14142 (2) APPLYeANT TO F ILLININFOUILATION WITHIN REDLINES _USE 13L POINT PEN ONLY
'ilkBUILDOs
ING
LPERMIT NUMBER'
&lamSSG BINQ PROJECT IDENTI FICA APPLICATION & PEAWr
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ADDRESS /p'
S' 0 AI� BUILDING —ELECTRICAL—PLUMBING—MECHANICAL 14142
OWNER'S PLAN CHECK VALIDATION
NA E. - OTY. ELECTRIC PERMIT' FEE -
f ONE i t
NAMERncr R's . UTLETS-SWITCHES-RECEP 10.00/1.00
LIC.NO. LIGHTING FIXTURES 10.00/1.00
- npNTRACT S. . APPLIANCES-RESIDENTIAL a 4.00
• PHONE PANELS . 10.00 DATE OF APPLICATION
ARCHITECT PLAN�CHECK FEE P.C.NO,
OR PANELS (OVER'200 AMIN 20.00 . I_y
ENGINEER
LIC'NO. SIGNS TRANS. 3.00
ADDRESS SPECIAL CIRCUIT' 5.00
AENG. - PERMIT VALIDATION
ADDRESS ' ' � .` .
ZIP .EMP.METER OR POLE INS. � 20.00
ADDRESS T S MOTORS - SEE FEE SCH. �1tt• �, Gap efQ'• Q'�I
? SERVICE CHANGE 20.00
woo LICENSED CONTRACTORS DECLARATION
Q v stn I hereby affirm,thal I am licensed under provisions ol'Chapter 9 ISSUANCE DATE
va
A G i (commencing with Section 7000)of Division 3 of the Business and - - BLDG. ELECT. LG. MECH.
H H z Professions Code,and my license is in full force and effect. ❑ ❑ •❑
ZO 0 w W License Class Lic.Number
Data Contractor '
,t r Z - BUILDING PERMIT
II: rc w a OWNER-BUILDER DECLARATION
O A u INFORMATION
u, ;n ,HA I hereby affirm that 1 am exempt from the Contractor's License MISC.— REFER'TO OflD
FLL0< Law for the following reason.(Sec.7031.5,Businessmal Professions PERMIT ISSUANCE 10.00 VALUATION $/FT.
� w0 Cade:Any city or.county which requiresa permit to construct,alter,
I[ a improve,demolish,or repair any structure,prior to its issuance,also ELEC.CONTR. LIC.NO. - ELEC.
a O a requires the applicant for such permit to file a signed statement that - TOTAL -
K ow he Is licensed pursuant to the provisions of the Contractors LicensePERMIT TO
r 'i, Law(Chapter 9(commencing with Section 7000)of Division 3 ofthe "
io Business and Professions Code)or that he is exempt therefrom and QTY. PLUMBING PERMIT FEE I
aH $ the basis for the alleged exemption.Any violation of Section 7031.5 STORIES TVP BTR.
a by any applicant for a permit subjects the applicant to a civil penalty ALTER-DRAIN -WATER IEA.) 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 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,AR EA,CON D. 5.00
Code:The Contractor's License Law does not apply to an owner of
1101¢111 who builds or improves thereon,and who does such work FIXTURES-PER TRAP 5.00 S¢FT.FLOOR AREA TOTAL ACREAGE'
himself re not into his own employees,fora,provided that such improve-
ments are not inch his or employee sale.If,ed that such
(he building GAS-EA.SYSTEM-i INCA OUTLETS 6.00 .
or improvement is sold within one year of completion,the owner- GAS-EA.SYSTEM-OVER 4 (EA.) 2.00'
builder will have the burden of proving that he did not build or Im- BUILDING USE
prove for purpose of sale.). INDUSTRIAL WASTE INTER ' 3000 RES IND CON Fee Omer
❑ I,as owner of the property,am exclusively contracting . .
with E1 ElEl ❑ El
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 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 SEWER-SANITARY-STORM EA.200ft/10.00
the Contractor s License Law. TRACT NO. PARCEL NO.
❑ l am exempt under Sec. ' ,B.&P.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 -
1 hereby affirm that 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.0.). -
Policy No. - Company
O ❑ Certified copy is hereby furnished.. FIRE SPRINK ENERGY T-24 ,
Z Z 0' Certified copy is filed with the city inspection division. MISC.- REFER TO ORD.
O Applicant V ❑ N❑ Y ❑ N❑
Fy PERMIT ISSUANCE 10.00 �^I�^
Lu CERTIFICATE EXEMPTION FROM WORKERS' W
W > COMPENSATION
FLOOD ZONE A.L.u.c.
INSURANCE PLG.CONTR. LIC.NO. PLG.
CL o (This section need not be completed if tie permit is for one _ TOTAL Y❑ N❑ Y ❑ N❑
O hundred dollars IS 100)orless.)
I certify that in the performance of the work for which this per- FEE SUMMARY
ly F mit is issued,I shall not employ any per on. any manner as m QTY. MECHANICAL PERMIT FEE
0 w been su 'ec to tre Wit of Cali
n Date APPlica ALTER OR ADD TO MECH. 5.00 BUILDING
} N NOTI E O A LICANT: I a er making this Certificate of Ex-
F Z emption,you should become s 'eel to the Workers'Compensation APPLIANCE- 5.00 PLAN CHECK'
provisions of the Labor Code, you must forthwith comply with FEE
C.1 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.EM.) 6.00 - SEISMIC FEE
1 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
3097,Civ.C.). ? 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 I have read this application and state that the above VENTILATION FAN (SINGLE) .4.00
information is correct.1 agree to comply with all city and county PLUMBING dd
ordinances and state laws relating to building construction, and BOILER-COUP(3 H.P.or 100,000 B.T.U.) 6.00
hereby authorize representatives of this city to enter upon the BOILER-COMP (Over 100.000 BTU)SEE FEE SCH. MECHANICAL
above-mentioned property for inspection purposes,
(We) agree to save, indemnify and keep hurinless the City of MISC.- REFER TO ORD. ,
Cupertino against liabilities,judgments, costs and expenses which - CONST.TAX
&Ne
any way accrue against said Cit in consequence of the PERMIT ISSUANCE 10.00
ofth' pe i� MECH.CONT. LIC.NO. MECH.
TOTAL TOTAL a
`o pplicant/Contractor - Dalef�0(/
OFFICE COPY
POST THIS D NEAR FRONT OF BUILDING • - UM
►r• CIT F CUPERTINO PERMITNMRER
INSPECTION DIVISION �� ��
r JOB INSPECTION RECORD
' 10568 LONNA LANE PERMIT EXPIRATION JOB ADDRESS NIT# LOT#
U
PERMIT EXPIRES IF WORK''
JACK TI SHOMAKER LLOYD
OWNER CONTRACTOR IS NOT STARTED WITHIN
INSPECTION DATE I INSPECTOR INSPECTION RECORD 180 DAYS OF PERMIT ISSU-
FOUNDATION ANCE OR 180 DAYS FROM
LIFER
LAST CALLED INSPECTION.
"r' - •. 'I
PR EG UNITE - PERMIT VALIDATION
POUR NO CONCRETE UNTIL ABOVE HAS BEEN SIGNED
UNDERGROUND /SLAB / �`��
PLUMBING -
r __ l
ELECTRICAL ISSUANCE DATE
MECHANICAL - .840G. ELECT I PLG. MECH.
DO NOT POUR FLOOR UNTIL ABOVE HAS BEEN SIGNED BUILDING PERMIT '
_ INFORMATION
WOOD FLOOR VALUATION
PLUMBING
MECHANICAL
PERMIT TO
ELECTRICAL
FRAMING
INSULATION r - - STORIES. TYPE CONSTR.
- OCC.GROUP RES.UNITS
PLACE NO SUBFLOOR UNTIL ABOVE HAS BEEN SIGNED
ROOF e. SO.FTFLOOR AREA TOTAL CRENGE
DIAPHRAGM - _
BUILDING USE
'• D7 HES IND CON PB OrEe,
APPLY NO ROOFING UNTIL ABOVE HAS BEEN SIGNED C 11 El 1:1 ❑ ❑
ROUGH 'nYK-^',J,�',^,'-�' ASSESSORS PARCEL NO.
PLUMBING _ `C
GAS TEST - TRACT NO. PARCEL NO.
MECHANICAL
ACC.GATE ACC.FILE NO.
ELECTRICAL - FINALS ti
INSP.
FRAMING SAN *
20NING ENG.SITE NO.
INSULATION - � PLUMBING _
GAS '
FIRE SPRINK ENERGY T 24
MECHANICAL,
COVER NO WORK UNTIL ABOVE HAS BEEN SIGNED HEATING Y F] N❑ Y ❑ N[]LATH-INTERIOR ELECTRICAL FLooD zoNE .L.uc.
LATH-EXTERIOR FIRE DEPT. Y❑ N❑ Y ❑ No
SHEETROCK - GRADE FEE SUMMARY
SHEAR INTERIOR BUILDING
-
SHEAR EXTERIOR- TEMPORARY APPROVALS BUILDING
FIREWALLS - ELECTRIC PLAN CHECK
' GAS FEE '
NO TAPE OR PLASTER UNTIL ABOVE HAS BEEN SIGNED JOCCUPANCY ISEISMIC FEE
OCCUPANCYOF BUILDING ISNOTPERMITTEDUNTIL BUILDING FINAL I SSIGNED BY BUILDING INSPECTOR. MICROFILM
I
ARRANGE FOR INSPECTION BY PHONING 252-4505, ELECTRIC
F ONE WORKING DAY BEFORE REQUIRED INSPECTION. PLUMBING
z PLEASE GIVE JOB ADDRESS WHEN PHONING.
- SEE PERMIT FOR EXPIRATION DATE - MECHANICAL
- - CONST.TAX
IMPORTANT!
PLEASE READ REVERSE SIDE BEFORE TOTAL
CALLING FOR FINAL INSPECTION.
OFFICE COPY ,
SEWER CONNECTION PERMIT
SERIAL NO.
CUPERTINO SANITARY DISTRICT
20065 Stevens Creek Blvd.
LID No.............Parcel No............. Room 204 (408) 253.7071 P 12 218
Tract No.....................Lot No............. Cupertino, Ce., 95014
A.P.N.Bk.�a S.yPg �.~�..Par--O -./eDate.....�c NC-M 1 7.........7.............. 19.S
The undersigned, being the owner (or owner's agent) of the property located at..................................................
74
consisting of the following TYPE OF BUILDING:
Residential: Single family ..K. Multiple ........ No. Unita......I....
Commercial ........ Industrial ........ Other ...................................... No. Units............
does hereby request a permit to connect to the sewer system of the Cupertino Sanitary District.
In consideration of the granting of this permit, the undersigned agrees:
1) To comply with all existing regulations and Ordinances of Cupertino Sanitary District and all future
regulations and Ordinances which may be adopted.
2) To maintain the house lateral, that portion of the side sewer within private property, and to provide
access to the lateral sewer through a cleanout raised to grade at the property line or at the limits of
any existing District easement.
3) To acquire a permit from the ...... ...... ................................. Building Depart.
ment and obtain inspection of and approval by said Building Department prior to covering of the work
or use of the sewer. `` j
In the event this sewer cower- Property Owner's Name 4-T. 4 Er n e 6t . 5 f U M G rA
...............................................
tion Is not installed and the permit Mailing address if ,5o M &
VOIDED, the fees receipted below different from above ....... ..................................................................
shall be forfeited and a subsequent Telephone .....2..4� 9G........................................
. ...
permit required.
B
y - :. .�-fi
........ .... t
........ .... .....................................,..
FEES:
Connection Permit Fee a
10
Sewer Service charges to June 30, 19.gs($........l..":....../mo. x....C.mo.) .........7.z..:....
Inspection Fee for backflow protection device .............................
................Additional Dwelling Units at $------------------------/ea. (Zone No.........)
�.m
TOTAL $..........g.��:...'�..
r q°
Receipt Of $.....r�..l.?..........- acknowledged and permit granted.
MARK THOMAS & CO. INC.
District Manager
_///Engineer
...... ......
By ... l l3