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12375 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY BUI LDI NG PROJECT I DENTI FI ION PERMIT NUMBER 1UIUmNGCA. P� r„w cn-c_ APPLICATION & PL.,iMIT 7J`&$ 7.3 66)1f R BUILDING —ELECTRICAL—PLUMBING —MECHANICAL 12375 OWI •� NAMERa �`• ” PLAN CHECK VALIDATION UTY n s "ELECTRIC PERMIT f FEE' ' i GU US i lal PHONEa57— . —/ CONTRACTOR's T me p / r, OUTLETS-SWITCHES-RECEP 10.00/1.00 P%/Cf 9UI) J �.LS%A LIC.No. 6p-767 LIGHTING FIXTURES 10.00/1.00 rorvTRac ADORESS /-i TOR's p�PA.ro 'J APPLIANCES-RESIDENTIAL 4.00 /' .p �r �tcs, 1e PHONEy��'� p�i- PANELS 1D.co DATE OF APPLICATION QUORRCHITECT PANELS (OVER 200 AMP) 26.00 PLAN CHECK FEE P.C.NO. ENGINEER LIC.NO, SIGNS TRANS. 3.00 ADDRESS ENG. SPECIAL CIRCUIT 5.00 PERMIT VALIDATION ZIP ITEMP. METER OR POLE INS. 20.00 APPLICANT'S ADDRESS p MOTORS SEE FEE SCH. O) Orcx_, ve,/H<Ill�e(c✓k Cpl. 9v SERVICE CHANGE 20.00 of Y/G� '0 o LICENSED CONTRACTORS DECLARATION ( U Qin u 1 hereby affirm that I am licensed under provisions of Chapter 9 ISSLE N< i (commencing with Section 7000)of Division 3 of the Business and BLDG. EL T. PLG. MECH. o F y i Professions Cos�n,and my icense is in full for W� I G z o m License las ��'� Lic.Numbe Eb+ G 7 w — Date — Contractor a OH i F _� a ac w u OWNER-BUILDER DECLARATION EVI NG.PERMIT '-.+ 'K D; e, w I hereby affirm that I am exempt from the Contractor's License MISC.— REFER TO ORD w u o¢ Law for the following reason.(Sec.7031.5,Businessland Professions VALU S/FT. — PERMIT ISSUANCE 10.00 �N Cprove.dmolishor county pair any requture,es a prior ttoconstrueLahar.o X IS Q O improve.demolish,or repair any structure,prior t0 its Issuance,also ELEC.LONTR. LIC.NO. ELEC. / i S m IL requires the applicant for such permit to file a signed Statement that TOTAL PERMIT TO w he is licensed pursuant to the provisions of the Contractor's License ''QQ r i Q Law(Chapter 9(commencingwith Section 7000)of Division 3 ofthe - °""- S'� Ll6.�T bE a-O i rs Business znalTrofessions Code)or that he is exempt therefrom and GTY: PLUMBING PERMIT -s FEE,t' IS r$ the basis for the alleged exemption.Any violation of Section 7031 5 STORIES TYPE R. a. by any applicant for a permit subjects the applicant toacivii penalty ALTER-DRAIN -WATER (EA.) 5.00 of not more than five hundred dollars(5500).): ❑ I,as owner of the property,or my employees with wages as BACK FLOW PROTECT.DEVICE 4.00 OCC.GROUP REB.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 Cade:The Contractors License Law does not apply to an owner of _• property who builds or improves thereon,and who does such work 3 FIXTURES-PER TRAP 5,60 SO.FT.FLOOR AREA TOTAL ACREAGE himself or through his own employees,provided that such improve. ments are not intended or offered for sale.I L however,the building GAS-EA.SYSTEM-11NC.40UTLETS 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- IGAS-EA.SYSTEM-OVER 4(EA.) 2.00 BUILDING USE prove for purpose of sale.). RES IND CON PS Omer ❑ I,as owner of the property,am exclusively contracting with INDUSTRIAL WASTE INTER. 30.00 El Cl El El ❑ licensed contractors to construct the project(Sec.7044,Business LAWN SPRINKLERS-1 INC 5 V.B. 600 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 contmctons)licensed pursuant to the Contractor's License Law. SEWER-SANITARY-STORM10.00 TRACT NO. PARCEL NO. El am exempt under Sec. ,B.&P.C.for this WATER HEATER W/VENT reason Owner Date WATER SYSTEM . 0 ACC.DATE ACC.FILE NO. WORKERS'COMPENSATION DECLARATION WATER TREATING EQUI x 1 hereby affirm that I have a certificate of consent to self-insure, Is%wr Q ZONING ENG.SITE NO. or a certificate of Work�er rCompensation Insurance,or a certified �/ ca thereyy'�'�SS��A gg��,,ab.C). Policy No.&Sf�C�"�pJmpany S/W� /l R.C` Q ❑ pi�ttfi6edcopyishettby furnished. FIRE SPRINK ENERGY T-24 Z 2V d'/CertifiedlJop is f t cn inspection division. 0 � applicant 7�4�( I�i� '�� MISC.- REFER TO ORD. Y ❑ N❑ Y ❑ N❑ Gly CERTI F ICAT E OF EX EM PTION F RO M WO R K E RSPERMIT ISSUANCE 10.00q U FLOOD ZONE A.LU.C. LU > COMPENSATION INSURANCE PLG.CONTR. LIC.NO. PLO d DCS^o (This Section need not be completed if the permit is for one TOTAL Y❑ INF] Y ❑ NEI D Z hundreddollars(SIOOIorless.) I U O 1 certify that in the performance of the work for which this per- ' - ,FEE SUMMARY'S`. 1- mit is issued,I shall not employ an CITY. "x""'MECHANICAL PERMIT FEE11 ...lire LL P Y Y Person in any manner is[o - Wbecome subject to the Workers Compensation Laws of California. ' OL Date Applicant ALTER OR ADD TO MECH. 5.00 BUILDING �Q } h NOTICE TO APPLICANT: If,after making this Certificate of F.x- f.- ? emption,you should become subject to the Workers'Compensation APPLIANCE5,00 PLAN CHECK / provisions of the Labor Code, you must forthwith comply with FEE fp U such provisions or this permit shall be deemed revoked. AIR HANDLING UNIT(TO 1 F.M) 00 CONSTRUCTION LENDING AGENCY AIR HANDLING UNIT(OVER IODCAQF ,00 SEISMIC FEE I hereby affirm that there is a construction lending agency for EXHAUST HOOD (WITH the performance of the work for which this permit is issued(Sec. MICROFILM 3097, .am HEATING UNIT (TO 10 O B.T 0 Lender's Name Lender's Address HEATING UNIT(OVER 10 .U.19.50 ELECTRIC • I certify that I have read this application and state that the aboveVENTILATION FAN (SINGLE) 4.00 information is correct. I agree to comply with and all city county PLUMBING ordinances and state laws relating to building co"hoctiun, send BOILER-COMP(3 H.P.or100,000B.T.U.) 6.00 hereby authorize representatives of this city to enter upon the BOILER-COMP IOver 100.000 BTU)SEE FEE SCH, 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 N. CONST.TAX may in any way accrue against said City in consequence of the PERMIT ISSUANCE 10.00 grand�reof[his permit. MECH.CONT. LIC.NO. MECH. latu.yFiI 3b. /87 roTAL /!y(� TOTAL , Signature of Applicant/ nlractor Data / - OFz1Ce COPY POST THIS CARD NEAR FRONT OF BUILDING ' - PFRM1IIT NUMBER Cf t OF CUPERTINO 2375 INSPECTION DIVISION JOB INSPECTION RECORD �/� PERMIT EXPIRATION JOB ADDRESS CJI=' f`�1/—\�—",N T# l0T# PERMIT EXPIRES IF WORK OWNER CONTRACTOR IS NOT STARTED WITHIN INSPECTION DATE I INSPECTOR INSPE TIO ORD 100 DAYS OF PERMIT ISSU- FOUNDATION ANCE OR 180 DAYS FROM UFER LASTCALLED INSPECTION. PREGUNITE PERMIT VALIDATION a POUR NO CONCRETE UNTIL ABOVE HAS BEEN SIGNED UNDERGROUND /SLAB PLUMBING ELECTRICAL ISSUANCE PATE MECHANICAL BLpc. ELECT. PLG. MECH. ❑ ❑ ❑ DO NOT POUR FLOOR UNTIL ABOVE HAS BEEN SIGNED +BUILDING PERMIT WOOD FLOORINFORMATION PLUMBING VALUATION S/FT. MECHANICAL ELECTRICAL PERMIT To FRAMING INSULATION STORIES TYPE CONSTR. OCC,GROUP RES.UNITS PLACE NO SUBFLOOR UNTIL ABOVE HAS BEEN SIGNED 1• ROOF SO.FT.FLOORAREA TOTALACREAGE DIAPHRAGM BUILDING USE RES IND CON PB Om,,, APPLY NO ROOFING UNTIL ABOVE HAS BEEN SIGNED ❑ ❑ ❑ ❑ ❑ ROUGH ASSESSORS PARCEL NO. PLUMBING GAS TEST TRACT NO. PARCEL NO. MECHANICAL EACC.DATE ACC FILE NO. ELECTRICAL "FINALS 'DATE INSP."; FRAMING SAN # PLUMBING _� 'ZONING ENG.SITE NO. INSULATION J GAS MECHANICAL FIRE SPRINK ENERGY T-}A -o�lCOVER NO WORK UNTIL ABOVE HAS BEEN SIGNED `* HEATING Y ❑ N❑ Y ❑ N❑ LATH—INTERIOR ELECTRICAL FLOO o zoNE aL.u.c. LATH—EXTERIOR FIRE DEPT. Y❑ NO Yo N❑ SHEETROCK GRADES -- W,,Mft tD '/� $ -.FEE SUMMARY SHEAR INTERIOR BUILDING —/y. ve SHEAR EXTERIOR TEMPORARY APPROVALS BUILDING FIREWALLS ELECTRIC PLAN CHECK GAS FEE NO TAPE OR PLASTER UNTIL ABOVE HAS BEEN SIGNED OCCUPANCY SEISMIC FEE OCCUPANCY OF BUILDING IS NOTPERMITTED UNTIL BUILDING FINAL ISSIGNED BY BUILDING INSPECTOR. MICROFILM ARRANGE FOR INSPECTION BY PHONING 252-4505, ELECTRIC • o� ONE WORKING DAY BEFORE REQUIRED INSPECTION. PLUMBING L : 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. °�Cc CC7�