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4992 (2) A.PPLICAANT TO FILL-IN INFORMATION WITHIN RED LINES —'USE BALL POINT PEN ONLY T ✓ " §LILDING PROJECT IDENTI FICATIOIk@7 ey. PERMIT NUMBER;BUILDIN APPLICATION PERMIT ADDREss P "�`V7 ap . BUILDING — ELECTRICAL—PLUMBING —MECHANICAL PLAN CHECK VALIDATION, NAME TV. ELECTRIC PERMIT FEE CONTRACTORS NAME ' OUTLETS-SWITCHES-R ECEP '5.00/1.00 LIa NO LIGHTING FIXTURES .' 5.00/1.00 CONTRACTOR'E1 ADDRESS APPLIANCES-flESIDENTIAL 4.00 PHONEPANELS - 5.00 DATE OF APPLICATION ARCHITECT 'PLAN CHECK FEE P.C.NO. oR SIGNS '6.00 ENGINEER ' uc.NG. SIGNS TRANS. 3.00 ADDRESS ErvG. SPECIALCIRCUIT - 5.00 PERMIT VALIDATION iiP TEMP.METER OR POLE INS. 15.00 �') APPLI MOTORS SEE FEE SCH. Xt ADDRESS ss - - q •- SERVICE CHANGE 10.00 09 _ LICENSED CONTRACTORS DECLARATION a u w 1 hereby affirm that I am licensed under provisions of Chapter 9 - ATE (commencing with Section 7000)ofDivlsloo3 of the Business and rn¢ n BLDG.- ELECT. PLG. MECH. r n z Professions Code,and my license is in full force and effect. 0 m 141 o G License Class Lia.Number - - Data Contractor - a E BUILDING PERMIT a Ono affirm that I am DERexempt DECLARATION PH MATION X '1- ca I hereby affvm that.l int exempt from the Contractor's License MISC.'— - REFER TO ORD 1 HLse J . 'Law for the following reason.(Sec.7031.5,Business Professions PERMIT ISSUANCE 6.00 Code:Any city or county which requires a permit to construct,alter, QO� QQ Q 0 'Improve,demolish,Or repair any structure.prior ID Its Issuance,also ELEC.CONTE. + CLIC.NO. ELEG �- - •. 'y a O u requires the applicant for Seth permit to(ie a signed statement that - TOTAL - PERMIT TO he is licensed pursuant to the provisions of the Contractor's License .HiQ. La. Chapter9(commencing with Section 7000)of Division 3 of the ��l/,T2-4J0 K, Y�fHJ 14 D Business and Professions Code).,'that he is exempt therefrom and QTY. PLUMBING PERMIT FEE or H $' 'the basis for the alleged exemption.Any violation of Section 7031.5 STORIES ,TYPE CONSTR. by any applicant for a permit subjects the applicant toacivilpenalty ALTER-DRAIN -WATER (EA.) 41.00 - •of not more than five hundred dollars(55001.)', . . ' ❑' I,as owner of the property,or my employees with wages as BACK F LOW PROTECT:DEVICE. 2.00 . OCCGROUP EES.uw TS 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. 4,00 Code:The Contractor's License Law does not apply to an owner of property who builds or improves thereon,and who does such work FIXTURES-PER TRAP 4.00 ..SO.FT.FLOOR AREA TOTAL ACREAGE himself or through his own employees,provided that such improve- GAS q;00 mems are not intended or offered for Sale.If,however,the building , or improvement is sold within one year of completion'tire owner- GAS-EA'.SVSTEM-OVER 4(EA.) 1.00 BUILDING USE builder will have the burden of proving that he did not build or int- RES:! IND CON U PB Omer Prov for purpose of sale.). INDUSTRIAL WASTE INTER. 20.00 I,as owner of the property,am exclusively contracting with - ❑ _❑ ❑ ❑ ❑ licensed can tractors Yo,construct the project(Sec.7044,Business LAWN SPRINKLERS-1 INC 5 V.B. 5.00 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 t , contracts.for such projects with a contractons)licensed pursuant to the Contractor's License Law.. SEWER-SANITARY-STORM EA.200ft/8.00 TRACTNO. PARCELNO. ❑ lam exempt under Sec. ,B.&P:C.for this WATER HEATER WIVENT - 4.00 - 0 Uate Owner WATER SYSTEM 4.00 ACC.DATE ACG FILE NO. • 'WORKERS'COMPElsSATION'DECLARATION WATER TREATING EQUIP.' . 4.00, 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 C.). - Policy No. Company Q ❑ Certifiedc.pyishereby'famished- FIRE SPRINK ENERGY T-24 Z ❑ Certified copy'is filed with tlte.city inspection division.' MISC.- REFER TO ORD. O Applicant . Y [:] N❑ Y [:] NE] ' p: rn - PERMIT ISSUANCE 6.00 FLOOOZONE A.L.U,C. LU CIiRTIPICCOM E EXEMPTION FROM WORKERS' W >� COMPENSATION INSURANCE PLG.CONTR. uc.NO. PLc. - "' 0. Cl (This section need not be completed if the permit is In,one TOTAL - �Y❑, N❑ V ❑ N❑. hundred dollars($100)ov IessJ U O 1 certify that in the performance of the work for which this per- OTV. MECHANICAL PERMIT FEE FEE SUMMARY LL H mit is issued,I shall not employ any person in any tanner so as to U become subject to the Workers'Compensation Laws of California. W Date' Applicant BUILDING �t� - a ALTER OR ADD TO MECH: 4.00 V } N NOTICF. TO APPLICANT If,after making this Certificate lix. F Z empEon,vision you should become subject m the Workers'Compensasa tion APPLIANCE 4.00 .PLAN-CHECK, provisions of the Labor Cit shallhalloo most forthwith comply with FEE - such provisions or this permit hallbe deemed revoke.). AIR HANDLING UNIT(TO 10,000QF.M.) 3.00 - CONSTRUCTION LENDING"AGENCY AIR HANDLING UNIT(OVER 10=C.EM.) 5.00 SEISMIC FEE` xJV I hereby affirm that theta is a construction lending agency for - EXHAUST HOOD(WITH DUCT) 2.00 the peiformance of the work for which this permit is issued(Sec. - - MICROFILM 3097,Cie.C.). f HEATING UNIT(TO'100,000 B.T.U.) 4.00 Lender's Name - HEATING UNIT(OVER 100,000 B.T.U.)7.50 ELECTRIC ' - Lender's Address I certify that I have read this application and state that the above VENTILATION FAN (SINGLE) 3.00 , information is correct 1 agree tocomply,with all clty'and county PLUMBING - ordinances and•state'laws.relatrng m-building.ocnstruction, and B0'LER F_COMPI3 H.P.or 100,000 B.T.U.) 4.00 hereby authorize representatives of this'efy to enter upon the BOILER-COMPIOver 100,000 BTU)SEE FEE SCH. MECHANICAL above-mentioned property for inspection purposes. (We) .gree to save, indemnity and keep harmless the City of MISC.-= REFER TO ORD. . Cupertino against liab" ents, costs and expenses which CONST.TAX may in any way a rue again id_ City,in consequence of the - 'PERMIT ISSUANCE - 3.00 �•'• t. grn ,f this per —� O MECH.CONT. LIC.NO. TOTAL, TOTAL L J S [are ol'Ap a t onhactor F M - - ' OFFICE COPY CITY OF CUPERTINO INSPEMON RECORD (OFFICE COPY) ADDRESS LOT NO— OWNER ao72 c PERMIT ISSUED DATE ELECTRICAL DATE INSP. u�ildin Erica Plumbing Power Pole mechanica r oun em1 as ec u Wiring o ar Walis Fire Sprinkler m _ bi ixF^tures nt xt Motors Misc. Groundui e ower Uther FINAL INSPECTIONS DATE INSP. Not Approved Gas Electric Plumbing PLUMBING DATE INSP. Mee Tianica �nZ—. /l-aG P` Ian Backflow JO - Underground . . . ra ung Undertloor Planningartier ire t. ou i oup ete Health t. bolar Rough m in aterio_ t er in . rain oDrain as ,Other BUILDING DATE INS-P. of rove Pad Certification oun =tion ELECTRICAL DATE INSP. re- unite Slab-Membrane Underfloor S.M. Eond Beam Ducts & Insulation -T( Underfloor oor it ers Fire Dampers Floor Steel ire ace ie owns Grease Duct i; Hood is ramsi�a Flour Shaft eismec racin A ' d – _yN Condensate sate rain Walls- ane s Equipment Anchorage Frame ues 4 Comb. Air adrL—at Uther oars nt xt. of rove Firewa s Other Not rove