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11652 (2) _ APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY BU LDI NG PROJECT I DENTI FICATI ON PERMIT NUMBER SOILOINc APPLICATION & PERMIT 11652 ADDRESS BUILDING-ELECTRICAL-PLUMBING-MECHANICAL OWNERPLAN CHECK VALIDATION NAME 'cr. i OTY. ELECTRIC PERMIT FEE ONE NAMERAcroRs _ OUTLETS-SWITCHES-RECEP 10.00/1.00 LIC.NO. �3 LIGHTING F IXTURES 10.00/1.00 r,ONTRAcrOR's APPLIANCES-RESIDENTIAL 4.00 ' AOO/REsps '" > Ar 9�/t, U/,1'!l �/J�NONE/ `T S_C PANELS 10.00 DATE OF APPLICATION ARCHITECT - PANELS (OVER 200 AMP) 20.00 PLAN CHECK FEE P.C.NO. OR ENGINEER LIC.NO. SIGNS TRANS. 3.00 ARCH.OR ENG. SPECIAL CIRCUIT S.00 PERMIT VALIDATION ADDRESS ZIP EMP.METER OR POLE INS. 20.00 ADDRESS r'S AMOTORS SEE FEE SCH. ADDRESS SERVICECHANGE 20.00 f�" '02 LICENSkiD CONTRACTORS DECLARATION `/�l5/� <u u I hereby affirm Thal I am licensed under provisions of Chapter 9 DANCE DATE Q w (commencing with Section 7000)Of Division 3 Of the Business and B ECT. PLG. MECH. Professions Code,and my license is in full fo a S- o i m o icens�lass Lie.Number ❑ H w Dafe X��' ��Cnmractor El a y f J BUILDING PERMIT ¢ ce w < OWNER-BUILDER DECLARATION INF RMATION o a U MISC.- REFER TO ORD E ; H 1 hereby affirm that I am exempt from the CnNmclor's License UA S/FT. _ u Og Law forthe following reason.(See.7031.5,Business and Professions PERMIT ISSUANCE 10.00 4`,� n Code:Anycity orcounty which requires a permit to construct,alter, /�� Y �� Q Q Q Improve,demolish,Or repair any'Declare,prior l0 i15155uance,also $LEC.CONTR. LIC.NO. ELEC. Y i - DLL requires lire applicant for such permit to file a signed statement that TOTAL PERMIT TO . E $ he is licensed pursuant to the provisions of the Contractor's License p rit Law(Chapter 9(commencing wit It Section 7000)of Division 3 of the .41x- U a Business and Professions Code)of that he is exempt therefrom and CITY. PLUMBING PERMIT FEE X30 ¢s-c� the basis for the alleged exemption.Any violation Of Section 703 1.5 STORIES TYPE CONSTR. by any applicant for a permit subjects the applicant to a civil penally ALTER-DRAIN& VENT-WATER (EA.) 5.00 of not more than five hundred dollars($5000.): ❑ I,as owner of the property,or my employees with wages as BACK FLOW PROTECT.DEVICE 4.00 OCG.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,COND. 5.00 Code:The Contractor's License Law does not apply to an owner of properly who builds or improves thereon,and who does such work FIXTURES-PER TRAP 5.00 50.FT.FLOOR AREA TOTAL ACREAGE himself or through his own employees,provided that such improve- GAS 6.00 meets are not intended or offered for sale.If,however,the building . 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 im- RES IND CON Re Omer, prove for purpose of sale.). IINDUSTRIAL WASTE INTER. 30.00 ❑ 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 an owner of property who builds or improves theremt and who LAWN SPRINKLERS-OVER 5 (EA.) 1.00 contracts for such projects with a conlractons)licensed pursuant to SEWER-SAN V-STORM EA.200ft/10.00 the Contractor's License Law. TRACT NO. PARCEL NO. ❑ I am exempt under Sec. ,BAP.C.for this WATER HEATER W/VENT 6.00 reason Owner Date WATER SYSTEM 5.00 ACC.GATE ACC,FILE NO. WORKEiRS'COMPENSATION DECLARATION WATER TREATING EQUIP. 5.00 1 hereby affirm that 1 have a certificate of consent to self-insure, ZONING or a certificate of Workers'Compensation Insurance,or a certified ENG.SITE NO. copy thereof(Sec.3800,Lab.C.L,� ENC -1 Policy No. Company_ /T 0 ❑ Certified hereby ft I'll FIRE SPRINK ENERGY T 24 Z copy-ir th tl inspection division. p Appl' a ,!!s[/ -� l^"`� MISC.- REFER TO ORD. Y ❑ N❑ Y ❑ N❑ ~ in PERMIT ISSUANCE 10.00 FLOOD ZONE A.L.U.C. LU CIiRTIFICCOI? E EXEMPTION TINS FROM WORKERS' W � COMPtiNSATION INSURANCE PLG.CONTR. LIC.NO. PLG. CL C1 (This section need not be completed if the permit is for one TOTAL Y❑ NEI Y❑ N❑ hundred dollars(S 100)or les.) U O 1 certify that in the performance of the work for which'his per- OTY. MECHANICAL PERMIT FEE FEE SUMMARY LL F mit is issued,1 shall not employ any person in any manner so as to 0 U become subject to the Workers'Compensation Laws of California. w Date Applicant BUILDING .� Q. ALTER OR ADD TO MECH. 5.00 10 } to NOTICE TO APPLICANT: If,after making this Certificate of Ex- I- 2 emplina,you should become subject to the Workers'Compensatinn APPLIANCE 5.00 PLAN CHECK provisions of the Labor Code, you must forthwith comply wish FEE U such provisions or this permit shall be deemed revoked, AIR HANDLING UNIT(TO 10,000GF.M.) 4.00 CONSTRUCTION LENDING AGENCY AIR HANDLING UNIT(OVER 10MC.F.M.) 6.00 SEISMIC FEE 16Z 1 hereby affirm (hat 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(TO 100,000 B.T.U.) 8.00 MICROFILM 3097,Civ.C.). Lender's Name Lender's Address HEATI NG UNIT(OVER 100,000 B.T.U.)9.50 ELECTRIC 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 hereby authprim representatives this city 10 enter Upon the' BOILER-COMP(Over 100,000 BTU)SEE FEE SCH. MECHANICAL above-mentioned propert for ins coon purposes. (We) agree to indem and keep harmless (he City of MISC.- REFER TO ORD. Cupertino a liabilitie t ments, costs and expenses which CONST.TAX may i w e t l said,Ci Clonsequence of the PERMIT ISSUANCE 10.00 of thls pennil. MECH.CONT. LIC.NO. MECH. \ ��,lEf� - TOTAL TOTAL �( Signalere Of Applicant/Contractor Date OFFICE COPY POST THIS CARD NEAR FRONT OF BUILDING PFRMIT NUMBER CITY OF CUPERTINO 11652 INSPECTION DIVISION JOB INSPECTION RECORD - l% /LI ��/C� �f vn PERMIT EXPIRATION _ JOB ADDRESS �•�- C.� UNIT# LOT# T PERMIT EXPIRES If WORK OWNER 1 Pi CONTRACTOR J H. TrMlta_ IS NOT STARTED WITHIN INSPECTION DATE I INSPECTOR INSPECTION RECORD 180 DAYS OF PERMIT ISSU- FOUNDATIONt�,J/ ANCE OR 180 DAYS FROM ��0o LASTCALLED INSPECTION. UFER PERMIT VAUC�TION PREGUNITE � -1b31b ruy�A.n 4,d,( �'!L, T� 1264'- ItALttlt -14S�S 6 6dTlrL fob f�a l� bd�l, ✓ POUR NO CONCRETE UNTIL ABOVE HAS BEEN SIGNED UNDERGROUND /SLAB, / • PLUMBING q/r/ /K ELECTRICAL ISSUANCE DATE MEDHAN IC L BLDG. ELECT. PLG. MECH, DO NOT POUR FLOOR UNTIL ABOVE HAS BEEN SIGNED BUILDING PERMIT WINFORMATION WOOD FLOOR VALUATION SYFT. PLUMBINGL� -76 MECHANICAL 7 ELECTRICAL PERMIT To IPEP�/TR- SF/O�JE� FRAMING INSULATION sroRlEs TYPE CONSTR. OCC.GROUP RES.UNITS ex PLACE NO SUBFLOOR UNTIL ABOVE HAS BEEN SIGNED ROOF SO FT FLOOR AREA TOTAL ACREAGE DIAPHRAGt„-_ BUILDING USE RLS IND CON PB O'ne' APPLY NO ROOFING UNTIL ABOVE HAS BEEN SIGNED ❑ ❑ ❑ ❑ ❑ ASSESSORS PARCEL NO. ROUGH PLUMBING _ TRACT NO. PARCEL NO. GAS TEST MECHANICAL ACC.DATE ACC.FILE NO, ELECTRICAL FINALS DATE INSP. FRAMING SAN # ZONING ENG.SITE NO. INSULATION PLUMBING GAS FIRE SPRINK ENERGY TZ< MECHANICAL Y❑ N❑ Y ❑ N❑ COVER NO WORK UNTIL ABOVE HAS BEEN SIGNED HEATING LATH—INTERIOR ELECTRICAL FLOOD ZONE A.LU.C.. _• _ LATH—EXTERIOR FIRE DEPT. Y[:] No Y N[] SHEETROCK GRADE FEE SUMMARY SHEAR INTERIOR BUILDING BUILDING SHEAR EXTERIOR TEMPORARY APPROVALS t` FIREWALLS ELECTRIC PLAN CHECK GAS FEE NO TAPE OR PLASTER UNTIL ABOVE HAS BEEN SIGNED JOCCUPANCY SEISMIC FEE OCCUPANCY OF BUILDING IS NOTPERMITTED UNTIL BUILDING FINAL ISSIGNED BY BUILDING INSPECTOR. MICROFILM I ARRANGE FOR INSPECTION BY PHONING 252-4505, ELECTRIC o� 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 .'F,'` TOTAL CALLING FOR FINAL INSPECTION. OFFICE COPY I -