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15360C APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY BUILDING PROJECT IDENTIFICATION BUILDING ADDRESS OWNER'S NAME M f4 RI 7� rt �t Al !�S - �T'� PHONE U5( r rA NAME - t V �Fv E 2 LIC, NO. CONTRACTOR'S ADDRESS PHONE ARCHITECT OR ENGINEER LIC. NO. ARCH. OR ENG, ADDRESS APPLICATION & PERMIT 53fi0 UILDING - ELECTRICAL- PLUMBING - MECHANICAL ADDRESS a M I AJ DR o o LICENSED CONTRACTORS DECLARATION 1 hereby affirm that 1 am licensed under provisions of Chapter 9 NQ w (commencing with Section 7000) of Division 3 of the Business and r lo,z Professions Code, and my license is in full force and effect. Z O N - i License Class Lic. Number o N F Date Contractor wU OWNER -BUILDER DECLARATION X LL m I hereby affirm that I am exempt from the Contractor's License LL o a Law for the following reason. ( Sec. 703 1.5, Business and Professions ~ - w Code: Any city or county which requires a permit to construct, alter, w a i improve, demolish, or repair any structure, prior to its issuance, also ELEC. w o ¢ requires the applicant for such permit to file a signed statement that a w N he is licensed pursuant to the provisions of the Contractor's License s. Law (Chapter 9 (commencing with Section 7000) of Division 3 of the z - a Business and Professions Code) or that he is exempt therefrom and QTY. ¢ o the basis for the alleged exemption. Any violation of Section 7031.5 d 3 m by any applicant for a permit subjects the applicant to a civil penalty of not more than five hundred dollars ($500).): a I, as owner of the property, or my employees with wages as their sole compensation, will do the work, and the structure is not intended or offered for sale (Sec. 7044, Business and Professions Code: The Contractor's License Law does not apply to an owner of property who builds or improves thereon, and who does such work himself or through his own employees, provided that such improve- ments are not intended or offered for sale. If, however, the building or improvement is sold within one year of completion, the owner - builder will have the burden of proving that he did not build or im- prove for purpose of sale.). ❑ I, as owner of the property, am exclusively contracting with licensed contractors to construct the project (Sec. 7044, Business and Professions Code: The Contractor's License Law does not apply to an owner of property who builds or improves thereon. and who contracts for such projects with a contractor(s) licensed pursuant to the Contractor's License Law. ❑ 1 am exempt under Sec. . B.&P.C. for this reason Owner Date O Z Z O LU 0- ::) ::) Z U o_ U- 0 U.1 Ow WORK ERS'COMPENSATION DECLARATION hereby affirm that 1 have a certificate of consent to self -insure. or a certificate of Workers' Compensation Insurance, or a certified copy thereof (Sec. 3800, Lab.C.). Policy No. Company ❑ Certified copy is hereby furnished. ❑ Certified copy is filed with the city inspection division. Applicant CERTIFICATE OF EXEMPTION FROM WORKERS' COMPENSATION INSURANCE PLG. (This section need not be completed if the permit is for one hundred dollars (S 100) or less.) I certify that in the performance of the work for which this per- QTY 'mit is issued. 1 shall not employ any person in any manner so as to b h Workers' Compensation Laws of California. ELECTRIC PERMIT CUTLETS -SWITCHES - RECEP 10.00/1.00 _IGHTING FIXTURES 10.00/1.00 NPPLIANCES - RESIDENTIAL 4.00 PANELS 10.00 PANELS (OVER 200 AMP) 20.00 SIGNS TRANS. 3.00 SPECIAL CIRCUIT 5.00 TEMP. METER OR POLE INS. 20.00 MOTORS SEE FEE SCH. SERVICE CHANGE 20.00 MISC. - REFER TO ORD PERMIT ISSUANCE 10.00 :ONTR. LIC. NO. TOTAL LE TOTAL PLUMBING PERMIT ALTER -DRAIN & VENT -WATER (EA.) 5.00 BACK FLOW PROTECT. DEVICE 4.001 DRAINS -FLOOR, ROOF, AREA, COND. 5.00 FIXTURES - PER TRAP 5.00'. GAS - EA. SYSTEM -1INC. 4 OUTLETS 6.00 GAS - EA. SYSTEM - OVER 4 (EA.) 2.00 INDUSTRIAL WASTE INTER. 30.00 LAWN SPRINKLERS - 1 INC 5 V.B. 6.00 LAWN SPRINKLERS - OVER 5 (EA.) 1.00 SEWER -SANITARY -STORM EA. 200ft/10.00 MECH. TOTAL WATER HEATER W/VENT 6.00 WATER SYSTEM 5.00 WATER TREATING EQUIP. 5.00 MISC. - REFER TO ORD. PERMIT ISSUANCE 10.00 CONTR. LIC. NO. PLG. TOTAL MECHANICAL PERMIT become su Iect tot e Date Applicant NOTICE TO APPLICANT: If, after making this Certificate of Ex- emption, you should become subject to the Workers' Compensation provisions of the Labor Code, you must forthwith comply with such provisions or this permit shall be deemed revoked. CONSTRUCTION LENDING AGENCY I hereby affirm that there is a construction lending agency for the performance of the work for which this permit is issued (Sec. ALTER OR ADD TO MECH. 5.00 APPLIANCE 5.00 AIR HANDLING UNIT (TO 10SWC.F.M.) 4.00 AIR HANDLING UNIT (OVER 10000 C. F.M.) 6.00 EXHAUST HOOD (WITH DUCT) 5.00 HEATING UNIT (TO 100,000 B.T.U.) 8.00 3097, Civ.C.). Lender's Name HEATING UNIT (OVER 100,000 B.T.U.)9.50 Lender's Address 1 certify that I have read this application and state that the above information is correct. 1 agree to comply with all city and county VENTILATION FAN (SINGLE) 4.00 BOILER- COMP (3 H.P. or 100,000 B.T.U.) 6.00 ordinances and state laws relating to building construction, and hereby authorize representatives of this city to enter upon the BOILER -COMP (Over 100,000 BTU) SEE FEE SCH. above-mentioned property for inspection purposes. (We) agree to save• indemnify and keep harmless the City of Cupertino against liabilities, judgments, costs and expenses which may in any way accrue against said City in consequence of the ranting of this permit. ` MISC. - REFER TO ORD. PERMIT ISSUANCE 10.00 MECHCONT. LIC. NO. . MECH. TOTAL re of Applicant/Contractor uate APPLICANTS COPY PLAN CHECK VALIUAI IUN FEE L uivaL B 2 8 1996 DATE OF APPLICATION PLAN CHECK FEE P.C. N C IT PERMIT VALIDATION FEE FEE BLDG. ELECT. PLG. MECH. ❑ I ❑ ❑ ❑ BUILDING PERMIT INFORMATION VALUATION /FT. rte.}-a�•� PERMIT TO��„G STORIES TYPE CONSTR. FLOOR AREAI TOTALACREAGE BUILDING USE RES IND CON PB Other o ❑ ❑ ❑ ❑ ASSESSORS PARCEL NO. TRACT NO. PARCEL NO. ACC.DATE ACC. FILE NO. ZONING ENG. SITE NO. FIRE SPRINK ENERGY T-24 Y ❑ N ❑ Y ❑ NE: FLOOD ZONE A.L.U.C. Y N❑ Y❑ NC FEE SUMMARY BUILDING PLAN CHECK FEE l) SEISMIC FEE :.. MICROFILM ELECTRIC PLUMBING MECHANICAL CONST. TAX TOTAL / S �' POST THIS CARD NEAR FRONT OF BUILDING CITY OF CUPERTINO INSPECTION DIVISION JOB INSPECTION RECORD l / / JOB ADDRESS57)/�i.vaU li✓ � _ UNIT # LOT # — OWNER /14/4 -x -?EO%% CONTRACTOR PERMIT NUMBER 15350 PERMIT EXPIRATION PERMIT EXPIRES IF WORK IS NOT STARTED WITHIN 180 DAYS OF PERMIT ISSUANCE OR 180 DAYS FROM LASTCALLEDINSPECTION- INSPECTICN DATE INSPECTOR INSPECTION RECORD NOTE: ALL GRADING AND DRAINAGE SHALL BE INSTALLED TO COMPLY WITH THE APPROVED PLANS AND CITY OF CUPERTINO STANDARDS. UFER PER%uT VALIDATION ISSUANCE DATE PR EGU N I TE GARAGE SLABS POUR NO CONCRETE UNTIL ABOVE HAS BEEN SIGNED UNDERGROUND/SLAB PLUMBING ELECTRICAL tlLbG ELECT PLG ^EC - MECHANICAL DO NOT POUR FLOOR UNTIL ABOVE HAS BEEN SIGNED BUILDING PERMIT INFORMATION WOOD FLOOR VALUATION SIFT PLUMBING MECHANICAL PERMIT TO 41� C, wL ELECTRICAL FRAMING STORIES TYPE CONSTR INSULATION UCC GROUP RES UNITS PLACE NO SUBFLOOR UNTIL ABOVE HAS BEEN SIGNED 5U FT FLUOR AREA TOTAL ACREAGE ROOF NOTE: NO FINAL INSP. SHALL BE MADE BEFORE THE CONSTRUCTION TAX IS PAID DIAPHRAGM BUILDING USE RES IND CON PB 0111 - ❑ ❑ ❑ ❑ ❑ ROOF SHEATHING APPLY NO ROOFING UNTIL ABOVE HAS BEEN SIGNED FINALS DATE INSP. ASSESSORS PARCEL NO ROUGH SAN.a PLUMBING ELECT. ENERGY TRACT NO PARCEL NO TUBS & SHOWER PAN PLUMBING ENERGY MECHANICAL MECH.ENERGY ACC DATE ACC FILE NO ELECTRICAL BUILDING ENERGY FRAMING ELECT. FINAL TEST zo%IN6 ENG SITE NO INSULATION PLUMBING GAS TEST GAS FIRE SPR INK O NE ENERGY T :4 E N[ MECHANICAL COVER NO WORK UNTIL ABOVE HAS BEEN SIGNED HEATING FLOOD ZONE N� ALU C L NC EXTERIOR SHEAR ELECTRICAL RELEASE INTERIOR SHEAR FIRE DEPT. FEE SUMMARY SHEETROCK GRADE EXTERIOR LATH BUILDING BUILDING }� INTERIOR LATH TEMPORARY APPROVALS SCRATCH COAT ELECTRIC PLAN CHECK FEE GAS SEISMIC FEE 3 S� NO TAPE OR PLASTER UNTIL ABOVE HAS BEEN SIGNED OCCUPANCY OCCUPANCY OF BUILDING IS NOT PERMITTED UNTIL BUILDING FINAL ISSIGNED BY BUILDING INSPECTOR. MICROFILM ARRANGE FOR INSPECTION BY PHONING 252-4505, `l' ONE WORKING DAY BEFORE REQUIRED INSPECTION. � 0 PLEASE GIVE JOB ADDRESS WHEN PHONING. Z - SEE PERMIT FOR EXPIRATION DATE - ELECTRIC PLUMBING MECHANICAL CONST. TAX IMPORTANT! PLEASE READ REVERSE SIDE BEFORE CALLING FOR FINAL INSPECTION. TOTAL kz� S� APPLI(,ANTS POSTING COPY