUILDING .. APPLICATION & PERMIT ADDRISs • '� �kiW/, � BUILDING-ELECTRICAL-PLUMBING-MECHANICAL 1.2786 3 0 OWNERS PLAN CHECK VALIDATION QTY. ELECTRIC PERMIT FEE PHONE ONTRACTOR5 ` (, NAIVE OUTLETS-SWITCHES-RECEP 10.00/1.00 LID.No,=doLIGHTING FIXTURES 10.00/1.00 CO ACTOR'S ADOREss APPLIANCES-RESIDENTIAL 4.00 PHONE -/33t PANELS10.00 DATE OF APPLICATION ARSOF wrscT PANELS (OVER 200 AMP) 20.00 PLAN CHECK FEE P.C.NO. ENGINEER LIC.No. SIGNS TRANS. 3.00 ' ADDRESS END, SPECIALCIRCUIT 5,00 PERM IT VALIDATION ZIP TEMP. METER OR POLE INS. 20.00 APPLICANT'S ADDRESS MOTORS SEE FEE SCH. ////1111 SERVICE CHANGE 20.00 CI , - Foo LICENSED CONTRACTORS DECw1D�" LARATION !� ¢uu I hereby affirm that I am licensed under provisions of Chapter 9 m<y (commencing with Section 7000)of Division 3 of the Business and O LECT.CE PLG. MECH. - Hoz Professions Co dn my license is in full for alp�f El 11o w = OL 6 117 J6. o License Cl a Lic.Number_ ¢ m J Date Contractor 6 ¢ Ir:¢ ¢ OWNER-BUILDER DECLARATION BUILDING PERMIT w °' MISC.- REFER TO ORD INFORMATION g H I hereby affirm that I am exempt from the Contractor's License H u.o 4 Law for the following reason.(See.7031.5,Businessand Professions PERMIT ISSUANCE VALUATION $/FT. Yw0E Code:Any city orcounly which requires a permit to construct,alter, _ 10'00 / A ,x Ie ¢ O improve,demolish,or repair any structure,prior to its issuance,also ELEC.CONTR. LIC.NO. ELEC. V i o ¢ requires the applicant for such permit to file a signed statement that TOTAL PERMIT w $m he is licensed pursuant to the provisions of the Contractor's License �� /rT,/'T/ HiQ Law(Chapter 9(commencingwith Section 7000)of Division 3 ofthe L f z D Business and Professions Code)or that he is exempt therefrom and OTY. PLUMBING PERMIT FEE M H$ the basis for the alleged exemption.Any violation of Section 7031.5 STORIIfS 'TYPE CONSTR. ii by any applicant for a permit subjects the applicant to a civil penalty ALTER-DRAIN (EA.) 5.00 of not more than five hundred dollars($500)J: - ❑ I,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,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 FIXTURES-PER TRAP S-- SO.FT.FLOOR AREA TOTAL ACREAGE himself re through his own employees,provided that such improve- o improvemenotnt or within ronefor year If,however,the the owner- GAS-EA.SYSTEM-11NC.4OUTLETS 6.00 or improvement is sold within one year of completion,the owner- GAS•EA.SYSTEM-OVER 4(EA.) 2.00 builder will have the burden of proving that he did not build or im BUILDING USE prove for purpose of sale.). RES IND CON PB Other ❑ 1,as owner of the property,am exclusively contracting with . INDUSTRIAL WASTE INTER. 30.00 ❑ ❑ ❑ ❑ ❑ 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 Contractor's License Law does not apply to an owner of property who builds or improves thereon,and who LAWN SPRINKLERS-OVER 5(EA.) 1.00 contracts for such projects with a contractor d licensed pursuant to the Contractor's License Law, SEWER-SANITARY-STORM EA.200ft/10.00 TRACT NO. PARCEL NO. ❑ lam exempt under Sec.' ,B.&P.C.for this anon WATER HEATER W/VENT 6.00 ' Owner Date WATER SYSTEM 5.00 ACC.GATE ACC.FILE NO. WORKERS'COMPENSATION DECLARATION WATER TREATING EQUIP. Sim , I hereby affirm that 1 have a certificate of consent toself-insure, or a certificate of Workers'Compensation Insurance,or a certified ZONING ENG.SITE NO. copy theremf(Sec.3800,Lab.C.)d' Policy No. Company Q ❑ Certified copy is hereby furnished. - FIRE SPRINK EN ERGY T-24 Z ❑ Certified py is 11 w' s the city 'nspeclion division. H Applicant MISC.- REFER TO ORD. Y ❑ N❑ Y ❑ N❑ D: y CERTI GATE OF EXE ION FROM WORKERS' PERMIT ISSUANCE 10.00 FLOOD ZONE A.L.U.C. W - COMPENSATION INSURANCE PLG.CONTR. LIC.No. PLG. Z. (This section need not be completed if the permit is for one TOTAL Y❑ NE] Y ❑ 'N❑ hundred dollars(S I00)or less.) U O 1 certify that in the performance of the work for which this per QTY. MECHANICAL PERMIT FEE FEE SUMMARY LL H minis issued,I shall not employ any person in any manner so as to O W become subject to the Workers'Compensation Laws of California. ] y Date Applicant ALTER OR ADD TO MECH. 5.00 BUILDING �U_ S >_ N NOTICE TO APPLICANT: If,after making this Certificate of Ex- F ? emption,you should become subject to the Workers'Compensation APPLIANCE 5.00 PLAN CHECK provisions of the Labor Code, you must forthwith comply with FEE - / (.7 such provisions or this permit shall be deemed revoked. AIR HANDLING UNIT(TO 10,0 QF.M.) 4.00 CONSTRUCTION LENDING AGENCY AIR HANDLING UNIT(OVER 10=C.F.M.) 6.00 SEISMIC FEE I hereby affirm that there is a construction lending agency for EXHAUST HOOD(WITH DUCT) 5.00 the performance of the work for which this permit is issued(Sec. MICROFILM 3097,Civ.C.). I H EATING UN IT(TO 100,000 B.T.U.) 8.00 Lender's Name HEATING UNIT(OVER 100,000 B.T,U.)9.50 Lender's Address ELECTRIC 1 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 hereby authorize representatives of this city to enter upon the BOILER-COMP (Over 100,000 BTU)SEE FEE SCH. MECHANICAL above-mentioned property for inspection purposes. (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 10.00 CONST.TAX may in any w true against said City in con quarte of the gran[i oft pe iL MECH.CONT. LIQ NO. MECH. c1tiC TOTAL TOTAL Si re Ap icant ontr tar e IF OFFICE COPY I ! POST THIS CARD NEAR FRONT OF BUILDING PFRNUTNUMeER CITY OF CUPERTINO 12786 INSPECTION DIVISION 'pmt JOB INSPECTION RECORD t D /J� - a�y PERMIT EXPIRATION JOB ADOR ESS- ;/ r-LOT4 PERMIT EXPIRES IF WORK OWNER CONTRACTOR IS NOT STARTED WITHIN INS RA DATE INSPECTOR INSPECTION RECORD -180 DAYS OF PERMIT ISSU- FOUNDATICIN - ANCE OR 180 DAYS FROM LIFER LASTCALLED INSPECTION. PREGUNITE PERMIT VALIDATION POUR NO CONCRETE UNTIL ABOVE HAS BEEN SIGNED UNDERGROUND /SLAB f I PLUMBING � - ELECTRICAL ISSUANCE DATE MEGH AN iCAL BLDG. ELECT, PLG. MECH. ❑ ❑ DO NOT POUR FLOOR UNTIL ABOVE HAS BEEN SIGNED BUILDING PERMIT r INFORMATION - WOOD FLOOR' VALUATION s/FT. PLUMBING MECHANICAL ELECTRICAL PERMIT TO T FRAMING Sky LHJ INSULATION - .STORIES TYPE CONSTEL 1 OCG GROUP RES,UNITS PLACE NO SUBFLOOR UNTIL ABOVE HAS BEEN SIGNED 33 ROOF - SO.FT,FLOORAREA TOTAL ACREAGE �• �7 DIAPHRAGM BUILDING USE �':• ` HES IND CON PB Omer APPLY NO ROOFING UNTIL ABOVE HAS BEEN SIGNED ❑ ❑ ❑ ❑ ❑ ROUGH ASSESSORS PARCEL NO. ,' � PLUMBING - GAS,LEST TRACT NO. PARCEL NO. MECHANICAL - ELECTRICAL FINALS DATE INSP. ACC,DATE ACC.FILE NO, FRAMING SAN # INSULATION PLUMBING ZONING ENG.SITE NO, GAS MECHANICAL FIRE SPRINK ENERGYT24 COVER NO WORK UNTIL ABOVE HAS BEEN SIGNED HEATING Y El "❑ E] "❑ LATH-INTERIOR ELECTRICAL FLOODZONE -A.L.uc. LATH-EXTERIOR FIRE DEPT. Y❑ N❑ Yo N❑ SHEETROCK , '3 p— GRADE FEE SUMMARY SHEAR INTERIOR - - BUILDIN ,T SHEAR,EXTERIOR TEMPORARY APPROVALS BUILDING1 , ••„� FIREWALLS ELECTRIC - PLAN CHECK GAS FEE ,NO TAPE OR PLASTER UNTIL ABOVE HAS BEEN SIGNED occuPANcv SEISMIC FEE J OCCUPANCY OF BUILDING ISNOTPERMITTED UNTIL BUILDING FINAL ISSIGNED BY BUILDING INSPECTOR. MICROFILM ;L ARRANGE FOR. INSPECTION BY PHONING 252.4505, ELECTRIC IW ONE WORKING DAY BEFORE REQUIRED INSPECTION. PLUMBING' z PLEASE GIVE JOB ADDRESS WHEN PHONING. — SEE PERMIT FOR EXPIRATION DATE — MECHANICAL IMPORTANT! CONST.TAX PLEASE READ REVERSE SIDE BEFORE TOTAL CALLING FOR FINAL INSPECTION. OFFICECOPY '