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13600APPLICANT TO FILL IN INFOWATION WITHIN RED LINES - USE BALL POINT PEN ONLY BU LDI NG PROJECT I DENTI FIC BUILDING ADDRESS ��C� Cit �S 7l d. �4W 1�4V APPLICATION & PE T BUILDING -ELECTRICAL -PLUMBING -MECHANICAL PERMIT NUMB 13600 OWNER'S NAME 01f),kOA vcch14) �(DHONE 151-44:1`9 QTY. . ELECTRIC PERMIT FEE 1 PLAN CHECK VALIDATION DATE OF APPLICATION CONTRACTOR'S rr��AME SS�iea 4CLIDJ1710L LIC, No. M(001.9 UTLETS-SWITCHES-RECEP 10,00/1.00 LIGHTING FIXTURES 10.00/1.00 CONTRACTOR S alo�o�REss p /� ' .4p� 6� Gv-}- D.` PHONE / GVIJ�/ APPLIANCES -RESIDENTIAL 4.00 PANELS 1Q.QQ ARCHITECTPANELS OR ENGINEER LIC,NO. (OVER 200 AMP) 20.00 PLAN CHECK FEE P.C. NO. SIGNS TRANS. 3.00 ARCH. OR ENG. ADDRESS SPECIAL CIRCUIT 5,00 PERMIT VALIDATION TEMP. METER OR POLE INS. 20.00 ZIP APPLICANTS ADDRESS MOTORS SEE FEE SCH. SERVICECHANGE 20.00 % q �1//�/ LICENSED CONTRACTORS DECLARATION - i' I hereby affirm that I am licensed under Provisions of Chapter 9 ISSU DATE (commencing with Section 7000) of Division 3 of the Business and Professions Code, and m license is in full force sd, effect. License lass'Br: a Lic. Num 11 RLOG, I ,� `Y -tB j� Lf PLG. MECH. ❑ ❑ Date Contracto BUILDING PERMIT OWNER -BUILDER DECLARATION I hereby affirm that I am exempt from the Contractor's License Lewforlhe following reason. (Sec. 7031.5, Business and Professions Code: Any cityorcounly which requires a permit to constract,alteq improve, demolish, or repair any structure, prior t0 its issuance, also requires the applicant for such permit to file a signed statement that he is licensed pursuant to the provisions of the Contractors License Law(Chapter 9(commencingwith Section 7000) of Division 3 oflhe Business and Professions Code) or that he is exempt therefrom and INFORMATION MISC. - REFER TO ORD VALUATION SIFT. PERMIT ISSUANCE 10.00�s ELEC. CONTR. LIC. NO. ELEC. TOTAL PERMIT DTV. PLUMBING PERMIT FEE -' STORIES ECONSTR. TYPE CONSTR. the basis for the alleged exemption. Any violation of Section 7031.5 ALTER -DRAIN -WATER IEA.) 5.00 by any applicant for a permit subjects the applicant toacivilpenalty of not more than five hundred dollars (S500)J. ❑ 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 DCC. 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 an 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 -11 NC. 4 OUTLETS 6.00 or improvement is sold within one year of completion, the owner- builder will have the burden of proving (h at he did not build or mi. prove for purpose of sale.). I, as owner of the property, am exclusively contracting with . .. GAS - EASYSTEM -OVER 4 (EA.) 200 BUILDING USE RES IND CON PB Omer ❑ ❑ EI'❑ C3❑ INDUSTRIAL WASTE INTER. 30.00 LAWN SPRINKLERS- 1 INC 5 V.B. 6.00 LAWN SPRINKLERS - OVER 5 (EA.) 1.00 A554SSORS PARCEL NO. 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 contrathe Coctsctor'shceneLwithacontractoHs)licensed pursuant to the Contractor's License Law. SEWER -SANITARY -STORM EA. 200ft/10.00 TRACT NO. PARCEL NO. ❑ lam exempt under Sed., R&P.C. for this .area WATER HEATER W/VENT 6.00 Owner Date SYSTEM 5.00 WATER ACC DATE ACG. FILE NO. WORK F-RS'COMPF-NSATION DECLARATION WATER TREATING EQUIP. 5.00 I hereby affirm that I have a certificate Of consent to self -insure. or a certificate of Workers' Compensation Insurance, or a certified ZONING ENG. SITE N0. copy the of Se . 8 0, Lab.C.). ^ /� Policy No nimpy SIT TELL %a - ❑ Certified copy is hereby furnished. ❑ C33 tified copygqis I d w' t the city inspection division. APPlicadted 1 L FIRE SPRINK Y ❑ N ❑ ENERGY T-24 Y ❑ N❑ MISC. - REFER TO ORD. CERTIFICATE EXEMPTION FROM WORKERS' PERMIT ISSUANCE 10.00 FLOOD ZONE A. L. u.C. PLG. CONTR. LIC. N0. PLG. TOTAL COMPENSATION INSURANCE (This section need not be completed if the permit is for One Y ❑ N ❑ Y ❑ N ❑ hundred dollars ($100) or less.) I certify that in Use 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 BUILDING 6d S become subject to the Workers' Compensation Laws of California. Date ApplicantALTER NOTICE TO APPLICANT: If, after making this Certificate of Ex- OR ADD TO MECH500 . . 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.EM.) 6.00 SEISMICFEE S� CONSTRUCTION LENDING 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, i MICROFILM HEATING UNIT (TO 100,000 B.T.U.) 8.00 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 state that the above information is correct. I agree to comply with all city and county ordinances and state laws relating to building construction, and VENTILATION FAN (SINGLE) 4.00 PLUMBING BOILER-COMP(3 H.P. or 100,000 B.T.U.) 6.00 BOILER -COMP (Over 100,000 BTU) SEE FEESCH. 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, indemnify and keep harmless the City of Cupertino against liabilities, judgments, costs and expenses which may in any way accrue against said City in consequence of the CONST. TAX PERMIT ISSUANCE 10.00 granting of this permit.MECH. CONT. LIC, NO* MECH. TOTAL ' TOTAL �� Signature o Applican onlr etor Ua e OFFICE COPY 0A: • POST THISD NEAR FRONTOF BUILDING • CIT OF CUPERTINO INSPECTION DIVISION JOB INSPECTION RECORD - JOB ADDRESS 20900 STEVENS CREEK UNIT# _LOT# OWNER ..UNION. CHRUCH OF' CUPFtp'TWR BATES PEST CONTROL; PFRMITNUMBER PERMIT EXPIRATION PERMIT EXPIRES IF WORK IS NOT STARTED.WITHIN 180 DAYS OF PERMIT ISSU- ANCE OR 180 DAYS FROM LASTCALLED INSPECTION. INSPECTION DATE INSPECTOR INSPECTION RECORD FOUNDATION - UFER PREGUNITE - PERMIT VALIDATION ' �--- y�/��'' ISSUANCE DATE POUR NO CONCRETE UNTIL ABOVE HAS BEEN SIGNED- UNDERGROUND/SLAB PLUMBING ELECTRICAL MECHANICAL" - ., BLDG. ELECT. ❑ PLG. ❑ MECH. ❑. - .. DO NOT POUR FLOOR UNTIL ABOVE HAS BEEN SIGNED _ - U�y ,� BUI LDING PERMIT Q INFORMATION VALUATION ,$/FT. WOOD FLOOR PLUMBING - MECHANICAL - - - ELECTRICAL�PERMI',,�T/��) A/Y ✓ FRAMING INSULATION - STORIES TYPE CONSTR. - OCC. GROUP RES. UNITS PLACE NO SUBFLOOR UNTIL ABOVE HAS BEEN SIGNED " ROOF - SO. FT, FLOOR AHEA TOTAL ACREAGE - DIAPHRAGM ' BUILDING USE RES IN CON PB 001, 0 ❑ ❑ ❑ ❑ APPLY NO ROOFING UNTIL ABOVE HAS BEEN SIGNED ROUGH ASSESSORS PARCEL NO. PLUMBING GAS TEST 8_ �` —se TRACT NO. PARCEL NO. MECHANICAL .. ' - ELECTRICAL FINALS � DATE INSP. ACC. DATE' ACC, FILE NO. - FRAMING SAN INSULATION - PLUMBING ZONING ENG. SITE NO. GAS MECHANICAL, FIRE SPRINK Y ❑ NE] ENERGY TpC Y ❑ N[] COVER NO WORK UNTIL ABOVE HAS BEEN SIGNED HEATING LATH—INTERIOR ELECTRICAL FLOOD ZONE Y N A.L.0C. . Y 0 N❑ LATH—EXTERIOR FIRE DEPT. SHEETROCK - GRADE FEE SUMMARY SHEAR INTERIOR BUILDING G/ C BUILDING /., ; d SHEAR EXTERIOR - TEMP01AARY APPROVALS FIREWALLS ELECTRIC PLAN CHECK FEE - . ' GAS NO TAPE OR PLASTER UNTIL ABOVE HAS BEEN SIGNED OCCUPANCY SEISMIC FEE OCCUPANCY OF BUILDING IS NOT PERMITTED UNTIL BUILDING FINAL IS SIGNED BY BUILDING INSPECTOR. I MICROFILM ARRANGE FOR INSPECTION BY PHONING 252-4505, 0� ONE WORKING DAY"BEFORE REQUIRED INSPECTION. 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 % OFFICE COPY