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11077APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE B+ POINT PEN ONLY BU I LDING'PROJECT I DENTI FICATPERMIT "APPLICATION & PERMIT — ELECTRICAL— PLUMBING — MECHANICAL NUMBER 1107 BUILDING ADDRESS (� p Ovj f 0fil .7"�,LQ ((smBUILDING fvGCS OWNER S . NAME /�Ms�E �,/� ( 9 / FHDNE —'J ( QTY. ELECTRIC PERMIT FEE PLAN CHECK VALIDApIOy a S-- CONTRACTOR I NAME rolls OUTLETS -SWITCHES -RECEP 10.00/1.00 LIGHTING FIXTURES 10.00/1.00 LIC, NO. CONTRAS ADDRESS APPLIANCES- RESIDENTIAL 4.00 PANELS 10.00 PHONE DATE OF APPLICATION ORCHITECT ENGINEER LIC. NO. PANELS (OVER 200 AMP) 2000 PLAN CHECK FEE P.C. NO. SIGNS TRANS. 3.00 ADDRESS ENG. SPECIALCIRCUIT 5.00 PERMIT VALIDATION TEMP. METER OR POLE INS. 20,00 ZIP Q D; s APPLICANTS ADDRESS MOTORS SEE FEE SCH. SERVICE CHANGE 20.00 � __10-� f; {q_ LICENSED CONTRACTORS DECLARATION 1 hereby affirm that I am licensed under provisions of Chapter 9 CE DATE (commencing with Section 7000) of Division 3 of the Business and Professions Code, and my license is in full force and effect. License Class Lin. Number ELECT. PLG. MECH. ❑' ❑ ❑ ❑ Dam Contractor OWNER.BUILDER DECLARATbN 1 hereby affirm that I am exempt from the Contractor's License Law for the following mason. (Sec. 7031.5. Businessand Professions Code: Any city or county which requirese permit to Construct, alter, BUILDING PERMIT ' 'INFORMATION 1 MISC. — REFER TO ORD PERMIT ISSUANCE 10.00 VALUATION $/FT. ELEC. CONTR. LIC NO. EIEC. TOTAL CITY. PLUMBING PERMIT FEE s isstmnce, also improve, e applicant repair h permit to File R signed requirestheapplicantfor suchpermitto files Signedstatement that he is licensed pursuant to the provisions of the Contractor's License ase Law (Chapletand therefion om the Business and Pm Professions s Code) or that he is exempt there rem and odeng ) or Section is 00) exempt and PERMIT TO Yn /\f—•A-1 /\ / lleged of Section malty the basis basis for the alleged exemption. Any applicant by any applicant fora permit subjectsthe $500licant toacivil penalty of not more than five hundred dollars [$500)J: STORIES TYPE CONSTR. ALTER-DRAIN&VENT-WATER(EA.) 5.00 ❑ 1, as owner of the property, or my employees with wages as their role compensation, will do the work, and the structure is nut BACK FLOW PROTECT. DEVICE 4,00 OCC. GROUP RES. UNITS DRAINS -FLOOR, ROOF, AREA, COND. 5.00 intended or offered for sale (Sec. 7044, Business and Professions Code: The Contrac(or's License Law does not apply to an owner of F IXTUR ES - PER TRAP 5.00 GAS - EA. SYSTEM - i INC. 4 OUTLETS 6.00 property who builds or improves thereon, and who does such work himself or through his own employees, provided that such improve. mems are not intended oroDered For sale. If, however, the building SQ FT. FLOOR Afl EA TOTAL ACREAGE or improvement is sold within one year of completion, the owner. builder will have the burden of proving that he did not build or tm- GAS - EA. SYSTEM -OVER 4 IEA.) 2.00 BUILDING USE prove for purpose of sale.). ❑ 1, as owner of the property, am exclusively contracting to RES IND CON PS Other ❑ ❑ 0 ❑ 0 INDUSTRIAL WASTE INTER. 30.00 licensed contractors to construct the project (Sec. 7044, Business end Professions Code: The Contractor i License Law does not apply LAWN SPRINKLERS - 1 INC 5 V.B. 6.00 ASSESSORS PARCEL NO. to an owner of properly who builds or improves thereon, and who LAWN SPRINKLERS - OVER 5 (EA.) 1.00 mntructs for Such projects with a contractor(.,) licensed punuont to the Contractor's License Law, D I um exempt under Sec. ,B.&P.C. for this reason SEWER -SANITARY -STORM EA. 200ft/10,00 TRACT NO, PARCEL NO. WATER HEATER W/VENT 6.00 Owner I Date WATER SYSTEM 5.00 ACC.DATE ACC. FILE NO. WATER TREATING EQUIP. 5,00 WORK ERS'COMPEN A'�1 NDE/p. ARATION 1 hereby affirm ]hat I hove a <ertillcatc J consent to self -insure. or a evnificate of Workers' Compensation Insurance, or it certified ZONING ENG. SITE NO. copy thereof (See. 3800, Lab.C.). Policy No.Company ❑ CeRiftedcopy is hereby furnished. ❑ Certified copy is fled with the city inspection division. Applicant FIRE SPANK Y[:] N[ ENERGY T-24 Y0 IN MISC.- REFER TO ORD. CERTIFICATE 01' EXEMPTION FROM WORKERS' COMPENSATION INSURANCE: — ''PLG. 0 his section need not be completed if the permit is for one PERMIT ISSUANCE 10.00 FLOOD ZONE Y N� A.L.U.C. Y No CONTR. LIC. NO. PLG. TOTAL hundred dollars 1$100) or less.) I certify that in the performance of the work for which this per- mil is issued, I shall not employ any person in any manner so as to CITY. MECHANICAL PERMIT FEE FEE SUMMARY BUILDING 3�S-a be- nln subject to the Workeni Compers tion Laws of California. Date Applicant ALTER OR ADD TO MECH. 5.00 NOTICE TO APPLICANT: If, after making IN, Certificate of IIx APPLIANCE 5.00 _ PLAN CHECK FEE 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 he deemed invoked. AIR HANDLING UNIT (TO 10000 C F.M.) 4,00 AIR HANDLING UNIT (OVER 10,000CEM.) 6.00 SEISMIC FEE If—& CONSTRUCTION LENDING AGENCY I hereby affirm that tare is a constructir n ]coding agency f.. EXHAUST HOOD (WITH DUCT) 5.00 the performance of the work for which this murnit is issued (5ec. 3097, Civ.C.). MICROFILM HEATING UNIT (TO 100,000 B.T.U.) 8.00 Lender's Name Lender's Address HEATING UNIT (OVER 100,000 B.T.U.) ELECTRIC VENTILATION FAN (SINGLE) 4.00 I cert ify that] have read l his application and slate that the above information is correct. I agree to comply with all city and county ordinances inances and stale laws relating building construction, and PLUMBING BOILER -COMP 13 H.P.OT 100,000 B.T.U.) 6.00 hereby authorize representatives of this City to enter upon the above-nse hentioned property for inspection purpos. 801 LER-COMP (Over 100,000 BTU] SEE FEE SCH. MECHANICAL (We) agree to save, indemnify and keep harmless the City of MISC. - REFER TO ORD, Cupertino against liabilities, judgments, costs and expenses which may in any way accrue against a II C'ty in consequence of the granting Of this pC011il. / 2S 1/O PERMIT ISSUANCE 10.00 CONST. TAX MECH. CONT, LIC. NO, MECH, TOTAL TOTAL c�—J" mlinaturd OT ApplinfttlC=Gr I, IF Date OFFICE COPY Wo POST THIS"^. RD NEAR FRONT OF BUILDING . I� CI r'90 Ft U PE RT W 0 INSPECTION DIVISION JOB IN ECTION RECORD - JOB ADDRESS lo0q UNIT# LOT# OWNER CONTRACTOR PERMIT NUMBER 11077 > , PERMIT EXPIRATION ' PERMIT EXPIRES IF WORK IS NOT' STARTED WITHIN 180DAYSOF PERMIT ISSU- ANCE OR 180 DAYS FROM r LAST CALLED INSPECTION. INSPECTION I DATE I INSPECTOR INSPECTION RECORD FOUNDATION - LIFER PREGUNITE PERMIT VALIDATION P. ISSUANCE DATE POUR NO CONCRETE UNTIL ABOVE HAS BEEN SIGNED UNDERGROUND/SLAB PLUMBING ELECTRICAL MECHANICAL BLDG. ELECT. PLG. ME 00 NOT POUR FLOOR UNTIL ABOVE HAS BEEN SIGNED ' 7 BUILDING PERMIT INFORMATION WOOD FLOOR VALUAT ON - $/FT. PLUMBING" - MECHANICAL ELECTRICAL PERMIT TO FRAMING INSULATION STORIES TYPE CONSTR, - OCG GROUP RES. UNITS PLACE NO SUBFLOOR UNTIL ABOVE HAS BEEN SIGNED ROOF SQ FT. FLOOR AREA TOTAL ACREAGE DIAPHRAGM' ' BUILDING USE R WD CON PB Other 1:1 I] 0 ❑ APPLY NO ROOFING UNTIL ABOVE HAS BEEN SIGNED ROUGH ASSESSORS PARCEL NO. , PLUMBING GAS TEST � , TRACT NO. PARCEL NO, MECHANICAL - ELECTRICAL FINALS ., ACCGATE . , ACCFILE NO, FRAMING SAN # ' INSULATION PLUMBING ZONING ENG. SITE NO. REINSP. GAS -FIRE $PRINK v ru� ENERGYT2A v ❑ Np MECHANICAL COVER NO WORK UNTIL ABOVE HAS BEEN SIGNED HEATING LATH -INTERIOR ELECTRICAL FLOOD ZONE v[] NE] A.L.U,C. vo N❑ LATH -EXTERIOR FIRE DEPT. SHEETROCK GRADE )?47 j,,q�14 IF - •- FEE SUMMARY SHEAR INTERIOR BUILDING- BUILDING SHEAR EXTERIOR TEMPORARY APPROVALS FIREWALLS ELECTRIC PLAN CHECK FEE • GAS PLASTER UNTIL ABOVE HAS BEEN SIGNED OCCUPANCY SEISMIC FEE 7TAPER YOF BUILDING IS NOT PERMITTED UNTIL BUILDING FINAL IS SIGNED BY BUILDING INSPECTOR. MICROFILM - ARRANGE FOR INSPECTION BY PHONING 252-4505, ONE WORKING DAY BEFORE REQUIRED INSPECTION. PLEASE GIVE JOB ADDRESS WHEN.PHONING. - SEE PERMIT FOR EXPIRATION DATE - ELECTRIC PLUMBING MECHAN1cAL CONST. TAX IMPORTANT! PLEASE READ REVERSE SIDE BEFORE CALLING FOR FINAL INSPECTION: TOTAL OFFICE COPY