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9507APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY BU LDI NG PROJECT I DENTI FICATI ON APPLICATION & PERMIT BUILDING -ELECTRICAL -PLUMBING -MECHANICAL PERMIT NUMBER Q % J 5 O BUILDING ADDRESS22825 San,Juan Road, Cupertino OWNER'S Arianist Province ,f t -hes Pari fir. PHONE 255-2444 QTY. ELECTRIC PERMIT FEE PLAN CHECK VALIDATION CONTRACTORS NAME OWNER LIC. NO. r, OUTLETS-SWITCHES•RECEP 10.00I1.00^,LIZ J LIGHTING FIXTURES 10.00/1.00 CONTRCD ORESOR's AS S APPLIANCES - RESIDENTIAL 4.00 PANELS 10.00 same as above PHONE DATE OF APPLICATION ARCHITECT oR Jack Christenson ENGINEER C 4696 Ruth & Going Sec. No. PANELS (OVER 200 AMP) 20.00 O.00 PLAN CHECK FEE P.C. NO. SIGNS TRANS. - 3.00 ARCH EOR ENO. SPECIALCIRCUIT S.QQ PERMIT VALIDATION 919 The Alameda S.J. ZIP95126 EMP. METER OR POLE INS. 20.00 ,10, 00 •, ) -.. •'r•� APPLICANTS AL°�1 5 San Juan Road, Cupertino MOTOR EE FEE SCH. SERVICE CHANGE 20,00 LICENSED CONTRACTORS DECLARATION TEMP. POLE 30.00 IE 1 hereby affirm that 1 am licensed under provisions of Chapter 9 (rommoncing with Section 7000) DIDivision 3 Df the Busine19 cold Professions Code, and my license is in full force and effect Class Lie. Number ISSUANCE DATE BLDG. ELECT. PLG. MECH. ❑ El El Date Contractor OWNER -BUILDER DECLARATION 1 hereby affirm that I am exempt from the Contractor's License Law fortheity owingreywhich requirsa Basin essand Professions Code: Any city wr which sequinse Permit toconstruct,al ter, D - Q - BUILDING PERMITT�,'; h INFORMATION';" MISC.- R qq�� D 'YV PERMIT ISSUANCE 10.00 0,00 VALUATION $/FT. ' EC. CONTR. LIC. NO. ELEC. - TOTAL / % '' QTY. PLUMBING PERMIT' "' FEE sh rep IlnprOVC, demolish. or Rplllr any structure, prior tO its issuance, aI50 , also requires the applicant for such permit to file a signed statement thatD he is licensed pursuant to the provisions of the Contractor's License Law (Chapter 9(commencing with Section 7000) of Division3ofthe Business and Professions Code) or that he is exempt therefrom and PERMIT TO ELGGT the basis for the alleged exemption. Any violation of Seclion 7031.$ by any applicant for a permit subjects the applicant to a civil penalty of not more than five hundred dollars ($500).): STORIES TYPE CONSTR, ALTER-DRAIN&VENT-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 F LOW PROTECT. DEVICE 4.00 OCC. GROUP RES. UNITS HOOF, AREA, CON D. 5.00 intended or offered for Sale (Sec. 7044, Business and ProfessionsDRAINS-FLOOR, Code: The Contractor's License Law does not apply to an owner of FIXTURES - PER TRAP 5.00 GAS-EA.SVSTEM-1 INC.4OUTLETS 6.00 property who builds or Improves thercon, and who does such work himself or through his own employees, provided that such improve- mentsarenot intended or offered for sale. If, however, the building SO. FT, FLOOR AREA TOTAL ACREAGE or improvement is sold within one year of completion, the owner- builder will have tilt burden of proving that he did not huild or int. prove for purpose of sale.). ❑ 1, as owner of the property, am exclusively contracting with GAS - EA. SYSTEM - OVER 4 (EA.) 2.00 BUILDING USE RES IND CON PS Ott... ❑ ❑ ❑ ❑ ❑ INDUSTRIAL WASTE INTER. 30.00. 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 thereon, and who LAWN SPRINKLERS - 1 INC 5 V.B. 6.00 ASSESSORS PARCEL NO. LAWN SPRINKLERS - OVER 5 (EA.) 1.00 contracts for such projects with a contractors) licensed pursuant to the Contractor's License La w. ❑ I um xempt under Se . ,B.&I'.C. for tills anon SEWER -SANITARY -STORM EA. 200ft/10.00 TRACT NO. PARCEL NO. WATER HEATER W/VENT 6.00 Owner Midtj, WATER SYSTEM 5.00 ACC. DATE ACC. FILE NO. WATER TREATING EQUIP. 5.00 WORK ERS'COMPFNSATll9 DECLARATION I hereby affirm that I have a certificate (it consent to self -insure, ZONING ENG. SITE NO. or a certificate of Workers' Compensation Insurance, or a certified - copy thereoffSec. 3800, Lab.CJ. Policy No. Company MISC.- REFER TO ORD. ❑ Certified copy is hereby furnished. ❑ Certified copy is filed with the city inspeclion division. APPlicint FIRE SPRINK Y ❑ No ENERGY T 24 Y ❑ No CERTIFICATE OF EXEMPTION FROM WORKERS' COhIPIiNSATION INSURANCE (This Section need not be completed if the permit is for one PERMIT ISSUANCE 10.00 FLOODZONE Y ❑ N ❑ A.L.U.C. V ❑ N ❑ PLG. CONTR. LIC. NO. PLG. TOTAL 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 QTY MECHANICAL PERMIT FEE FEE SUMMARY - become subject to the Workers' Compensation laws of California. ALTER OR ADD TO MECH. 5.00 Date Applicant _ - NOTICE TO AI'1'LICANI' If, u0er, making this Certificate of Ex- BUILDING 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 be deemed revoked. AIR HANDLING UNIT (TO 10MC.F.M.) 4.00 AIR HANDLING UNIT(OVER IQ,OODC.FM.) 6.00 SEISMIC FEE CONSTRUCTION L17NDING AGENCY I hereby affirm that there is a construction lending agency for EXHAUST HOOD (WITH DUCT) 5.00 the performance of the work for which this permit is issued (Sec. 3097, Civ.C.L MICROFILM HEATING UNIT (TO 100,000 B.T.U.) 8.00 Lender's Name Lender's Address HEATING UNIT 100,000 B.T.U.) 9.50 ELECTRIC /a 17v VENTILATION FAN (SINGLE) 4.00 I certify that l have read this application and state that lite above information is correct. I agree to comply with all city and county ordinances and state laws relating to building construction, and PLUMBING BOILER- COMP(3 H.P. or 100,000 B.T.U.) 6.00 hereby authorize above- authorize representatives of this city to enter upon the ned property forinsp ofth i purposes. BOILER -COMP (Over 100,000BTU) SEE FEE SCH. MECHANICAL (We) agree to save, indemnify and keep harmless the City of Cupertino against liabilities, jhulhoments, costs and expenses which may in any way a agai st of City in consequence of the MISC. -• REFER TO ORD. CONST. TAX PERMIT ISSUANCE 10.00 gra of this p it. .Sr MECH. CONT. 'LIC. NO. MECH. TOTAL _ TOTAL I91131me of Applicant/Contin or ate M OFFICE COPY • ve I I �_J1 wul L11.1 11mu INSPECTION DIVISION JOB INSPECTION RECORD — �^ r5�� JOB ADORES �� �� f�GS�,FrN r%✓n-'✓ �` % UNIT# _LOT# OWNER /�) r CONTRACTOR 95[17 _ PERMIT EXPIRATION PERMIT EXPIRES IF WORK IS NOT STARTED WITHIN 180 DAYS OF PERMIT ISSU- ANCE OR 180 DAYS FROM LAST CALL EDINSPECTI ON. -- INSPECTION DATE INSPECTOR INSPECTION RECORD FOUNDATION LIFER PREGUNITE PERMIT VALIDATION ISSUANCE DATE POUR NO CONCRETE UNTIL ABOVE HAS BEEN SIGNED UNDERGROUND/SLAB PLUMBING ELECTRICAL MECHANICAL BLDG. ❑ ELECT, ❑ PLG. ❑ I MECH. ❑ 00 NOT POUR FLOOR UNTIL ABOVE HAS BEEN SIGNED BUILDING PERMIT P MINFORMATION VALUATION $/FT. % WOOD FLOOR PLUMBING DE MECHANICAL ELECTRICAL City PERMIT TO ot'Cu ertino FRAMING INSULATION STORIES TYPE CONSTR. DEC, GROUP _ 11(5, UNITS PLACE NO SUBFLOOR UNTIL ABOVE HAS BEEN SIGNED ROOF $1), FT. Fl OG11 AlIFA (DIAL CII(AI:k DIAPHRAGM BUILDING USE HES IND - CON PB 0111,, 0 � ❑ O - Q APPLY NO ROOFING UNTIL ABOVE HAS BEEN SIGNED ROUGH ASSESSORS PARCEL NO. — PLUMBING GAS TEST IHACTNo, PARCEL NO, MECHANICAL ELECTRICALFINALS DATE INSP. ACC. DATE _ ACC, FILE NO FRAMING SAN # INSULATION IPLUMBING ZONING _ ENG SITE NO. GAS MECHANICAL FIRE SPRINK r NC] ENERGY T 24 r.❑ NC] COVER NO WORK UNTIL ABOVE HAS BEEN SIGNED HEATING LATH—INTEfl10RS, ELECTRICAL L _ FLOOD mNF. Y ❑ "❑ A.L.uc. Y ❑ NO LATH—EXTERIOR FIRE DEPT. t(, �_ B`1 SHEETROCK GRADE FEE SUMMARY SHEAR INTERIOR BUILDING BUILDING SHEAR EXTERIOR TEMPORARY APPROVA FIREWALLS JELECTRIC PLAN CHECK FEE GAS NO TAPE OR PLASTER UNTIL ABOV SEISMIC FEE OCCUPANCY OF BUILDING IS NOTPERMITTED UNTIL BUILDING FINAL ISSIGNED . BY BUILDING INSPECTOR. Pc "y a'• 'rs l MICROFILM WARRANGE FOR INSPECTION BY PHONING 252-4505, 1- ONE WORKING DAY BEFORE REQUIRED INSPECTION. z� PLEASE GIVE JOB ADDRESS WHEN PHONING,_- - SEE PERMIT FOR EXPIRATION DATE ELECTRIC PLUMBING MECHANICAL CONST. TAX IMPORTANT! I. PLEASE READ REVERSE SIDE BEFORE CALLING FOR FINAL INSPECTION. TOTAL AN'LICANTS PG:; T tNC CGP 1' .