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C 8504 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY BUILDING PROJECT I DENTI FI N PERMIT NUMBER pu,Lp,NG APPLICATION & P IT aooREas 8504 X BUILDING -ELECTRICAL-PLUMBING-MECHANICAL !o Ra►,n� Ln OWNER'S I ' NAME PLAN CHECK VALI DATION tV a -iso She PHONE DTV. ELECTRIC PERMIT FEE NoAMFRAcroRS UTLETS-SWITCHES-RECEP 10.00/1.00 1 e r vavn act I D.NO. ?q//GLff LIGHTING FIXTURES 10.00/1.00 r✓ ADNrRAcroRs PPLIANCES-RESIDENTIAL 4.00 ooREss p �/ � /� U"/J ZA17(Fy` - PRONE 71-OI[/ PANELS 10.00 DATE OF APPLICATION OR ARCHITECT PANELS (OVER 200 AMP) 20,00 PLAN CHECK FEE P.L.NO. ENGINEER ��ZZ ,4 4 AMot/z4 a sec.No. (/ SIGNS TRANS. 3.00 noCess ENG' p SPECIAL CIRCUIT 5.00 PERMIT VALIDATION rJ l'O gV0. zip WAJnV EMP.METER OR POLE INS. 20.00 APPLICANT 5 MOTORS ADDRESS SEE FEE SCH. /- '24( -eSERVICE CHANGE PAIM 20.00 '02 LICENSED CONTRACTORS DECLARATION TEMP.POLE - 30.00 a L,u I hereby affirm that I am licensed under provisions of Chapter 9 A 111J, irocil! RAIASVANIIE OA y¢w (commencing with Section 7000)of Division 3 of the Business and - BLDG. CT. L ;;;,*M.AECH. H n- Professions Code,a d myy license is in full force and effect ❑ ❑ ❑ zoo License Class_��-f4 ark--tic.Number;?yOGH� OZ r w' Da[e N/an/.rContractor ( ' —7r7ON City of Cupertino 2 w OWNER-BUILDER DECLARATION B INFORMATION w ;LL n I hereby affirm IItat 1 am exempt from the Contractor's License MISC.- - REFER TO ORD ruOJ Law for the following reaso n,(Sec.7031.5,B usinesS and ProfessionspERMIT ISSUANCE 40.00 VALUATION $/FT. E Code:A ny ci ty or county wh ichreq of res a perm i t t o const ruct a l her, 9dro6 Q Q 4 20 Improve,demolish,Or repair any structure,prior to its ISsllan CC,also ELEC.CONTR. LIC.NO. ELEQ /] DLL requires the applicant for such permit to file a signed statement that TOTAL E( w m he is licensed pursuant to the provisions of the Contractor's License PERMIT TO FIi La.(Chapter 9(commencing with Section 7000)ofDlvislon 3 of the 4 Business and Professions Code)or that he is exempt therefrom and OTV. PLUMBING PERMIT FEE - "F JT IS 0 the basis for the alleged exemption,An b p heapplioao to action malty STORIES TYPE CONSTR. u ; _ by any orethat for nFive permit subjects the applicant toaCivil penally ALTER-DRAIN -WATER (EA.) 5.00 of not more than five hundred dollars(5500)J: ❑ 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 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 docs such work FIXTURES-PER TRAP 5.00 SO.FT.FLOOR AREA TOTAL ACREAGE • himself'Or through his own employees,provided that such improve- ments are not intended or offered for sale.If,however,the building GAS-EA.SYSTEM-1 INC.4 OUTLETS 6.00 or improvement is sold within one year of completion,the owner- GAS EASYSTEM 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.). I 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,BusinessLAWN 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 con(ractor(s)licensed pursuant to the Contractor's License Law. SEWER-SANITARY-STORM EA.200ft/10.00 TRACT NO. PARCEL NO. ❑ tom exempt under Sec. ,B.&I'.C.I'ar Ibis WATER HEATER W/VENTPAID &w on p Owner /_ DJt0 WATER SYSTEM 5A0 ACC.DATE ACC.FILE NO. WORK F-RS'COMPENSA'I'ION DECLARATION WATER TREATING NlAy. 6 . 19 , O fe I herehy affirm that I have a certificate ofconscnt to self-im,ufe. 2 ��` ZONING ENG.SITE NO. or a certificate of Workers'Compensation Insurance,or a certified s^Pf. copy thereof IS c 3800,Lab.C.). AtlL 50 W Cupertino Policy No. ¢�nlf Company_fjf44k4C9j6 ZC/ell- O ❑ Certified copy is hereby furnished. FIRE SPRINK ENERGY T-24 Z Z, ❑ Certified copy is filed WiQ(�l the city inspection division. FO Applicant 5`2041447IOL jd MISC.- REFER TO ORD. Y [3 N� Y [-] NO CC CERTIFICATE OF EXEMPTION FROM WORKERS' PERMIT ISSUANCE "'00 FLOOD ZONE A.L.U.O. W COMPENSATION INSURANCE PLG.CONTR. LIC.NO. PLG. CL Z( This section need not be completed if the permit is for one TOTAL Y E] N Y C] NE hundred dollars(5100)or less.) - C) O 1 certify that in the performance of Om work for which this per- OTY MECHANICAL PERMIT FEE FEE SUMMARY' LL H mit is issued,I shall not employ any person in any manner so as to Ow become subject to the Workers'Compenja;iM LawsofCaliforniu. BUILDING a�SZ CL Date Applirmt IYY�L ALTER OR ADD TO MECH. 5.00 } to NOTICE TO APPLICANT: If,after mak' g this Certificate of Ex- I-., Z emption,you should become subject to the Workers'Compensmion APPLIANCE 5.00 PLAN CHECK provisions of the Labor Code, you must forthwith comply with FEE 3I U such provisions or this permit shall be deemed revoked. AIR HANDLING UNIT(TO 10,000CF.M.) 4.00 rz CONSTRUCTION LENDING AGENCY AIR HANDLING UNIT(OVER iQ000C.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 whiFh this permit is issued(Sec. MICROFILM 3097,Civ..m %F'7 HEATING UNIT(TO 100,000 B.T.U.) 8.00 Lender's Name /I Lender's AddrCsi4 HEATING UNIT(OVER 100,000 B.T.U.)9.50 ELECTRIC I certify that I have read this application and store that the above VENTILATION FAN (SINGLE) 4.00 • information is correct 1 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 100,000BTU)SEE FEESCH. 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 way accrue against said City in consequence of the granting of this permit' ECH.CONT. LIC.NO. TOTAL Z �ruamt�� n i TOTAL /SS3 Signature of Applicant/Contractor Dole OFFICE COPY POST THIS CARD NEAR FRONT OF BUILDING PEAMITNUMBER CIS OF.. CUPERTINO • �� INSPECTION DIVISION 7 JOB INSPECTION RECORD zo/ el /�� PERMIT EXPIRATION fell,JOB ADDRESS '1C�lKL�A'I/ U # � LOT# '"- PERMIT EXPIRES IF WORK- OWNER Mai CONTRACTOR �,/�/1 �(I �G IS NOT STARTED WITHIN INSPECTION DAT INSPECTOR INSPECTION RECORD 180 DAYS OF.PERMIT ISSU. FOUNDATION - - ANCE OR 180'DAYS FROM UFER LAST CALLED INSPECTION. PREGUNITE + PERMIT VALIDATION •- POUR NO CONCRETE UNTIL ABOVE HAS BEEN SIGNED UNDERGROUND /SLAB - PLUMBING ELECTRICAL ' ssuANCE o E MECHANICAL - Bloc ELECT. rLc. MECR. DO NOT POUR FLOOR UNTIL ABOVE HAS BEEN SIGNED BUILDING PERMIT WOOD FLOOR - INFORMATION PLUMBING VALUATION SIFT„ MECHANICAL L' b ELECTRICAL - PEr /ITT FRAMING INSULATION STORIES. TYPE CO • - OCC GROUP RES.UNITS !.PLACE NO SUBFLOOR UNTIL ABOVE HAS BEEN SIGNED ROOF , SO,FT.FLOORAREA TOTAL ACREAGE DIAPHRAGM BUILowc USE RES IND CON PB Otnn -""---- " APPLY NO ROOFING UNTIL ABOVE HAS BEEN SIGNED ❑ ❑ ❑ ❑ ❑ ROUGH nssessoRS PARCEL No. PLUMBING GAS TEST ' TRACT NO. PARCEL NO. MECHANICAL ' ELECTRICAL FINALS DATE INSP. ACC.DATE ACC..FILE NO, FRAMING SAN # ' INSULATION PLUMBING ZONING.' ENG.SITE NO.. ✓��7�� GAS MECHANICAL FIRE SPRINK ENERGY,T-Z5 COVER NO WORK UNTIL ABOVE HAS BEEN SIGNED HEATING Y ❑' No Y ❑ "❑ ' .U.U.C.LATH-INTERIOR � � ELECTRICAL FLOOD ZONE A LATH-EXTERIOR - FIRE.DEPT. v❑ ry❑ Y ❑ N❑ . SHEETROCK • GRADE FEESUMMARYI SHEAR INTERIOR BUILDING SHEAR EXTERIOR TEMPORARY APPROVALS BUILDING FIREWALLS ELECTRIC PLAN CHECK GAS FEE NO TAPE OR PLASTER UNTIL ABOVE HAS BEEN SIGNED OCCUPANCY'. SEISMIC FEE l OCCUPANCYOF 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 - 1z' LUMBING 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. ' - OFFICE COPY - -