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10795APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY , '9UILDING PROJECT IDENTIFICATION &PERMIT BUILDING -ELECTRICAL -PLUMBING -MECHANICAL PERMIT NUMBER 10795 BDILOINc Plytl�eAPPLICATION AOORE55 n 22 0 ,Y /� Y I OWNER'S %/ "AME ` �/CITY. ✓/ PHONE /,�'�91,4-- ELECTRIC PERMIT FEE PLAN CHECK VALIDATION DATE OF APPLICATION coNTRAcroR's - NAMEqq tk.�%� /�}-% L.C. ND. UTLETS-SWITCHES-RECEP 10.00/1.00 LIGHTING FIXTURES 10.00/1,00 - CONTRACTORS n ADDRESS C ' Au �Q v PHONE D_/ APPLIANCES- RESIDENTIAL 4.00 PANELS 10.00 RCHRECT OR ENGINEER Elc. No. PANELS (OVER 200 AMP) 20.00 PLAN CHECK FEE P.C. NO. ISIGNS TRANS. 3.00 ARCH, OR ENG. ADDRESS SPECIAL CIRCUIT 5.00 PERMIT VALIDATION TEMP. METER OR POLE INS. 20.00 ZIP ✓,ji` lA /(•/% APPLICANT'S ADDRESS MOTORS SEE FEE SCH. SERVICE CHANGE 20.00 LICENSED CONTRACTORS DECLARATIONc- 1 hereby affirm that I am licensed under provisions of Chapter 9 R&M DATE (commencing with Section 7000) of Division 3 of the Business and Professions Code, u it my license is in full force,,�J'tnm{{{{ •[fe r. License Class Lie- Nrunb .yJ BLDG. I ELEC PLG. I MECH. ❑ Date Cm. factor BUIL I ERMIT OWNER -BUILDER DECLARATION 1 hereby affirm that I am exempt from the Contractor's License Law for the following reason. (Sec. 7031.5, Businessand 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 t0 file a signed statement that he Is licensed pursuant to the provisions of IIIe Contractors LicurSe Law (Chapter 9(commencing with Section 7000) of Division 3 of the Business and Professions Code) or that he is exempt therefrom and the basis for the alleged exemption. Any violation of Section 7031.$ pRMATION A $/FT. S MISC. - REFER TO ORD PERMIT ISSUANCE 10.00 ELEC. CONTE. LIC. NO. ELEC. TOTAL PERMITT f+ CITY. PLUMBING PERMIT FEE 1 STORIES TYPE CONSTR. by any applicant for a permit subjects the applicant to a civil penalty of not more than five hundred dollars (S500)J: ALTER -DRAIN & VENT -WATER (EA.) 5.00 ❑ 1, as owner of the property, Or my employees with wages as the sole compensation, will do the work, and the structure is not intended or offered for Sale (Sec. 7044, Business and I'rofessions Code: The Contractor's License Law does not apply to an owner of properly who IT mills or Improves thereon, and Who does such work BACK FLOW PROTECT. DEVICE 4.00 OCC. GROUP RES. UNITS DRAINS -FLOOR, ROOF, AR EA, COND. 5.00 FIXTURES - PER TRAP 5.00 50. FT, FLOOR AREA TOTAL ACREAGE himself or through his own employees, provided that such improvo- merits are not intended or offered for sale. If, however, the huilding GAS-EA.SVSTEM-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 of sale.). ❑ I, as owner of the property, am exclusively contracting with GAS - EASYSTEM - OVER 4 (EA.) 2.00 . BUILDING USE RES IND CON PB Other ❑ ❑ ❑ ❑ ❑ INDUSTRIAL WASTE INTER. 30.00 LAWN SPRINKLERS - 1 INC 5 V.B. 6.00 LAWN SPRINKLERS - OVER 5 (EA.) 1,00 ASSESSORS PARCEL NO. licensed contractors to construct the project (Sec. 7044, Business and Professions Code: The Contractor's License Law docs not apply to an owner of property who builds or improves thercun, and who contracts 1'or such projects with a comm¢tons) licensed pursuant to the Contractors License Law. SEWER -SANITARY -STORM EA. 200ft/10.00 TRACT NO, PARCEL NO. ❑ I am exempt under Sec. ,B.&P.C. for this reason WATER HEATER W/VENT 6.00 Owner Date 5.00 WATER SYSTEM ACC. DATE ACG FILE N0. WORKERS'COMPENSATION DECLARATION WATER TREATING EOUIP. 5.00 I hereby affirm that I have a certificate of consent to self -insure, or a certificate of Workers' Compensation Insurance, a certified % copy,then of (Sec. 3800=nihcd. POlicy No. Co❑ 20NING ENG. SITE NO. CefliRCd copyh P Certifi islhspection Jivisimt. licanr FIRE SPRINK N ENERGY T-24 ❑A V NCERTIFICATE MISC.- REFER TO ORD.❑❑ OF EXEMPTION FROM WORKERS' PERMIT ISSUANCE 10.00 T4Y OOD 20NE A.L.U.C. PLG. CONTR. LIC. NO. PLO . TOTAL COMPENSATION INSURANCE (This section need not be completed if the permit is for one V ❑ N❑ Y ❑ N❑ CITY. MECHANICAL PERMIT FEE FEE SUMMARY hundred dollars (S 100) or less.) I 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 BUILDING Gv become subject to the Workers' Co in pensut ion Laws of California Date Applicant NOTICE TO APPLICANT: If, after making this Certificate of Ex- ALTER OR ADD TO MECH. 5.00 APPLIANCE 5.00 PLAN CHECK emption, you should become subject to the Workers' Compensation provisions of the Labor Code, you must forthwith comply with such provisions or this permit shall be deemed revoked. FEE AIR HANDLING UNIT (TO 10)000C.F.M.) 4.00 AIR HANDLING UNIT (OVER 10=C.F.M.) 6.00 SEISMIC FEE CONSTRUCTION LENDING AGENCY I hereby affirm that there is a construction lending agency for the performance of thework 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 NO UN IT (OV ER 100,000 B.T.U.) 9.50 ELECTRIC Lender's Name Lender'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 BOILER H.P. or 100,000 B.T.U.) 6.00 _PLUMBING - BOILER -COMP (Over 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. CONST. TAX e, ' unify and keep harmless the City of Chies judgments, costs and expenses which mcru gainst id City in consequence Of the gr'. im,2%-�lp PERMIT ISSUANCE 10.00 MECH. CONT. LIC. NO. MECH. roTAL TOTAL a S J ig of rei ol'Alfpficant/Cothractifir Date OFFICE COPY Mali�, POST THIS CARD -NEAR FRONT OF BUILDING • CITY OF CUPERTINO INSPECTION DIVISION JOB INSPECTION RECORD �j JOB ADOR ESS r/e+ U # LOT# OWNER CONTRACTOR PPAMII NUMBER 10795 PERMIT EXPIRATION PERMIT EXPIRES IF WORK IS NOT STARTED WITHIN 180 DAYS OF PERMIT ISSU- ANCE OR 180 DAYS FROM LASTCALLED INSPECTION. INSPECT4bN DATE I INSPECTOR INSPECTION'RECORD FOUNDATION - LIFER PREGUNITE PERMIT VALIDATION I UANCE DATE POUR NO CONCRETE UNTIL ABOVE HAS BEEN SIGNED— UNDERGROUND/SLAB PLUMBING - ELECTRICAL MECHANICAL BLDG, LECT, ❑ PLG. MECH. ❑ ❑ DO NOT POUR FLOOR UNTIL ABOVE HAS BEEN SIGNED BUILDING PERMIT INFORMATION WOOD FLOOR VALUATION $/FT. PLUMBING MECHANICAL ELECTRICAL PERMIT TO FRAMING INSULATION STORIES TYPE CrhSTFL - OCC, GROUP RES, UNITS PLACE NO SUBFLOOR UNTIL ABOVE HAS BEEN SIGNED ' ROOF SO, FT, FLOOR AREA TOTAL ACREAGE DIAPHRAGM ILDING USE RES 0 CON P9 Olne, ❑ El ❑ IIIIAPPLY NO ROOFING UNTIL ABOVE HAS BEEN SIGNED❑ '.ROUGH " ASSESSORS PARCEL NO. PLUMBING GAS TEST TRACT NO, PARCEL NO, MECHANICAL ELECTRICAL FINALS ' DATE INSP. ACC. DATE ACG FILE NO FRAMING -Z _ (� SAN # INSULATION PLUMBING ZONING ENG. SITE NO. GAS MECHANICAL FIRE SPRINK Y ❑ N❑ ENERGY T,24 Y ❑ N❑ COVER NO WORK UNTIL ABOVE HAS BEEN SIGNED HEATING LATH -INTERIOR I ELECTRICAL FLOOD ZONE Y❑ N❑ ALUC. . , Yo N❑ LATH -EXTERIOR FIRE DEPT. SHEETROCK GRADE FEE SUMMARY SHEAR INTERIOR - BUILDING BUILDING _ SHEAR EXTERIOR TEMPORARY APPROVALS FIREWALLS ELECTRIC - PLAN CHECK FEE GAS NO TAPE OR PLASTER UNTIL ABOVE HAS BEEN SIGNED OCCUPANCY SEISMIC FEE OCCUPANCYOF BUILDING IS NOT PERMITTED UNTIL BUILDING FINALISSIGNEDBY BUILDING INSPECTOR. MICROFILM ARRANGE FOR INSPECTION BY PHONING 252.4505, F� ONE WORKING DAY BEFORE REQUIRED INSPECTION. z PLEASE GIVE JOB ADDRESS WHEN PHONING. - SEE PERMIT FOR EXPIRATION DATE - ELECTRIC PLUMBING MECHANICAL CONST. TAX IMPORTANT! PLEASE READ REVERSE SIDE BEFORE ' CALLING FOR FINAL INSPECTION. TOTAL OFFICE COPY a