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13681 (2) APPLICANT TO FILL IN INFORMATION WITHIf)'zRED LINES - USE BALL POINT PEN ONLY BUILDING PROJECT IDENTIFICATION PERMIT NUMBER BUILDING [ / APPLICATION & PERMIT ADDRESS r D_`1 fa c e -ry ►-Bee 13681G / e BUILDING-ELECTRICAL-PLUMBING-MECHANICAL OWNER'S In r -GI PLAN CHECK VALIDATION "AME by rK QTY. ELECTRIC PERMIT FEE p 4 s PHDN .384Z CONTRA NAME croR OUTLETS-SWITCHES-'RECEP 10.0011.00 P 10 N LIC.NO. ILIGHTING FIXTURES 10.0011.00 f,ONTRACTOR's PPLIANCES-RESIDENTIAL 4.00 / ,ADDRESS PHONE PANELS 10.00 DATE OF APPLICATION ARCHITECTPANELS (OVER 200 AMP) 20.00 PLAN CHECK FEE P.C.NO. OR ENGINEER LIC.NO, SIGNS TRANS. 3.00 AS ENG. SPECIALCIRCUIT S.00 PERMIT VALIDATION ADDRESS ZIP EMP.METER OR POLE INS. 20.00 ADDRESS �( /` E g� T(�� ,�0 MOTORS SEE FEE SCH. ADDRESS 14141 + `v`r / •eC Lie ��) ~ L°ca 1 61 C2 SERVICE CHANGE 20.00 ��/d 7 w o a ICENSED CONTRACTORS DECLARATION - / U swi ' I hereby affirm that Sec I am licensed under provisions of Chaplet 9 'Cr ISSUANCE DATE I- Q H (Commencing with d my l 700e)i of Division 3 oftheBusiness and BLDG. ELECT. PLG. MECH. r o z Professions Code,and my license is in full force and effect. I` p` s�)�01 ❑ ❑ z o 12- License Class Lic.Number lI 9 w Date Contractor BUILDING PERMIT It w u OWNER-BUILDER DECLARATION INFORMATION X O e.w I hereby affirm that I am exempt from the Contractor's License MISC.- REFER TO ORD LLY D VALUATION $/FT. o¢ Law for the following reason,(Sec.7031.5,Business and Professions PERMW ISSUANCE 10.00 I Wyf Code:Any city or county which requires a permit to construct,alter, rc ea¢ O improve,demolish,or repair any structure,prior to its issuance,also EIEC.CONTR. LIC.NO. ELEC. n e.l]LL requires the applicant for such permit to file a signed statement that TOTAL - PERMIT TO w2 m he is licensed pursuant to the provisions of the Contractor's License CC��..,�l� � -� a- Law(Chapter 9(commencingwith Section 7000)of Division 3 o(the v�e5-1fiez DM Ii o� Business and Professions Code)or that he is exempt therefrom and QTY. PLUMBING PERMIT FEE ¢r the basis for the alleged exemption.Any violation of Section 7031.5 STORIES TYPE CONSTR. i;-- by any applicant for a permit subjects the applicant toacivilpenalty gLTER-DRAIN&VENT-WATER (EA.) 5.00 o not more than five hundred dollars(5500).): ❑ 1,as owner of the property,or my employees with wages as BACK FLOW PROTECT. DEVICE 4.00 OCC.GROUP RES.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,GOND. 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 work F IXTUR ES-PER TRAP 5.00 SO.FT.FLOOR AREA TOTAL ACREAGE himself or through his own employees,provided that such improve- - mentsarenotintendedorofferedforsale.If,however,the building GAS-EA.SYSTEM-l1NC.40UTLETS 6.00 or improvement is sold within one year of completion,the owner- GAS-EA.SYSTEM-OVER 4(EA.) 2.00 BUILDING USE builder will have the burden of proving that he did not build or an- RES IND CON PB Other Pima,for purpose of sale.). I N DUSTR I A L W ASTE INTER. 30.00 -❑ 1,as owner of the property,am exclusively contracting with F-1 El El ASSESSORS 11 licensed contractors t0 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 - 3o an owner of property who builds or improves thereon,and who LAWN SPRINKLERS-OVER 5(EA.) 1.00 contracts forsuch projects with a contractor(s)licensed pursuant to SEWER-SANITA the Contractors License Law. RY-STORM EA.200ft/10.00 TRACT NO. PARCEL NO. D lamexemptunder Sec. ,B.&P.C.forlhis WATER HEATER W/VENT 6.00 reason Owner Ua WATER SYSTEM 5.00 ACC.DATE ACC.FILE NO. WORK ERS'COMPF•NSATION DECLARATION WATER TREATING EQUIP. 5.00 1 hereby affirm that I have a certificate of consent to self-insure, ZONING ENG.SITE NO. or a certificate of Workers'Compensation Insurance,or a certified - copy thereof(Sec.3800,Lab.C.). Policy No. Company _ 0 O Certified copy is hereby furnished. FIRE SPRINK ENERGY T 24 Z Z ❑ Certified copy is Bled with tiro city inspection division. .- . Y O Applicant [:] N❑ Y F] N[]MISC. REFER TO ORD y PERMIT ISSUANCE 10.00 FLOOD ZONE A.L.U.C. W CERTIFICATE E EXEMPTION FROM WORKERS' W COMPENSATION INS ? PLG.CONTR. LIC.NO. PLG. Y❑ N❑ Y [:] N❑ 0' a (This section need not he completedd if if thethe permit is for one TOTAL Z hundred dollars(S 100)or less.) U O 1 certify that in the performance of the work for which this per- QTY MECHANICAL PERMIT FEE FEE SUMMARY LL F mit is issued,I shall not employ any person in any manner so as to Ow becomesubjecltotheWorkers'CompensationLawsofCalifornia. BUILDING �s7 1L Date Applicant ALTER OR ADD TO MECH. 5.00 ). to NOTICE TO APPLICANT: If,after making this Certificate of Ex- L.. ? emption.you should become subject to the Wotkers;Compenmtion APPLIANCE 5.00 PLAN CHECK provisions of the Labor Code, you must forthwith'comply with FEE Q15-01i V such provisions or this permit shall be deemed revoked. AIR HANDLING UNIT(TO 10=11F.M.) 4.00 CONSTRUCTION LENDING AGENCY. AIR HANDLING UNIT(OVER 10=C.F.M.) 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. HEATING UNIT LTO 100,000 B.T.U.) 8.001MICROFILM 3097,Civ.C.). Lender's Name - HEATING UN IT(OV ER 100,000 B.T.U.)9.50 ELECTRIC ,�- Lender's Address x' I certify that I have read this application and slate that the aboveVENTILATION FAN (SINGLE) 4.00 information is correct. I agree to comply with all city unit county PLUMBING ordinances and state laws relating to building construction, and BOILER-COMP(3 H.P.Gr100,000B.T.U.) 6.00 law hereby authorize representatives of this city to enter upon the BOILER-COMP(Ovar100,000BTU)SEEFEESCH. MECHANICAL above-mentioned properly forinsp of purposes. (We) agree to save, indemnify and keep harmless the City of MISC.- REFER TO ORD. Cupertino against liabilities,judgments, costs and expenses which CONST.TAX may in any way accrue against said City a consequence of the PERMIT ISSUANCE 10.00 gmO'ng Of jhA-pemyil. / V, MECH.CONT. LIC,NO. MECH. tel. /c�-ds/A✓'` y TOTAL TOTAL I Signature of licant/Contractor Dnl N OFFICE COPY POST THIS CARD NEAB FROAT OF BUILDING - PERMIT NUMBER CITY OF CUPERTINO 13681 INSPECTION DIVISION JOB INSPECTION RECORD C\� "- PERMIT EXPIRATION JOB ADDRESS 10416 CHERRY TREE LANE UNIT# LOT# I - PERMIT EXPIRES IF WORK OWNER DOUGLAS H. FREEBORN CONTRACTOR N/A IS NOT STARTED WITHIN INSPECTION DATE I INSPECTOR INSPECTION RECORD - 180DAYS OFPERMIT.ISSU- FOUNDATION - ANCE OR 180 DAYS FROM LIFER LASTCALLED INSPECTION. PERMIT VALIDATION PREGUNITE POUR NO CONCRETE UNTIL ABOVE HAS BEEN SIGNED UNDERGROUND /SLAB PLUMBING ELECTRICAL - r.E.r , ISS ANCE BATE ' MECHANICAL RLGc. Ei,ECT. PLG. MECH. Gir a ut et� ❑ ❑ '00 NOT POUR FLOOR UNTIL ABOVE HAS BEEN SIGNED BUILDING PERMIT. . INFORMATION WOOD FLOOR VALUATION $/FT. PLUMBING MECHANICAL ELECTRICAL - PERMIT TO /� 9�jNEAP[� FRAMING ' INSULATION STORIES TYPE CONSTR. OCC.GROUP RES.UNITS FP.LIACE NO;SUBFLOOR UNTIL ABOVE HAS BEEN SIGNED FF� ROOF OO SQ FT,FLOOR AREA TOTAL ACREAGE FI `DIAPHR M I - BUILDING USE RES IND CON PB Olenl —AP PLVTN'0 ROOFING UNTIL ABOVE HASiBEEN.SIGNEO 0 ASS❑ESSORs0PARc0 O. 0 ROUGH PLUMBING GAS TEST TRACT NO, PARCEL NO. MECHANICAL ELECTRICALACC.OATE ACC.FILE NO. `TAi„,.FINALS ;DATE ANSP. FRAMING SAN # 'ZONING ENG.SITE NO. INSULATION PLUMBING GAS FIRE SPRINK ENERGY T 2 MECHANICAL ❑ ❑ ❑ ❑ \ v N v N COVER NO WORK UNTIL ABOVE HAS BEEN SIGNED' HEATING LATH—INTERIOR ELECTRICAL FLOOD ZONE aL.u.c. LATH—EXTERIOR IFIRE DEPT. - - _ Y N� v L.] N❑ SHEETROCK GRADE FEE SUMMARY SHEAR INTERIOR BUILDING i SHEAR EXTERIOR TEMPORARY APPROVALS BUILDING FIREWALLS ELECTRIC PLAN CHECK GAS FEE [NQTAPE OR PLASTER UNTIL ABOVE HAS BEEN SIGNED OCCUPANCY SEISMIC FEE OCCUPANCY OF.BUILDING ISNOT PERMITTED UNTIL BUILDING FINAL ISSIGNED BY BUILDING INSPECTOR. r. MICROFILM , ARRANGE FOR INSPECTION BY PHONING 252-4505, ELECTRIC j �g H ONE WORKING DAY BEFORE REQUIRED INSPECTION. PLUMBING' 1 J�Z0I PLEASE GIVE JOB ADDRESS WHEN PHONING. — SEE PERMIT FOR EXPIRATION DATE — MECHANICAL- } IcoNST.TAX MPORTANT! PLEASE READ REVERSE SIDE BEFORE TOTAL L CALLING FOR FINAL INSPECTION. -- OFFICE COPY -