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11459APPLICANT TO FILL IN INFORMATION WITHIN RED LINES'- USE BALL POINT PEN ONLY BUI LDI'.4G PROJECT I DENTI FICATION - APPLICATION & PERMIT G - ELECTRICAL- PLUMBING -MECHANICAL PERMIT NUMBER n I9 aDILDING , ppOREsa •'- '~ 2 Z 3 y 7 S�every c2��� ' OWNER'S - - NAseE SIEII� ZS HONE CITY. ELECTRIC PERM IT FEE PLAN CHECK VALIDATION (]V ( 6 C\/I CONTRACTOr ^' NAME / OUTLETS - SWITCHES -RECEP 10.00/1.00 LIGHTING FIXTURES, 10.00/1.00 1 ' uc. ND. CONTRACTOR'S I ADDRESS - I APPLIANCES - RESIDENTIAL 4.00 PANELS 10,00 PHONE DATE OF APPLICATION* ARCHITECT OR ENGINEER LIC, NO. PANELS (OVER 200 AMP) 20.00 ` PLAN CHECK FEE P.C. NO, SIGNS TRANS. 3.00 AARCH. OR DDRESS ENG. SPECIAL CIRCUIT - 5.00 PERMIT VALIDATION TEMP. METER OR POLE INS. 20,00 r� ZIP APPLICANTS - ADDDRESSDRESSI MOTORS SEE FEE SCH. SERVICE CHANGE 20.00C • r 7 61 "/�• / LICENSED CONTRACTORS DECLARATION -- I hereby affirm that I am licensed under provisions of Chapter 9 (commencing with Section 7000) of Division 3 of the Business and Professions Code, and my license is in full force and effect License Class Lic. NumberEK ISSUANCE DATE BLDG. ELECT. PLG. MECH. Dxte COBlrmr r BUILDING PERMIT INFORMATION OWNER -BUILDER DECLARATION I hereby affirm that I am exempt from the Contractor's License Law fortha following Poemn.(Sec. 7031;5, Business and Professions Code: Anycity orcounly which requires a permit to construct, alter, improve, demolish, or mlmir any structure, picot to its issuance, also requires the applicant for such permit to file a signed statement that he is licensed pursuant In the provisions of the Contractors License Law (Chapter 9 (comme Being with Section 7000) of Division 3 of the Ilusincss and Professions'Coc!0 or that In, is exempt therefrom anti MISC.- REFER TO ORD. PERMIT ISSUANCE - 10.0- _� VALUATION `�'2 el SIFT. ' , ELEC. CONTR. LIC. NO. ELEC. 3 - TOTAL QTY. PLUMBING PERMIT •FEE PERMIT TO �1 T FT � U� T� Q •� STORIES -., TYPE CONSTR. Ihebxsis forthe alleged exeroticn. Any' violation of Section 7031.5 by any applicant for it permit subjects the applicant to a civil penalty of not mom than five hundred dollars (S500L) „ ALTER -DRAIN -WATER IEA.) 5.00 ❑ 1, as owner of the will d t e my employees with wages us their sole compensation, will Ihe'ix and the structure is not BACK FLOW PROTECT. DEVICE ' 4.00 OCC. GROUP RES. UNITS DRAINS -FLOOR, ROOF, AREA,COND. 5.00 (S 4, Code:intended or offered for sole (Sec. ]does Business and Professions - 'Code: The ConlrScWr's License Law docs not applywho to an owner of C'pmpetly who'bullds or ImpmvWBles, prand whodoes such work ' 'himself re through his own employees, provided that such improve.he building hien notment (completion FIXTURES -PER TRAP 5.0 SD. FT. FLOOR AREA TOTALaOREAGE GAS- EA. SYSTEM -1INC. 4OUTLETS 6.00 improveis old within or: improvunem is sold within one year of completion, the owner one year theo owner. buil r will have. the burden or pro" g Ihst he Aid not build or im r�ror purposeufsale.'I I, as owner of [he property, an exclusively contracting with GAS - EA. SYSTEM - OVER 4 IEA.) 2.00 BUILDING USE RES IND CON PB Other 0 0 ED El INDUSTRIAL WASTE INTER. 30.00 li n d contractors t0 construct the project ISee. 7044, Business a d Professions Coda: The Contractor's License Law dues not apply an owner of property wan builds or improves thereon• and who LAWN SPRINKLERS- 1 INC 5 V,B. 6.00 LAWN SPRINKLERS - OVER 5 (EA.) 1.00 ASSESSORS PARCEL NO. con tracts fur such projects wi th i .atmonr(s)licensedpursuanl to the Contractor's License Law. SEWER -SANITARY -STORM EA. 200ftI10.00 TRACT NO. PARCEL NO. m exempt under Sec. ,R.&P.C. for this anon WATER HEATER W/VENT `6.00 Ow°er D a t c - - WATER SYSTEM 5.00 ACC. DATE ACC. FILE NO. WATER TRE ATING EQUIP, 5.00 WORKERS'COMPENSATION Dli ARATION 1 hereby affirm that I have a certificate of consent to self -insure. or a certificate of Workers' Compensation Insurance, ora cerlified ZONING ENG. SITE N0. copy thereof (See. 3800, Lab C.). Policy No. Company -'FIRE ' ❑ Certified copy is hereby furnished. Certified copy is filed with the city inspection division. Applicant SPRINK Y [:) N ❑ ENERGY T-24❑ ` Y O N� MISC.- REFER TO ORD. x. CERTIFICA'fEOF EXEMPTION FROM WORKERS' PERMIT'ISSUANCE 10.00 Q FLOOD ZONE A.L.U.C. COMPENSA'flONINSURANCE- (This section need not be completed if the permit is for one Y ❑ N Y ❑ 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. "mil is issued. I shall not employ any person in any, manner so as to CITY. MECHANICAL PER FEE FEE SUMMARY BUILDING U �a become subject to the Workers' Compensation Laws of California. Date 4ApplicantALTER OR ADD TO MECH. 5.00 - NOTICE TO APPLICANT:' If, after making this Certificate of h:x. APPLIANCE5.00 AIR HANDLING UNIT (TO 10,00DQF.M.) 4.00 PLAN CHECK FEE emption; you should become subject to"the Workeri Compensation provisions of the Labor Code, you must forthwith comply with such provisions or this permit shall be deemed revoked Y' AIR HANDLING UNIT (OVER 10=11F.M.) 6.00. SEISMIC FEE' a 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 fSec. 3097, Civ.C.). MICROFILM 'HEATING UNIT (TO 100,000 B.T.U.) 8.00 Lender's Name Lender's Address - H EATING UNIT IOVER 100,000 B.T.U.) 9.50 ELECTRIC _ VENTILATION FAN (SINGLE) 4.00 1 certify that 1 have read this application and state that the above is correct. 1 agree to comply with all city and county )ordinances ordinances and stale laws relating to building construction, and - PLUMBING J -" BOILER-COMP(3 H.P. or 100,000 B.T.U.) 6.00 hereby authorize representatives of thislcity to enter upon tire above-mentioned property for inspection purposes. BOILER -COMP (Over 100,000STUISEE FEESCH. MECHANICAL (Wen agree to save, indemnify and keep harmless the City of MISC. -' "' REFER TO ORD. Cupertino against liabilities, judgments, costs and expenses which �aYwy a True against Said t in copse uence of the C s PERMIT ISSUANCE 10.00 /Qert CONST. TAX MECH. CONT. LIC. NO. MECH.TOTAL /S ' TOTALlicant m r Data OFFICE COPY , POST THIS CARD NEAR FRONT OF BUILDING , " OF CUPERTINO PERMIT NDAiBER ,CITY 1.1:459 INSPECTION'DIVISION•`' JOB INSPECTION RECORD �- - PERMIT,EXPIRATION '• 7 7 c^ n /A� rr Q� 3 \ E'�S� I iK /I J`-�11VIi#' LOT# JOB ADDRESS %f /awl I - PERMIT EXPIRES IF WORK OWNER' .L CONTRACTOR, IS NOT STARTED WITHIN 180 DAYS OF'PERMIT ISSU- ,ANCE OR '180 DAYS FROM INSPECTI DATE INSPECTOR INSPECTION RECORD `. " FOUNDATION. r - - LASTCALLEDINSPECTION. LIFER - PERMIT VALIDATION PREGUNITE'•; • - - ISSUANCE DATE POUR NO CON RETE UNTIL ABOVE HAS BEEN SIGNED UNDERGROUND/SLAB./�� PLUMBING ELECTRICALt BL G. ELECT. PLG. MEGti- MECHANICAL. I � ti ,DO NOT POUR FLOOR UNTIL ABOVE HAS BEEN SIGNED - BUILDING PER INFORMATION WOOD FLOOR VAWATION $/FT, - -r, PLUMBING '/ •a MECHANICAL ELECTRICAL n �eRMIT To /b"n /, 117"1 Y' iAk FRAMING' STORIES TYPE CONSTR. INSULATION OCC.GROUP RES, UNITS. ' PLACE NO SUBFLOOR UNTIL ABOVE HAS BEEN SIGNED° • ROOF 50. FT. FLOOR AREA T01AL ACREAGE DIAPHRAGM il- • BUILDING USE ' IVES IND CON PB. ONr,El'- � El D APPLY NO ROOFING UNTIL ABOVE HAS BEEN SIGNED '❑ ' ASSESSORS PARCELNO.-' ROUGH PLUMBING �'-- - - TRACT NO. PARCEL NO. GAS TEST MECHANICAL- 'ACC.DATE ACC., FILE NO. ELECTRICAL ' . FINALS DATE INSP. .. i - FRAMING SAN---ZONING - ENG. SrrENO. INSULATION PLUMBING � � - ' - _ - GAS - FIRESPRINK 'Y ❑ NE]y 'ENERGY T@< ❑ N�' -� MECHANICAL COVER NO WORK UNTIL ABOVE HAS BEEN SIGNED HEATING FLOOD ZONE ° A.L.u.c. v . N� LATH—INTERIOR ' ELECTRICAL • 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 OCCUPANCY' • OCCUPANCY OF BUILDING IS NOTPERMITTED UNTIL BUILDING FINAL ISSIGNED BY BUILDING INSPECTOR.I. MICROFILM 5` J "ARRANGE-FOR INSPECTION BY.PHONING 252-4505, ELECTRIC PLUMBING 0� ONE.WORKING DAY BEFORE' REQUIRED INSPECTION. PLEASE GIVE, JOB ADDRESS WHEN PHONING. MECHANICAL Z -SEE.PERMITFOR'EXPIRATION DATE„- CONST. rax IMPORT'ANTC PLEASE READ REVERSE SIDE BEFORE TOTAL 'CALLING FOR FINAL INSPECTION:.. - .OFFICE COPY..