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9492 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES = USE BALL POINTPEN ONLY I ��• � 'BUILDING PROJECT IDENTIFICATION ' PERMITNUMBER• BDILDING u " f APPLICATION-& PERMIT IOORE55 BUILDING—ELECTRICAL—PLUMBING—MECHANICAL 9492 NANER's / PLAN CHECK VALIDATION G DTV. ELECTRIC PERMIT FEE 1 HONE NpM>ERAcroR' SWITCHES 10.00/1.00 UTLETS . •uc.No. LIGHTING FIXTURES 10,00/1,00 ADDRESSTOR's APPLIANCES-RESIDENTIAL 4.00 'PHONE PANELS 10.06 GATE OF APPLICATION ORRCHITEOT - - PANELS'(OVER 200 AMPI20.00 PLAN CHECK FEE P.C.NO. ENGINEER uc.NO. SIGNS TRANS.., 3.00 ADDRESS ENG SPECIAL CIRCUIT 5,66 ARCH.OR ZIP yVALIDATION . n 1 v • ' 'EMP.METER OR POLE INS. ,20.00 � AUG '2 1 1905 • APPLICANT'S - - ' ADDRESS - � MOTORS - SEE FEE,SCH, - SERVICE CHANGE'... 20.00 - - CRY of Cupertmn La LICENSED CONTRACTORS DECLARATION TEMP.POLE 30.00 a i W I hereby affirm that I am licensed under provisions of Chapter 9 ISSUANCE DATE a 'w (commencing with Section 7000)of Division 3 of the Business and BLDG. ELECT. PLG. MECH. r D z Professions Code,and my license is in full force and effect. i m License Class _ Lie.Number o , F m r Jo Date Contractor D rc w a OWNER-BUILDER DECLARATION' BUILDING PERMIT A. o Is - INFORMATION A. g,y I hereby affirm that 1 am exempt from the Contractors License MISC.— REFER TO,ORD 1- J Law for the following reason.(Sec.7031.5,Business and Professions PERMIT ISSUANCE 10.00 . VALUATION f "> � Code:Anycity orcounty which requires a permit to construct,after, .a ¢ a: O improve,demolish,or repair any structure,prior to its issuance,also ELEC.CONTR: LIC.NO._ 1 ELEC. O LL 'requires the applicant for such permit to file a signed statement that - - TOTAL X u he is licensed pursuant to the provisions of the Contractor's License PERMIT TO Fz > Law(Chapter 9(commencingwith Section 7000)of Division 3 ofthe �(�� f i o Business and Professions Code)or that he is exempt therefrom and QTY. PLUMBING PERMIT FEE M 1- the basis for the alleged exemption.Any violation of Section 7031.5' - STORIES TYPE CONSTR. a ; by any applicant for a permit subjects the applicant to a civil penalty - ALTER-DRAIN 5.00 . of not more than five hundred dollars($5000.): - - - ,13 I,as owner of the,property,or my employees with wages as BACK FLOW PROTECT.DEVICE 4.00 - OCC:GROOP, .REB.UNITS their Sale compensation,will do the work,and the structure is not intended,or offered for sale.(See. 7044, Business and Professions DRAINS-FLOOR,ROOF,AREA,COND. 5.00 Code:The Contractor's License Law does not apply to an owner of ' 'property who builds or improves thereon,and who does such well FIXTURES,PER TRAP 5.00 s0.vr.vLooR AREA TOTAL ACREAGE himself or through his own employees,provided that such improve ments are not intended or offered for sale.If,however,the building GAS-EA!SYSTEM-I INC.4 OUTLETS 6.00 or improvement is sold within one year of completion,the owner- GAS-EA.SYSTEM-OVER 4 IEA.) 2.00 J builder will have the burden of proving that he did not build or im- BUILDING USE prove for purpose of sale INDUST,RIALWASTE'INTER. 30.00 - ❑RES IND CON PS Other ' ❑ ❑ ❑ as owner of the properly,' exclusively contracting with licensedd contractors to construct thehe 1:1 1:1project l .00 Seo.7044,Business LAWN SPRINKLERS-1 INC 5 V.B. 6ASSESSORS 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 contractors)licensed pursuant to SEWER-SANITARY-STORM EA.200ft/10,00 the Contractor's License Law. TRACT NO. PARCEL NO. ❑ I amex inpt under Sec ,e.&P.C.for this WATER HEATER W/VENT 6.00 ' eason Saner Date WATER SYSTEM - 5.00 ACC.DATE Ata FILE No. WORKERS'COMPENSATION'DECLARATION. WATER TREATING EQUIP. 5.00 r I hereby affirm thal'I have a certificate of consent to self-insure, _ or a certificate of Workers'Compensation Insurance,or a certified ZONING ENG.SITE NO. copy thereof(Sec.3800,Lab.C.). - Policy No. Company O ❑ Certified copy is hereby furnished. FIRE SPRINK ENERGY TZ4 z Z ❑ Certified copy 'is filed with the city inspection division. , 'O Applicant MISC. 'i• _ REFER TO ORD. "Y ❑ N❑ v❑ :N❑ CC LU CF,RTIFICas ATE EXEMPTION FROM WORKERS- ' - PERMIT ISSUANCE 10.00 A.L.u.0. COMPE FLOOD ZONE' .W � 'COMPENSATION INSURANCE - PLG.CONTR., uc.Na. PLG; ' 1 0 (This Section need not be completed if the permit is'for one - TOTAL Y❑ N❑, -:Y0 N❑ V Zhundred dollars($100)or less.) O I certify that in the performance of the work for which this per- QTV FEE SUMMARY iy F mit is issued,I shall not employ any person in any manner so as to MECHANICAL PERMIT FEE O U become subject m the Workers'Compensation Laws of California. Date—Applicant ALTER OR ADD TO'MECHBUILDING /7 } tall NOTICE TO APPLICNT: If, after making this Certificate of E.- . '5,00 F 2 emption,you should become subject to the Workers'Compensation APPLIANCE 5.00 :PLAN CHECK g provisions of the Labor Code, you must forthwith comply with - FEE /� J 7 V such provisions or this permit shall be deemed revoked. 'AIR HANDLING UNIT(TO.10=C.F.M.) 4.00 CONSTRUCTION LENDING AGENCY AIR HANDLING UNIT(OVER 10MC.FM.),6.00 SEISMIC FEE 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. .MICROFILM r ' 3097,Civ.C.). HEATING UNIT(TO 100,000 B.T.U.) 8.00 Lender's Name HEATING UNIT(OVER 100,000 B.T.U.19.50 Lender's Address' - ELECTRIC '7 I 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 PLUMBING ordinances and state laws relating to building construction, and BOILER-COMP(3 H.P.or 100,000 B.T.U.) 6.00 1hereby authorize representatives of this city'I0 enter upon the BOILER-COMP Over 100,000 BTU)SEE FEE SCH. MECHANICAL ' r aabove-me,aborted property forinspection purpos. (We) ase gree to save, indemniriand keep harmless the City of MISC.-- REFER TO ORD. ' I - Cupertino against liabilities,judgments, costs and expenses whichCONST.TAX may in any way 'accrue against said City in consequence of the PERMIT ISSUANCE •10.0.0 grant his ermit' MECH:CONT_ LIC.NO. MECH. - TOTAL TOTAL g7 . / Ignalumof Ap cant/Contractor .Date "1 OFFICE COPY , POST THIS CARD NEAR FRONT OF BUILDING CITY OF CUPERTINO PERMIT NUMBER INSPECTION DIVISION 9492 JOB INSPECTION RECORD I n LPERMIT EXPIRATION JOB ADDRESS 2a14141 amwLi-k- C� UNIT# LOT# PERMIT EXPIRES IF WORK OWNER - CONTRACTOR IS NOT STARTED WITHIN MI'-`.'""?.`,INSPSCTION DATE INSPECTOR llnPECTION RECORD 180 DAYS OF PERMIT ISSU- FOUNDATION . i ANCE OR 180 DAYS FROM LIFER LASTCALLED INSPECTION. PREGUNITE PERMIT VALIDATION PAID -POUR NO,CONCRETE.UNTIL ABOVE HAS BEEN SIGNED, UNDERGROUND /SLAB AUG 27 PLUMBING 1985 ELECTRICAL Cl MECHANICAL SLOG. I ELECT. MECH. E3 El ❑ '40 NOT'POURTLOOR UNTIL"ABOVE'HAS BEEN SIGNED ;^�BUILDINO PERMITn$,,;4j,, WOOD FLOOR -':", --`i. ,IN F,ORMATIONd,;eQ A PLUMBING VALUATION SIFT. -\\ . MECHANICAL �� V ELECTRICAL PERMIT TO FRAMING INSULATION sroRlEs TYPE CONSTR.,a, OCC.GROUP RES,UNITS I ',NO:SUBFLOOR'-UNTIL?ABOVE'HASBEENSIGNEDa . ROOF SO.FT.FLOORAREA TOTAL ACREAGE DIAPHRAGM BUILDING USE RES .IND CON PB OMer ! PC iNO-ROOFING'•.UNTIL*ABOVE HAVIIEEWSIGNED>h ❑ ❑ ❑ ❑ ❑ ROUGH ASSESSORS PARCEL NO. PLUMBING -GAS TEST ..... .._.. ...._ __. ..._._____ . \... _ _ _. TRACT NO. _PARCEL NO. MECHANICAL ELECTRICAL - ACCOATE ACC.FILE NO. t $F,INALS N;7Y'�v `CVDATE'e,,Vl u,+ IV FRAMING - f/ SAN it INSULATION PLUMBING, ZONING ENG.SITE NO. GAS MECHANICAL FIRE SPRINK ENERGY T2 1COVER NO;WOR&UNTIL`ABOVVHAS BEEN,SIGNED.'R HEATING v❑ "❑ ❑ NE] LATH-INTERIOR ELECTRICAL - FLOOD ZONE A.L.UC, LATH-EXTERIOR - -- --- - - FIRE DEPT. Y❑ "❑ Y ❑ N❑ SHEETROCKGRADE �'" 4 FEESUMMARy`.y SHEAR INTERIOR BUILDING SHEAR EXTERIoqTEMPORARY APPROVALS BUILDING FIREWALLS ELECTRIC PLAN CHECK GAS _ ;TAPE,OR P,LASTER'.UNTIL°ABOVEMAS BEEN SI ON EDj OCCUPANCY SEISMIC FEE OCCUPANCY OF BUILDING IS NOT PERMITTED UNTIL BUI LDING FINAL IS SIGNED BY BUILDING INSPECTOR. MICROFILM ARRANGE FOR INSPECTION BY PHONING 252.4505, ELECTRIC H ONE WORKING DAY BEFORE REQUIRED INSPECTION. PLUMBING Z,�. PLEASE GIVE JOB ADDRESS WHEN PHONING. — SEE PERMIT FOR EXPIRATION DATE — MECHANICAL IMPORTANTI CONST.TAX PLEASE READ REVERSE SIDE BEFORE TOTAL CALLING FOR FINAL INSPECTION. OFFICE COPY