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17053 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY BUILDING PROJECT IDENTIFICATION PERMIT NUMBER Bamy, DNO APP JOATION & P.ERMIT � , 53 a000s UILDING �TRICA -PLUMBING-MECHANICAL " O OWNER'S PLAN CHECK VALIDATION QTY. ELECTRIC PERMIT FEE I-EY�S bLc s LV CONTRACTOR �S l� PRDNE a53 4 do l UTLETS-SWITCHES-RECEP 10.00/1.00 LIGHTING FIXTURES 10.00!1.00 , .C 0 al� �P�A4"lb� . CONTRACTORS PPLIANCES-RESIDENTIAL ($ 4.00 I ( FNorvE3 �S6 PANELS 10.00 DATE OF APPLICATION- ARCHITECT PANELS (OVER 200 AMP) 20.00 PLAN CHECK FEE P.C.NO. OR ENGINEER'(: f'�/1�1/j �H�-+L� Nopuc.NO. '' SIGNS TRANS. 3.00 _ ADDRESS E"D - SPECIALCIRCUIT� - 5,00 PERMIT VALIDATION ZIP TEMP.METER OR POLE INS. .20.00 APPLICANTS - MOTORS SEE FEE SCH. ADDRESS SERVICE CHANGE .20.00 �- �� woo LICENSED CONTRACTORS DECLARATION LA. UI / <U u I hereby affirm that I am licensed under provisions of Chapter 9 O ISSUANCE DATE N 4 mw (commencing with Section 7000)of Division 3 of the Business and BLDG. ELECT. PLG. MECH. r w z Professions Code, d my license is in full fo c f c. ❑ ❑ Q0 w o Lice las Lie.Numhe F m H j Date - Contractor City of Cupertino .- ¢L s BUILDING PERMIT m z W ¢ OWNER-BUILDER DECLARATION -INFORMATION oW MISC.- REFER TO ORD E ;LL N 'I hereby affirm that I am exempt from the Contractor's License VALUATION $/FT. F i, Cst Law for the following reason.(See.703 1,5,Businessand Professions PERMIT ISSUANCE ti2'BO OO w Code:Any city or county which requires a permit to construct,alter, ^ /�/1 2 ra¢C improve,demolish,or repair any structure,prior to its manatee,also ELEC.CONTR. LIC.NO. ELEC. ��//��• $T C O a- E G u _ requires the applicant for such permit to file a signed statement that TOTAL f AC,JC,J PERMIT TO E he is licensed pursuant to the provisions of the Contractor's License Law(Chapter 9(commencing with Section 7000)of Division 3 ofthe G.�.�II�(�L=O PATO ¢ Business and Professions Code)or that he is exempt therefrom and QTY. PLUMBING PERMIT FEE P_ _,0✓1- 1 O STORIES TYPE CONSTR. a- the basis far the alleged exemption.Any violation of Section en L5 c ; � by any applicant for apenleddolarsubjects the applicant toa civil penalty ALTER-DRAIN -WATER (EA.) 5.00 of not more than five hundred dollars($5001.): ❑ 1,as owner of the property,or my employees with wages as BACK FLOW PROTECT.DEVICE 4.00 OCC.GROUP RES.UNITS their Sale 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 Contractor's License Law does not apply to an owner of property who builds or improves thereon,and who does such work FIXTURES-PER TRAP S.00 SO.FT.FLOOR AREA TOTAL ACREAGE himself or through his own employees.Provided that such impro mve- re eats anot intended or offered for sale.If,however,the building GAS-EA.SVSTEM-11NC.40UTLETS 6.00 " or improvement is sold within one year of completion,the owner- GAS-EA.SYSTEM-OVER 4 IEA.) 2.00 BUILDING USE builder will have the burden of proving thus he did not build or im- $ I❑ ❑N ❑ O❑r prove for purpose of sale.). INDUSTRIAL WASTE INTER. 30.00 IrN�( ❑ I;as owner of the property,am exclusively contracting with licensed Contractors to construct the project(Sec. 7044,Business LAWN SPRINKLERS-1 INC 5 V.B. 6.00 ASSESSORS PARCEL NO. 'and Professions Code:The Contractor's License Law does not apply to as owner of property who builds or improves thereon,and who LAWN SPRINKLERS-OVER 5(EA.) 1.00 contracts for such projects with a contructor(s)licensed pursuant to the Contractor's'License Law. SEWER-SAN ITARY-MRM V-STORM EA.200ft/10.00 TRACT NO. � PARCEL NO. ❑ l am exempt under S�' �� ,BAP C.for this WATER HEATER W/VENT 6.00 reason Owner Date WATER SYSTEM 5.00 ACC.DATE ACC.FILE NO. WORKERS'COMPENSATION DECLARATION WATER TREATING EQUIP. 5.00 I hereby affirm that I have a certificate of Consent to self-iIISHM, ZONING ENG.SITE NO. or a certificate of Workers'Compensation Insurance,or a certified copy thereof(Sec.3800,Lab.C.).V _ a d Policy No. Company tti'Lrr� O ❑ Certified copy is hereby form It it. FIRE SPRINK ENERGY T-24 Z.Z 1� Cerftt((iee�/I��l $o,ppy i filed I t ty ins cbo Sion. Q Apblicant_�CL7ljd7.0 Aw "^�°--' '�' MISC.- REFER TO ORD. Y N v❑ N❑ CC - V PERMIT ISSUANCE 10.00 FLOOD ZONE ' A.L.U.C. lr N CIiRTIFICCOM E SATIOTINS FROM WORKERS' Ul >_ COMPENSATION INSURANCE PLG.cONTR. LIC.No. PLG. fL Q -(This section need not be completed if 0m permit is for one TOTAL V❑ N❑ IY❑ N❑ D Z hundred dollars IS 100)ur less.) U O 1 Certify that in the performance of the work for which this per- QTY. MECHANICAL PERMIT FEE FEE SUMMARY LL H mit is issued,bshall not employ any persl my manner so as lir O become subject to the Workeri Co ution Laws of California. - BUILDING /y /�� C y Date Applicant - - ALTER OR ADD TO MECH. 5.00 /0,W } N NOTICE'TO APPLICANT: ,after making this Certificate of Ex-emption,you should become subject to the Workers'Compensation APPLIANCE 5.00 PLAN CHECK Provisions of lite Labor Code, you must forthwith comply with FEE11 U -- such provisions or this permit shall be deemed revoked. AIR HANDLING UNIT(TO 10.000C.F.NL) 4.00 _ CONSTRUCTION LENDING AGENCY AIRHANDLING UNIT(OVER IODMC.FM.) 6.00 SEISMIC FEE . 50 I hereby affirm that III is a constru lending agency for EXHAUST HOOD(WITH DUCT) 5.00 the performance of the work f� ' tis permit is issued(Sec. HEATING UNIT(TO 100,000 B.T.U.) 8.00 MICROFILM 3097,Civ C.). Lender's Name Lender's Address HEATI NG UN IT(OV ER 100,000 B.T.U.)9.50 ELECTRIC gOO . 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 .herebyauthorize representatives of this city to enter upon the - BOILER-COMP(Over 100,000 BTUI 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, casts and expenses which CONST.TAX may in any way accrue against said City in consequence of the PERMIT ISSUANCE 10.00 ntin9 of this permit MECH.CONT. LIC.NO. MECH. •� /L - `r�•.O .. , TOTAL' IOTM C](.517 IJr� ignatu of Applicant/Contractor Date - OFFICE COPY ' POST THIS CARD NEAR FRONT OF BUILDING PERMIT`;UMBER CITY OF CUPERTINO 17053, INSPECTION DIVISION " JOB INSPECTION RECORD lo -5--32- Ce cN�-�,ee 'CT— PERMIT EXPIRATION JOB ADDRESS �L UNIT# LOT# � owNER -re ✓SGS - PERMIT EXPIRES IF WORK �.S 1 CONTRACTOR C a r4 GL O IS NOT STARTED WITHIN ' INSPECTION DATE INSPECTOR INSPECTION RECORD '180 DAYS OF PERMIT•-ISSU. FOUNDATION - ANCE-OR 180 DAYS FROM NOTE: - .LIFER � - ALL GRADING AND DRAINAGE SHALL BE INSTALLED LASTCA LLED INSPECTION. PREGUNITE TO COMPLY WITH THE•APPROVED PLANS AND CITY OF PERMIT VALIDATION CUPERTINO STANDARDS. r�0� GARAGE SLABS POUR NO CONCRETE UNTIL ABOVE HAS BEEN SIGNED UNDERGROUND /SLAB "too 0 U 1989 // A PLUMBING A - �tw '" �- - yl Ii. U USG / ELECTRICAL YD�Do ' ` ISSUANCE DATE ' MECHANICALMECH.A. (� `❑ - 0 00 NOT POUR FLOOR UNTIL ABOVE HAS BEEN SIGNED BUILDING PERMIT INFORMATION WOOD FLOOR VALUAT IDNoI SIFT. - PLUMBING MECHANICAL ELECTRICAL ,,PEtRMn'To(y� y� FRAMINGN�wed I• �"` `V INSULATION - ' STORIES TYPE CONSTR. ' OCC.GROUP RES.UNITS PLACE NO SUBFLOOR UNTIL ABOVE HAS BEEN SIGNED SO.FTFLOORARLA TOTAL ACREAGE • � ROOF NOTE:NO FINAL INSP,SHALL BE MADE BEFORE . DIAPHRAGM THE CONSTRUCTION TAX IS PAID -9UILDINGUSE N IND PI3 ROOF SHEATHING R� El ❑N 11 1:1' APPLY NO ROOFING UNTIL ABOVE HAS BEEN SIGNED FINALS DATE INSP. nssessons PAacEL No. ROUGH SAN.# PLUMBING - ELECT.ENERGY TRACT NO, PARCEL NO - TUBS&SHOWER PAN PLUMBING ENERGY _ MECHANICAL MECH.ENERGY " ' ELECTRICAL BUILDING ENERGY ACC,DATE ACC.FILE NO, 1- FRAMING ELECT.FINAL TEST - INSULATION PLUMBING zoNiNc ErvG.SITE NO. ° 0 GAS TEST GAS MECHANICAL FIRE$PRINK ENERGY T 24 COVER NO WORK UNTIL ABOVE HAS BEEN SIGNED HEATING NE) "E] EXTERIOR SHEAR ELECTRICAL RELEASE FLOODZONE aLI INTERIOR SHEAR - FIRE DEPT. Y❑ N • Y rv� Q SHEETROCK GRADE FEE SUMMARY EXTERIOR LATH BUILDING' — - INTERIOR LATH TEMPORARY APPROVALS- BUILDING SCRATCH COAT ELECTRIC CHECK , GAS NO TAPE OR PLASTER UNTIL ABOVE HAS BEEN SIGNED OCCUPANCY MIC FEE #�DOCCUPANCYOF BUILDING IS NOT PERMITTED UNTIL BUILDING FINALISSIGNED BV BUILDING INSPECTOR. OFILMARRANGE FOR INSPECTION BY PHONING 252-4505CTRIC • �1Qy LU ONE WORKING DAY BEFORE REQUIRED INSPECTIO"N. PLUMBING o PLEASE GIVE JOB ADDRESS WHEN PHONING. Z MECHANICAL — SEE PERMIT FOR EXPIRATION DATE — IMPORTANT! CONST.TAX PLEASE READ REVERSE.SIDE BEFORE TOTAL -D CALLING FOR FINAL INSPECTION. OFFICE COPY