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10170 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY - BUIL'bING PROJECT I DENTI FICATION PERMIT NUMBER BUILDING APPLICATION & PERMIT ADDRESS BUILDING-ELECTRICAL-PLUMBING-MECHANICAL 1017 O' O-NE 'S NAM ENC.R2/t0 CC- PLAN CHECK VALIDATION �V ✓P¢-LLe ZS2-la 6 S QTY. ELECTRIC PERMIT FEE ONE OtM1ERAcroR's OUTLETS-SWITCHES-RECEP 10.00/1.00 LIC.No. LIGHTING FIXTURES 10.00/1.00 ADDRESS oRs - PPLIANCES-RESIDENTIAL 4.00 - PHONE PANELS 10,00 DATE OF APPLICATION ARCHITECT PANELS (OVER 200 AMP) 20,00 PLAN CHECK FEE P.C.NO. ENGINEER ARH.ORLIC.NO. SIGNS TRANS. 3.00 ADDRESS ENG SPECIAL CIRCUIT 5.00 " PERMIT VALIDATION ZIP TEMP.METER OR POLE INS. 20.00 PN� ADDRESSTS MOTORS SEE FEE SCH. DECSERVICE CHANGE 20.00 EC �j,^ 0 1985 ' '02 oO LICENSED CONTRACTORS DECLARATION - TEMP,POLE 30.00 �s1t1/ of Cupertino a z W I hereby affirm that I am licensed under provisions of Chaplet 9 lSS(IANCE DATE ¢ y (commencing with Section 7000)of Division-3 of the Business and RL ELECT. PLG. MECH. F w i Professions Code,and my license is in full force and effect. ❑ ❑ ❑ Z o w- License Class Lie.Number o w� w Dale Contractor ' ¢ 2 w a OWNER-BUILDER DECLARATION - BUILDING PERMIT - O' O - - INFORMATION is g, vHi I hereby affirm that I am exempt from the Contractor's License MISC.- REFER TO ORD ,�O ¢ Law for the following reason.(See.7031.5,Businessand Professions VALUATION $/FT. I- - w � Code:Any cityorcounty which,equires a permit to construct,alter, PERMIT ISSUANCE 10.00 rt 2 Q 0 improve,demolish,or repair any structure,prior to its issuance,also ELEC.CONTR. LIC.NO. ELEC. iL m LL requires the applicant for such permit to file a signed statement that TOTAL u w he is licensed pursuant to the provisions of the Contractor's License PERMIT T H z a Law(Chapter 9(commencing with Section 7000)of Division 3 of the f i o Business and Professions Code)or that he is exempt therefrom and QTY. PLUMBING PERMIT FEE ¢I-$ the basis for the alleged exemption.Any violation of Section 7031.5 STORI S. TYPE CONSTR. by any applicant for a permit subjects the applicant to a civil penalty ALTER-DRAIN (EA.) 5.00 of not more than five hundred dollars(85000.): - ❑ 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 intended or offered for sale(Sec. 7044, Business and Professions DRAINS-FLOOR,ROOF,AR EA,COND. 5.00 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 5.00 SO.FT.FLOOR AREA TOTAL ACREAGE himself or through his own employees,provided that such improve- mentsatenotintended or offered for sale.I f,however,the building GAS-EA.SYSTEM-1 INC.4 OUTLETS 6.00 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- GAS-EA.SYSTEM-OVER 4(EA.) 2.00 BUILDING USE prove for purpose of the INDUSTRIAL WASTE INTER. 30.00 0 lO CON 0 ot❑nv ❑ 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 ASSESS07FARCELNO. 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 contmctots)licensed pursuant to the Contractor's License Law. SEWER-SANITARY-STORM EA.200ft/10.00 TRACT NO. PARCEL NO. ❑ 1 am exempt under Sec..,B.&P.C,for this WATER HEATER W/VENT 6.00 reason Owner a is x �D n,ro/ _ WATER SYSTEM 5.00 ACC.DATE ACC.FILE NO. WORK ERS'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.CJ. Policy No. Company O ❑ Certified copy is hereby furnished. BPRINK ENERGY T-T4 Z Z ❑ Certified copy is fled with.the city inspection division. FIRE p: O Applicant MISC.- REFER TO ORD. E] N❑ Y❑ N CC N CERTIFICATE OF EXEMPTION FROM WORKERS' PERMIT ISSUANCE 10.00 - FLOOOZONE A.L.U.C. LU > COMPENSATION INSURANCE PLG.CONTE. LIC.NO, pLG, n' O (This section need not be completed if the permit is for one TOTAL Y❑ N❑ Y❑ N❑ Z 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 LL U mit is issued,I shall not employ any person in any manner so as to become subject to the Workers'Compensation Laws of California. ED Date Applicant ALTER OR ADD TO MECH. 5.00 BUILDING >_ ANOTICE TO APPLICANT: If,after making this Certificate of Ex- - " I'- 2 emption,you should become subject to the Workers'Compensation APPLIANCE 5.00 PLAN CHECK provisions of the Labor Code, you must forthwith comply with FEE U suclh provisions or this permit shall be deemeit revoked. AIR HANDLING UNIT(TO 10,000C.F.M.) 4.00 CONSTRUCTION LENDING AGENCY AIR HANDLING UNIT(OVER 101000C.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, ). HEATING UNIT(70100,000 B.T.U.) 8.00 Lender's s Na Name Lender's Address HEATING 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 authorize representatives of this City it enter upon.the above-mentioned properly for inspection purposBOILER-COMP(Over 100,000 BTU)SEE FEE SCH. MECHANICAL es. (We) agree to save, indemnify and keep harmless the City of MISC.- REFER TO ORD. Cupertino against liabilities,judgments, costs and expenses which PERMIT ISSUANCE 10.00 CONST.TAX may any way accrue against said City in consequence of the - - g 1 ,oEf thisp iL MECILCONT. - LIC.NO. MECH. /✓� gM,cL,QiL 'rt-'(��-' TOTAL TOTAL Shgnatureof Applicant/Contractor Date 'OFFICE COPY POST THIS CARD NEAR FRONT OF BUILDING PERMIT NUMBER CITY OF CUPERTINO 1 � 7J INSPECTION DIVISION JOB INSPECT ON RECORD PERMIT EXPIRATION JOB ADDRESS &Iqt UNIT# _LOT# PERMIT EXPIRES IF WORK OWNER G CONTRACTOR IS NOT STARTED WITHIN INSPECTION, ;, DATE INSPECTOR INSPE TI RECORD 180 DAYS OF PERMIT ISSU- FOUNDATION ANCE OR 180 DAYS FROM UFER LAST CALLED INSPECTION. PREGUNITE p^[ vAL)DATION le a, tc bh -22- �6 POUR NO CONCRE E UNTIL ABOVE HAS BEE SIGNEDDEC 2 Q 1JE�5 UNDERGROUND /SLAB PLUMBING CRY of Cupertino ELECTRICAL ISSUANCE DATE MECHANICAL OLDG41 ELECT I PLG. I MECH. EX ❑ ❑ ❑ DO NOT POUR FLOOR UNTIL ABOVE HAS BEEN SIGNED BUILDING PERMIT WOOD FLOOR INFORMATION PLUMBING VALUATION S/FT. MECHANICAL ELECTRICAL PERMIT TO FRAMING INSULATION STORIES TYPE CONSTR. OCC.GROUP RES.UNITS PLACE NO SUBFLOOR UNTIL ABOVE HAS BEEN SIGNED ROOF 51) IT,FLNNR AREA H)IAL ACREAGE DIAPHRAGM BUILDING USE ' RES IND C N PB Olnw APPLY NO ROOFING UNTIL ABOVE HAS BEEN SIGNED 0 El ASSESSUf PARCEL NO. ROUGH PLUMBING GAS TEST TRACT NO. PARCEL NO. MECHANICAL ELECTRICAL FINALS DATE INSP. ACC DATE ACC,PILE NO. FRAMING SAN k INSULATION PLUMBING ZONING ENO.SITE NO. GAS FIRE SPRINK ENERGY Tad MECHANICAL COVER NO WORK NTIL ABO UVE HAS BEEN SIGNED I HEATING Y ❑ NE] Y E) N[3 LATH-INTERIOR ELECTRICAL FLOOD ZONE A EC. LATH-EXTERIOR FIR DDEPT. YO N❑ Y❑ No SHEETROCK GRADE FEE SUMMARY SHEAR INTERIOR BUILDING SHEAR EXTERIOR TEMPORARY APPR VALS BUILDING FIREWALLS ELECTRIC PLAN CHECK GAS FEE NO TAPE OR PLASTER UNTIL ABOVE HAS BEEN SIGNED OCCUPANCY SEISMIC FEE UCCUPANCY OF BUILDING ISNOTPERMITTED UNTIL BUILDING FINAL ISSIGNED BY BUILDING INSPECTOR, MICROFILM ARRANGE FOR INSPECTION BY PHONING 252-4505, ELECTRIC 0� ONE WORKING DAY BEFORE REQUIRED INSPECTION. PLumewG z PLEASE GIVE JOB ADDRESS WHEN PHONING. ` — SEE PERMIT FOR EXPIRATION DATE — MECHANICAL IMPORTANT! CONST.TAX PLEASE READ REVERSE SIDE BEFORE TOTAL CALLING FOR FINAL INSPECTION. OFFICE COPY