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12521D ¢ z F C O Q wU U z t H N 2 go w wa 3 d U X y -asI M 40 a w �y HZ> i -o 6H$ O _Zz F-, N CC UJ _ CL 7z UQ LL U Ow } N Z w�) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY i BUILDING PROJECT IDENTIFICATION I APPLICATION & PERMIT BUILDING - ELECTRICAL- PLUMBING - MECHANICAL PERMITNUMBER 12521 BUILDING ADORES 4 2 O OWNER'S ��/ NAME /�I rl NR+k�cY IZ �B.�I/n�l��j�OTY. PHONE! -02 V(J ELECTRIC PERMIT FEE�f0• PLAN CHECK VALIDATION cOMrmacrORs NAME / OUTLETS - SWITCHES -RECEP 10.00/1.00 led LIGHTING FIXTURES 10.0011.00 LIC. NO, CONTRACTOR'S ADDRESS PPLIANCES-RESIDENTIAL 4.00 PANELS 10.00 PHONE DATE OF APPLICATION ARCHITECT /EACeT VOCH/ lqus/K OR VI" ENGINEER LAC. Na. /3277 PANELS (OVER 200 AMP) 20.00 PLAN CHECK FEE P.C. NO. SIGNS TRANS. 3.00 ARCH,OR ENG. RESSD 9:1d AiO S% -Jr- 6-,X� . it SPECIAL CIRCUIT 5,00 PERMIT VALIDATION �y/n EMP. METER OR POLE INS. 20.00 APPLICANS T ADORE SS MOTORS1 SEE FEE SCH. IPA SERVICE CHANGE 20.00 1,0140 F �Jpfjq LICENSED CONTRACTORS DECLARATION I herehy affirm that] 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 and effect. License Class Lic. Number ISSUANCE 0 T - CuP V Y BLDG. T SBL MECH. ❑ ❑ Date Contractor B1P&1 - OWNER -BUILDER DECLARATION I hereby affirm that I um exempt from the Contractor's License Law for the fallowing reason. (See. 7031.5, Business and Professions Code: Any city or county which requires a permit to construct. alter, improve, demolish, or repair any Structure, prior lO its issuance, also requires the applicant for such permit to file a signed statement that he is licensed pursuantRSO to the provisions of the Contractor's License Ij�(�RMATION - MISC.REFER TO ORD VALUATION $/FT. i - �. •f/ IY PERMIT ISSUANCE 10.00 6r ELEC. CONTR. LIC. NO. ELEC. Gy TOTAL 0 EHPMq IS� TO PA3p5IvGR- Law (Chapter 9 (commencing with Section 7000) of Division 3 of the Business and Professions Code) or that he is exempt therefrom and QTY. PLUMBING PERMIT FEE��'' 4' STORIES TYPE CONSTR. the basis for the alleged exemption. Any violation of Section7031.5 by any applicant for a permit subjects The applicant on civil penally of not more than five hundred dollars (5500).): ALTER-DRAIN&VENT-WATER IEA.) 5.00 ❑ I, as owner of ilia property, or my employees with wages as their sole compensation, will do the work, and the structure is no[ intended or offered for sale (Sec. 7044, Business and Professions BACK FLOW PROTECT. DEVICE 4.00 OCG GROUP R- 3 RES. UNITS / DRAINS -FLOOR, ROOF, AR EA,COND. 5.00 Code: 'The Contractor's License Law docs not apply to an owner of properly who builds or improves thereon, and who does such work himself or through his own employees, provided that such improve. ments are not intended o-offened for sale. If, however, the building FIXTURES - PER TRAP 5.09 SD. FT, FLOOR AREA TOTAL ACREAGE GAS - EA. SYSTEM -1 INC.4 OUTLETS 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 ire - prove fur purpose of sale.). 1, as owner of the property, am exclusively contracting with . .. GAS - EASYSTEM •OVER 4 IEA) 200 BUILDING USE RES IND CON PB Omar 1-1 IN ❑ .PB INDUSTRIAL' WASTE INTER. 30.00 LAWN SPRINKLERS - 1 INC 5 V.B. 6.00 ASSESSORS PARCEL NO. an d contractors to construct The project (Sec. 7044, Business and Professions Code: The Contractor's License Law does not apply to an owner of properly who builds or improves thereon, and who LAWN SPRINKLERS - OVER 5 (EA.) 1.00 contrthe Cont forsudscenecLwithamnlmaorts)licensed pursuant to the Contractor's License Law. SEWER -SANITARY -STORM EA. 200ft/10.00 TRACT NO. PARCEL NO. ❑, l am exempt under Sec. 'BP.C.forthis reasonInell WATER HEATER W/VENT 6.00 .Owner Duce WATER SYSTEM 5.00 ACC.DATE ACC. FILE NO. WATER TREATING EQUIP. 5.00 WOR KER$' ' MPENSA'T'ION DECLARATION I hereby affirm that I have a certificate of consent to self -insure, or a certificate of Workers' Compensation Insurance ar It certified ZONING ENG. SITE N0. copy thereof (Sec, 3800, Lxb.0.), - Policy No, Company ❑ Certified copy is hereby furnished ❑ Certified copy is Bled with the city inspection division. Applicant FIRE SPRINK Y [] N� ENERGY T-24 Y 0 N� MISC. - REFER TO ORD. CI: R'TIFICATE OI' E X 17 IT ION P RO M WO R K Ii RS' PERMIT ISSUANCE 10.00 FLOOD ZONE A.L.U.C. PLG. CONTR. LIC. NO. PLG. TOTAL COMPENSATION INSURANCI'. (This section need not be completed if the permit is for one Y ❑ N Y ❑ N hundred dollars IS 100) or less.) 1 certify that in the performance of the work for which this per- mit is issued, I shall not employ any person in any manner so as to OTY. MECHANICAL PERMIT FEE FEE SUMMARY BUILDING become subject to the Workers' Compensation Laws of California. Date Applicant ALTER OR ADD TO MECH. 5.00 NOTICE TO APPLICANT: If, after making this Certificate of Ex- emption, you Should become subject to the Workers' Compensation APPLIANCE 5.00 PLAN CHECK provisions of the Labor Code, you most forthwith comply with such provisions or this permit shall be deemed revoked. AIR HANDLING UNIT (TO 10=C.F.M.) 4.00 FEE AIR HANDLING UNIT (OVER 10MC.EM.) 6.00 SEISMIC FEE .J0 CONSTRUCTION LENDING AGENCY I hereby affirm that there is a construction lending agency I'or EXHAUST HOOD (WITH DUCT) 5.00 the performance of the work far which this permit is issued (Sec. 3097, CN,C.). MICROFILM HEATING UNIT (TO 100,000 B.T.U.) 8.00 HEATING UNIT (OVER 100,000 B.T.U.)9.50 ELECTRIC 3Q 1. Lender's Name Lender's Address _ I certify that l 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 BOILER•COMPI3H.P.or100,000B.T.U.) 6.00 PLUMBING gOILER•COMP IOwn 100,000 BTU) SEE FEE SCH. MECHANICAL hereby authorize representatives of This city to enter upon the above-mentioned property for inspection purposes. MISC. - REFER TO ORD. PERMIT ISSUANCE 10.00 CONST. TAX (We) agree to save, indemnify and keep harndess the City of Cupertino against liabilities, judgments, costs and expenses which may in any way accrue against said City in consequence of the grantingofthis permit MECH. CONT. UC. NO. MECH. /_ TOTAL TOTAL Ov signelurcof App ant/Contractor Ute OFFICE COPY .POST THIS CARD NEAR. FRONT OF BUILDING 'PFR CITY OF CUPERTINO' MIT NUMBER 12521 INSPECTION DIVISION JOB INSPECTION RECORD ry��f PERMIT EXPIRATION / 0"a �U l O JOB ADDRESS ./ /!'r-fJK c. A4 UNITLOT# - PERMIT EXPIRES IF WORK OWNERbONTRACTOR IS NOT STARTED WITHIN 180 DAYS OF PERMIT'ISSU- ANCE OR 180 DAYS FROM LAST CALLED INSPECTION. INSPECTION DATE I INSPE TOR INSPECTION RECORD FOUNDATION —3•g USERS - PREGUNITE-' ! n PERMIT vnuonnaN POUR NO CONCRETE UNTIL ABOVE HAS BEEN SIGNED f UNDERGROUND/SLAB PLUMBING IssUANCE DATE' CLECT.1 PLG, iMECH, j ELECTRICAL' MECHAN ICAL 00 NOT POUR FLOOR UNTIL ABOVE'HAS BEEN SIGNED sul DING PERMIT INFORMATION WOOD FLOOR ,- vAhunnoN s/Fr. ` PLUMBING MECHANICAL ELECTRICAL �: +,,:, rk •PERM,n�rto�c„�'P ,,:,, FRAMING - _ '� INSULATION -.. sroales rvPpNsrR. /L•,• RESUUNITS !/ PLACE NO SUBFLOOR UNTIL ABOVE HAS BEEN SIGNED ROOF ' 50 PT. FLOOR AREA •!..✓h dG' TOTAL ACREAGE DIAPHRAGM BUILDING USE IND CON PH OOH L APPLY,NO-ROOFING UNTIL ABOVE HAS BEEN SIGNED iiROUGH • ASSESSORS PARCEL N O. PLUMBING. GAS TEST - - - TRACT NO. PARCEL NO. MECHANICAL. -� ELECTRICAL FINALS DATE INSP. ACC DATE. __7_0N —ING ACC. FILE N0. FRAMING, —� SAN * INSULATION - -may PLUMBING. - ENG. SITE rvo. - GAS ' - MECHANICAL , FIRE SPR,NK' Y ❑ N ENERGY T-24 Y ❑ N❑ COVER NO WORK UNTIL ABOVE HAS BEEN SIGNED HEATING LATH—INTERIOR ELECTRICAL FLOOD ZONE Y ❑ , No A.L,U.C. Y ❑ No LATH -EXTERIOR " - FIRE DEPT. ' SHEETROCK .- GRADE FEESUMMARY SHEAR INTERIOR BUILDING " BUILDING -x +-'EJ;e. SHEAR,EXTERIOR - TEMPORARY APPROVAL FIREWALLS, ELECTRIC - - PLAN CHECK FEE - NO TAPE OR PLASTER UNTIL ABOVE HAS BEEN SIGNED OCCUPANCY SEISMIC FEE ✓ OCCUPANCYOF BUILDING IS NOT PERMITTED UNTIL BUILDING FINALISSIGNED BYSUILDING INSPECTOR. MICROFILM ARRANGE FOR INSPECTION BY PHONING 252-4505, ELECTRIC F�. ONE WORKING DAY BEFORE REQUIRED INSPECTION:' a, PLUMBING 0 PLEASE GIVE JOB ADDRESS WHEN PHONING. Z - —SEE PERMIT FOR EXPIRATION DATE — MECHANICAL CONST. TAX IMPORTANTV TOTAL PLEASE READ REVERSE SIDE BEFORE . CALLING FOR FINAL INSPECTION. ,Y% OFFICE COPY HOSKINS ENGINEERS INC. 501 SOUTH BASCOM AVENUE SAN JOSE, CALIFORNIA 9512e (406) 971 -7500 November 17, 1988 N UV j Odd CITY OF CUPEFIfJU Mr. Reggie Boltz, Owner' Mr. Sam Deleone Sun Valley Roofing 16469 Los Gatos Blvd. Los Gatos, California 95032 Re: Private Residence 10240 Pharlap Drive Cupertino, California Enclosed please find a check for $300.00. This is a reimbursement of the fee paid by your office to this office. This return of fees is intended as a complete nullification of the agreement between you and Hoskins Engineers Inc. As part of this agreement you agreed to return all work performed by this office to this office. You agreed not to utilize the work performed by this office in obtaining your building permit or other permits required by government agencies. You further agreed not to use this information in any way whatsoever. You agreed not to communicate it to your contractors. You agreed not to communicate it to future engineering or architectural consultants. In addition we are notifying the City of Cupertino Building Department by a copy of this letter that we are no longer the "Engineer of record." By endorsing and cashing the enclosed check you agree to all of the above. Please return all of our work to this office as soon as possible. Thank you for your attention to the above. Yours truly, Marlene Delma, Office Manager MDH/mk / • cc: City of Cupertino, V Building Department