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8424LWA • Z2 HO Cc W - d O D Z UO LL U Ow } a A 0 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY BUILDING PROJECT IDENTIFICAT APPLICATION & PER BUILDING - ELECTRICAL- PLUMBING - MECHANICAL BER C74424 BUILDING ADDRESS OWNERS ' TION NAME QTY. ELECTRIC PERMIT FEE PHONE _ croR's NAME NAME UTLETS- SWITCHES -RECEP 10.00/1.00 LIGHTING FIXTURES 10.00/1.00 L"•�r DATE OF APPLICATION E4CTOE'S ADDlJ.�y.• CONTRAS RS (+ %� /-/LV S'S V, PHONE y�.�3 q- APPLIANCES -RESIDENTIAL 4.00 PANELS 10.00 ARCHITECT OR ENGINEER . a� �(i( uc. No. PANELS (OVER 200 AMPI 2Q.00 PLAN CHECK FEE P.L. NO. SIGNS TRANS. 3.00 ARCH.OR ENG- SPECIAL CIRCUIT 5.00 PERMIT VALIDATION EMP. METER OR POLE INS. 20.00 7/ i lsf S + • Zo, kl / j� dr APPLICANT ABOREsMOTORS SEE FEE SCH. SERVICE CHANGE 20.00 LICENSED CONTRACTORS DECLARATION TEMP. POLE 30.00 I hereby affirm that I am licensed under provisions of Chapter 9 ISSUA CE DATE (commencing with Section 7000) of Division 3 of the Business and Professions Code d y license is in full for a effEc License Cl'ss Lie. Numbe _ J BLDG. ELECT. PLG. MECH. ❑ ❑ ❑ Date Contractor O r DING PERMIT BUILORMATION OWNER -BUILDER DECLARATION 1 hereby collo that 1 am exempt from the Contractor's o License a. Business and Professions Law for the following reason. (See. requires Code: Any city or county which requirese permit to construct, alter, improve, demolish, Or repair any SINCtnfC, prior IV IIS ISSl1anCC, aI50 requires the applicant for such permit to file a signed swtcment that he is licensed pursuant to the provisions of the Contractor's License INFORMATION MISC.- REFER TO OR ION S/FT. PERMIT T PERMIT ISSUANCE 10.00 ELEC. CONTE. LIC. NO. ELEC. TOTAL Clt 0 QTY. PLUMBING PERMIT FEE Law (Chapter 9(commencing with Section 7000) of Division 3 ofthe Business and Professions Code) or that he is exempt therefrom and ��TyC%('i,1 )ee STORIES TYPE CONSTR. the basis for the alleged exemption. Any violation ol'Section 7031.5 I by any applicant for a permit subjects the applicant toa civil penalty of not more than five hundred dollars (8500)): ALTER-DRAIN&VENT-WATER IEA.) 5.00 ❑ I, as owner of the properly. or my employees with wages as their sole compensation, will do the work, and the Structure is not 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 Contractor's License Law does not apply to all owner of property who builds or improves thereon, and who does such work FIXTURES - PER TRAP 5.00 SO. FT. FLOOR AREA TOTAL ACREAGE himself or through ]its own employees, provided that such improve- mems are not intended or offered for sale. If, however, the building GAS - EA. SYSTEM- 1 INCA OUTLETS 6.00 or improveinent is sold within one year of Completion, the owner- builder will have the burden o1' proving that he did not build or im- prove for purpose Li - ❑ 1, as owner of the property, um exclusively contracting with - GASEA. SYSTEM - OVER 4 (EA.) 2.00 BUILDING USE RES IND CON PB On., ❑ ❑ ❑ ❑ ❑ 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 does not apply in an owner of property who builds or improves thereon, and who contracts for such projects with a contractors) licensed pursuant EO the Commctm's License Law. SEWER -SANITARY -STORM EA. 200Lt/10.00 TRACT NO. PARCEL NO. O I am exempt under Sec.-, B.&P.C. tin this eason WATER HEATER W/VENT 6.00 Owner Date WATER SYSTEM 5.00 ACL. DATE ACC. FILE NO. WATER TREATING EQUIP. 5.00 WORK ERS'COMPENSATION DECLARATION ' I hereby affirm that I have a cern acute of consent to sel&Inaue, or a certificate of Workers' Compensation Insurance, or a certified ZONING ENG. SITE NO. copy thereof(Scc. 3800, Lab.CJ. - PNo Conspmly . ZCedtfied copy is hereby furnished. CW B+ O1G %S� FIRE SPRINK ENERGY T 24 ❑ Certified copy is filed with Ehc city inspection division. Applicant Y ❑ IN Y ❑ N❑ i MISC. - REFER TO ORD. CERT[P[CAT 1: OF liX E M PI'I ON 17 ROM WO R K E RS' PERMIT ISSUANCE 10.00 FLOOD ZONE A.L.U.C. PLG. CONTE, LIC. NO. PLG. TOTAL COWIPENSA'I'ION INSURANCE ('Phis section need not be completed if the permit is for one Y ❑ N❑ Y ❑ N❑ MECHANICAL PERMIT FEE FEE SUMMARY hundred dolims($100) m Iess) I certify that in the performance of lite work for which this perQTY. mit is issued, I shell not employ any person in any manner so as to BUILDING become subject to the Workers' Compensation Laws of California. Dale ApplicmR NO'1'ICF TO APPLICANT': If, after making this Certificate of Ex- ALTER OR ADD TO MECH. 5.00 APPLIANCE 5.00 PLAN CHECK FEE �b 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. AIR HANDLING UNIT (TO 10=C.F.M.) 4.00 AIR HANDLING UNIT(OVER 10PMC-F.M.) 6.00 SEISMIC FEE �a CONSTRUCTION LENDING AGENCY I hereby affirm that there is a construction lending agency for the performance of the work 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.) 6.00 HEATING UNIT (OVER 100,000 B.T.U.) 9.50 ELECTRIC Lender's Name Lender's Address I certify that I have read this application and slate Out the above information is correct. 1 agree to comply with all city and county ordinances and state laws relating to building mlntruction, and VENTILATION FAN (SINGLE) 4.00 PLUMBING BOILER-COMP(3 H.P. Or 100,BTU B.T.U.) 6.00 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. (We) agree to save, imhooify and keep hanmess the City Ot Cupertino against liabilities judgments, costs and expenses which Sway accrue RISE said City in consequence of the CONST. TAX PERMIT ISSUANCE 10.00 CONT. LIC. NO. MECH TOTAL TOTAL �� A7 •matin• his permit. 1 are ol'Ap ice o tractor Ddo OFFICE COPY POST THIS CARD NEAR FRONT OF BUILDING CIT*F CUPERTINO INSPECTION DIVISION JOB INSPECTION RECORD /)/') �K•f /'�y�/ �� ] JOB ADDRESS 10(oO/ P[2L 'FiV W NIT# LOT 4: • OWNER CONTRACTOR RN"1QQNUf/MRER , ,642 j � PERMIT EXPIRATION PERMIT EXPIRES IF WORK IS NOT STARTED WITHIN 180 DAYS OF PERMIT IROM ANCE OR 180 DAYS FROM LASTCALLED INSPECTION. INSPECTION DATE INSPECTOR INSP CTION RECORD FOUNDATION LIFER PREGUNITE PERMIT VALIDATION ' ISSUANCE DATE POUR NO CONCRETE UNTIL ABOVE HAS BEEN SIGNED UNDERGROUND/SLAB PLUMBING ELECTRICAL MECHANICAL - ELECT. PLG.MECH. DO NOT POUR FLOOR UNTIL ABOVE HAS BEEN SIGNED suIL PERMIT INFORMATION WOOD FLOOR PLUMBING MECHANICAL. ELECTRICALFRAMING - 'INSULATION tN$/FT. CONSTR. . UNITSPLACE NO SUBFLOOR UNTIL ABOVE HAS BEEN SIGNED ROOF - ' ACR[A(iL DIAPHRAGM BUILDING USE HIS TND CON PE Onus ❑ ❑ ❑ ❑ ❑ APPLY NO ROOFING UNTIL ABOVE HAS BEEN SIGNED ASSESSORS PARCEL NO. ROUGH PLUMBING - GAS TEST TRACINO. PARCELNO. MECHANICAL - ELECTRICAL FINALS DATE INSP. ACC. DATE ACC. FILE NO. FRAMING SAN # ZONING ENG. SITE NO. INSULATION PLUMBING GAS FIRE SPRINK Y ❑ N[:] E ERGY LiO v ❑ No MECHANICAL COVER NO WORK UNTIL ABOVE HAS BEEN SIGNED HEATING FLOOD ZONE ❑ No A. L. U.C. Y o N❑ LATH -INTERIOR ELECTRICALY LATH -EXTERIOR FIRE DEPT. SHEETROCK GRADE FEE SUMMARY SHEAR INTERIOR BUILDING - BUILDING SHEAR EXTERIOR TEMPORARY APPROVALS FIREWALLS ELECTRIC PLAN CHECK FEE GAS SEISMIC FEE NO TAPE OR PLASTER UNTIL ABOVE HAS BEEN SIGNED JOCCUPANCY OCCUPANCY OF BUILDING ISNOTPERMITTED UNTILBUILDING FINAL ISSIGNED BY BUILDING INSPECTOR, MICROFILM ARRANGE FOR INSPECTION BY PHONING 252-4505, � ONE WORKING DAY BEFORE REQUIRED INSPECTION. z� PLEASE GIVE JOB ADDRESS WHEN PHONING. —SEE PERMIT FOR EXPIRATION DATE — ELECTRIC PLUMBING MECHANICAL coNsr. rnx IMPORTANT! PLEASE READ REVERSE SIDE BEFORE CALLING FOR FINAL INSPECTION. TOTAL' 11 OFFICE COPY APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY BU LDI NG PROJECT I DENT] FICATI ON APPLICATION & PERMIT . BUILDING - E?LECTRICAL-PLUMBING -MECHANICAL ERMIT NUMBER 4424 BUILDING ADDRESS • O fj'S91220 NAME OTY. ELECTRIC PERMIT FEE HECK VALIDATION PHONE NAME OUTLETS - SWITCHES -RECEP 10.00/1.00 LIGHTING FIXTURES 10.00/1.00 us.. NO. T A s ADDRESS �.�,. PPLIANCES- RESIDENTIAL 4.00--e' PANELS 10.00 PHONE DATE OF APPLICATION A TELT OR PANELS (OVER 200 AMP) 20.00 PLAN CHECK FEE P.C. NO. ENGINEER LIC. NO. SIGNS TRANS. 3.00 moo ESS E SPECIAL CIRCUIT 5.00 PERMIT VALIDATION EMP. METER OR POLE INS. 20.00 ZIv / 'AP As ADDRESS MOTORS SEE FEE SCH. SERVICE CHANGE 20.00S -- LICENSED CONTRACTORS DECLARATION TEMP. POLE 30.00 I hereby affirm that 1 in licensed under provismnsof Chapter 9 (commencing with Section 7000) of Division 3 of the Business and: Professions Code, and my license is in fall force and effect. License Class-� { Lie. Number 4Z -?t❑ DateConlmaor ISSUANCE DATE + BLDG. ELECT. PLG. MECH. BUILDING PERMIT INFORMATION O VNER-BUILDFR DECLARATION I hereby affirm tlum I sm exempt from the inessaclor',c I -scion, Law lotrtire ycitylorcountson.(Sue.7031S,er iinessandProfessions Code: Any city or county which strains a permit to construct, ,Bap improve, demolish, or repair any structure, prior to its issuance, also requires the applicant for such permit to file a signed statement that he is licensed pursuant to the provisions of the Contractor's License MISC.- REFER TO ORD PERMIT ISSUANCE 10.00 VALUATION $/FT. ELEC. CONTR. LIG NO, ELEC. TOTAL PERMIT TO - OTY. PLUMBING PERMIT FEE Law (Chapter 9 (commencing with Section 7000) of Division 3 of the Business and Professions Code) or that he is exempt therefrom and A.LI r STORIES TYPE CONSTR. the basis for the alleged exemption. Any violation of Sect ion 703 1. 5 by any applicant for a permit subjects the applicant on civil penalty of not more than five hundred dollars ($500).): - ALTER -DRAIN -WATER (EA.) 5.00 ❑ I, as owner of the property, or my employees with wages as their sole compensation, will do the work, and the structure is not 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 Contractors License Law does not apply to on owner of property Who builds or Improves thereon, and who does such work himself or through his own employees, provided that such improve- mentsarenotintendedorofferedforsale. If. however, the building FIXTURES - PER TRAP 5.00 SO. 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 im- Prove for purpose of sale.).RES 0 1, as owner of the property, am exclusively contracting with GAS - EA. SYSTEM -OVER 4 (EA.) 2.00 BUILDING USE -IND CON PB Other ❑ ❑. ❑ ]NDUSTRIAL WASTE INTER. 30.00 licensed contractors to construct the project (Sec. 7044, Business 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 - 1 INC 5 V.B. 6.00 LAWN SPRINKLERS - OVER 5 (EA.) 1.00 -0,'❑ ASSESSORS PARCEL NO. tumancts for such projects with o cuntractor(s) licensed pursuunt to the Contractor's License Law. -STORM EA. 2001t.00 SEWER -SAN V /10 TRACT NO. PARCEL NO. 0 Imo exempt, under See.-, B.&P.C. lar this reasonI Il WATER HEATER W/VENT 6.00 Owner Unto WATER SYSTEM 5.00 ACC.DATE ACCI FILE NO. WATER TREATING EQUIP. 5.00 WORKERS'COMPENSATION DECLARATION I hereby affirm that I have a certificate ofconsent to self -insure. or a certificate of Workers' Compensation Insurance, or certified ZONING ENG. SITE Na. copy thereof (Sec. 3800, Lab.C.). - Policy No. Company .,�,.p,s{..�®• - •7si MISC. - REFER TO ORD. FIRESPRINK Y ❑ N ❑ E ERGV T 24 #- v ❑ N❑ .p�Certiliedcopyishereby furm 2/ Cert ified copy is Filed with the cut 'unsp Mlon wino Applicant . CERTIFICATE OP EXEMPTION FROM WORKERS' PERMIT ISSUANCE 10.00 FLOODZONE/ A.L.UC. PLG.CONTR. LIC. NO. 1'PLG. TOTAL COMPENSATION INSURANCE ('Phis section need not be completed if the pe nuit is Ibr one Y ❑ NEI Y ❑ N QTY. MECHANICAL PERMIT FEE FEE SUMMARY hundred dollars IS 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 become subject to the Workers' Compensation Laws of California. Date Applicam ALTER OR ADD TO MECH. 5.00 NOTICE TO APPLICANT: IL after making this Certificate of Ex - coalition, 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 revoke APPLIANCE 5.00 PLAN CHECK FEE /(,d f AIR HANDLING UNIT (TO 10,0170C.F.M.) 4.00 AIR HANDLING UNIT(OVER 10PMC.F.M.) 6.00 SEISMIC FEE CONSTRUCTION LENDING AGENCY I hcrcby, affirm that there is a construction Icndlng agency In, 3097j°ce of the work for whiBh this permit is issued (Sea .CiYC EXHAUST HOOD (WITH DUCT) 5.00 MICROFILM HEATING UNIT (TO 100,000 B.T.U.) 8.00 HEATING UNIT (OVER 100,000 B.T.U.19.50 ELECTRIC '+ Lender's Name Lender's Address 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 ordinances and state laws relating to building construction, and PLUMBING BOILER-COMP13 H.P. Dr 100,000 B:T.U.) 6.00 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. (Wa) agree to save, indemnify and keep harmless the City of Cupertino against liabilities, judgments, costs and ex Peroses which ma an way accrue a RRI said City in consequence of the CONST. TAX PERMIT ISSUANCE 10.00 10.00 . Ifillitlg of is permit. MECH. CONT. LIC. NO. MECH, ro TOTAL TOTAL `/ 7 an onfactrrsI INSPECTOR COPY