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C 8637 (2) APP- ICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY UI LDING PROJECT 1 DE TI FICATION PERMIT NUMBER _FUILUsNG APPLICATION & PERMIT 8 637 ADDRESS Y �_ UILDING-ELECTRICAL-PLUMBING-MECHANICAL OWNER'S NAME �r CHECK VALIDATION J • 4/ew W5 OTV. ELECTRIC PERMIT FEE �t PNDNE CONTRACTOR'S NAME OUTLETS-SWITCHES-RECEP 10.00/1.00 ate- uc.No. LIGHTING FIXTURES 10.00/1.00 ADDRE�SSSS r�JoR's ^,1 PPLIANCES-RESIDENTIAL 4.00 S /r ✓v U yLl PNDNE /� PANELS 10.00 GATE OF APPLICATION OORCHITECT PANELS (OVER 200 AMP) 20.00 PLAN CHECK FEE P.C.NO. ENGINEER Llc,No, SIGNS TRANS. 3.00 ADDRESS ENG. SPECIAL CIRCUIT 5.00 PERMIT VALIDATION ZIP JrEMP.METER OR POLE INS. 20.00 APPLICANT'S D Aooflhss MOTORS SEE FEE SCH. SERVICE CHANGE 20.00 /jlnr{C 002 0o LICENSED CONTRACTORS DECLARATION TEMP.POLE 30.00 YOIDOJ a i W I hereby affirm that I am licensed under provisions of Chapter 9 ' (commencing with Section 7000)of Division 3 of the Business and BLDG. ECECT. ECH. 0 w i Professions Co nd y license is in full foc�e gndeft E-1 ❑ ❑ ❑ o i m o Licen Lie.Number jam/ F w�.J Uatc Contractnr_��TZ, _ - a w ¢ OWNER-BUILDER DECLARATION BUILDING PERMIT X ; D MISC.- REFER TO ORD INFORMATION u 1 hereby affirm that I am exempt from the Contractor's License VALUATION $/FT, a. 0 Law for the following reason.(Sec.7031.5,Business and Professions - PERMIT ISSUANCE 10.00 E v'�f Code:Any city or county which requiresa permit loconstrucLniter, Ix ¢Q O improve,demolish,or repair any structure,prior to its issuance,also ELEC.CONTR. LIC.NO. ELEC. y w m u requires the applicant for such permit to file a signed statement that TOTAL PERMIT TO he is licensed pursuant to the provisions of the Contractor's License r z a Law(Chapter 9(commencing with Section 7000)of Division 3 ofthe r E 4 0 Business and Professions Code)or that he is exempt therefrom and DTV. PLUMBING PERMIT FEE / �7 s�-t��je"�- a I- the basis for the alleged exemption.Any violation o'Section 7031.5 STORIES TYPE CON$TR. c; � by any applicant fora permit subjects the applicant loacis il penalty ALTER-DRAIN -WATER (EA.) 5.00 of not more than five hundred dollars($500).): ❑ 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 s intended or offered for sald(Sec. 7044, Business and Professions DRAINS-FLOOR,ROOF,AR EA,COND. 5.00 Code:The Contractor's License Law docs 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 m Through his own employees,provided that such improve- mems mselfonot intended hhisor employeesa e.provided thathowevsuch building GAS-EA.SYSTEM-1INC.4OUTLETS 6.00 or improvement is sold within one year of completion,lite owner- builder will have the burden of proving that he did not build or am. GAS-EA.SYSTEM-OVER 4 (EA.) 2.00 BUILDING USE Prove for purpose ofsale.). INDUSTRIAL WASTE INTER. 30,00 RES IND CON PB Omar ❑ 1,as owner ol'the property,am exclusively contracting with licensed contractors to construct the project(Sec.7044,BusinessLAWN SPRINKLERS-1 INC 5 V.B. 600 gSBE550Rg 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 contractor(s)licensed pursuant to (he Contractor's License Law. SEWER-SANITARY-STORM EA.200ft/10.00 TRACT NO. PARCEL NO. ❑ tum exempt under Sec. ,B.&P.C.for thisreason WATER HEATER W/VENT 6.00 Owner Dale WATER SYSTEM 5.00 ACC.DATE ACC.FILE NO. WORKERS'COMPF.NSATION DECLARATION WATER TREATING EQUIP. 5.00 1 hereby affirm that I have a certificate of consent to self-insure, or a certificate of We kers'Compensation Insurance,or a certified ZONING ENG.SITE NO. copy thereof fSec.3 O,Lab. Policy ere any der O ❑ Certifie yis here nils FIRESPRINK ENERGY T-24 Z Z ❑ Cc in On division. O Applicant MISC.- REFER TO ORD. Y ❑ N Y ❑ N� Ir CERTIFICA'I JF EXEMPTION FRO WORKERS' PERMIT ISSUANCE 10.00 FLOODZONE A.L.O.C. W > COMPENSATION INSURANCE PLG.CONTR. ❑C.NO. PLG. ❑ ❑N Y ❑ ❑ IL Z (This section need not be completed if the permit is for one TOTAL Y N hundred dollars IS 100)or less.) U O 1 certify that in the performance of the work for which this per, QTY. MECHANICAL PERMIT FEE FEE SUMMARY ly F mil is issued,I shall not employ any person in any manner sn as IO O w become subject to the Workeri Compensation Laws of California. 0. Dale Applicant ALTER OR ADD TO MECH. 5.00 BUILDING (fSLC� >_ W NOTICE TO APPLICANT: If,after making this Certificate of Ex- F ? emplion,you should become subject to the Workers'Compensation APPLIANCE 5.00 PLAN CHECK 99 provisions of the Labor Code, you must forthwith comply with FEE U such provisions or this permit shall be deemed revoked. AIR HANDLING UNIT(TO 10=CF.M.) 4.00 q� CONSTRUCTION LENDING AGENCY AIR HANDLING UNIT(OVER 10=C.RM.) 6.00 SEISMIC FEE I hereby affirm that there is a construction landing agency for EXHAUST HOOD (WITH DUCT) 5.00 the performance of the work for whirls this permit is issued(Sec. MICROFILM 3097,Civ.CJ. HEATING UNIT(TO 100,000 B.T.U.) 8.00 Lender's Name HEATING UNIT(OVER 100,000 B.T.U.)9.50 Lender's Address ELECTRIC I certify that 1 have read([its application and slate that lite above VENTILATION FAN (SINGLE) 4.00 information n correct. I agree to comply with all city and county BOILER-DOW 13 H.P.or 100,000 B.T.U.) 6.00 PLUMBING information and state laws relating to comply with construction,nand herehy auif a representatives of this city to enter upon the B01 LER-COMP IOver 100,000 BTU)SEE FEE SCH. MECHANICAL abovc-meuio d property for inspection purposes. (We) ogre to save, indemnify and kee harmless the City of MISC.- REFER TO ORD. CuperY menu, co expe s which CONST.TAX ma I a way accrue g st said City n con of the PERMIT ISSUANCE 10.00 i MECH.CONT. LIC.NO. MECH. �� TOTAL TOTAL Signature of App ca /Contractor -Date `� OFFICE COPY POST THIS CARD NEAR FRONT OF BUILDING PFRMIT NUMBER CITY OF CUPERTINO Q INSPECTION DIVISION / 8637 . JO INSPECTION RECORD PERMIT EXPIRATION JOB ADDRESS UNIT T PERMIT EXPIRES IF'WORK OWNER - CONTRACTOR IS NOT STARTED WITHIN INSPECTION DATE I INSPECTOR INSPECTION RECORD 180 DAYS OF PERMIT ISSU- FOUNDATION /J , + ANCE OR 180 DAYS FROM UFER 3—/3^�)` /�/�-�( L SPECTION. PREGUNITE -2(-t ' CCD 4e—F (cr. Yo WhE4 Ly PER IT VA A ION POUR NO CONCRETE UNTIL ABOVE HAS BEEN SIGNED UNDERGROUND /SLAB ` PLUMBING ELECTRICAL IssuAN DATE MECHANICAL ' MECHANICAL - RLOG. ELECT. MECH. DO NOT POUR FLOOR UNTIL ABOVE HAS BEEN SIGNED BUILDING qE RM1T. _ INFORMATION . WOOD FLOOR PLUMBING VALUATION $IF T. � - - MECHANICAL' ELECTRICAL - PERMIT FRAMING INSULATION STORIES r PE CONSTR. OCC.GROUP RES.UNITS PLACE NO SUBFLOOR UNTIL ABOVE HAS BEEN SIGNED SO.FT.FLOOR AREA .TOTAL ACREAGE I ROOF ' DIAPHRAGM BUILDING USE RES IND CON. PB. op- APPLY NO ROOFING UNTIL ABOVE HAS BEEN SIGNED ❑l ❑ ❑ ❑ ❑ ROUGH ASSESSORS FARCE L NO. ' , PLUMBING I GAS TEST TRACT NO, PARCEL NO. MECHANICAL , ACC.GATE ACC FILE NO. ELECTRICAL �� FINALS ' DATE INSP. FRAMING — SAN * ZONING ENG.SITE NO. INSULATION PLUMBING - GAS MECHANICAL FIRE SPRINK ENERGY T 24 COVER NO WORK UNTIL ABOVE HAS BEEN SIGNED HEATING ❑ NE:] ❑ "� LATH—INTERIOR ELECTRICAL FLOOD ZONE A.L.U.C.,� ' LATH—EXTERIOR FIRE DEPT. - Y❑ No . Y ❑ N❑' SHEETROCK - -] GRADE FEE SUMMARY SHEAR INTERIOR BUILDING p> — SHEAR EXTERIOR TEMPORARY APPROVALS BUILDING FIREWALLS ELECTRIC PLAN CHECK GAS - - FEE _ NO TAPE OR PLASTER UNTIL ABOVE HAS BEEN SIGNED OCCUPANCY -SEISMIC FEE J OCCUPANCY OF BUILDING IS NOT PERMITTED UNTIL BUILDING FINAL ISSIGNED BY BUILDING INSPECTOR. MICROFILM ARRANGE FOR INSPECTION BY PHONING 252-4505, ELECTRIC LU ON E OR KI 0 PLEASE VE JOB ADDRESS WHEN PHONING. PLUMBING ZMECHANICAL = SEE PERMIT FOR EXPIRATION DATE -' IMPORTANT!' CONST.TAX. PLEASE READ REVERSE SIDE BEFORE TOTAL CALLING FOR FINAL INSPECTION. OFFICE COPY -