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11173'APPLICANT TO FILL IN INFO MMATION WITHIN RED LINES - USE OL POINT PEN ONLY BU LD1 NG PROJECT 1 DENTI FICA APPLICATION &PERMIT BUILDING PERMIT NUMBER a . 11173. air`LDINq-_ .,- ADbREaa - - OWNER'S NAME•j�/J� . - ' A QTY. ELECTRIC PERMIT FEE PLAN CHECK VALIDATION / d(A77 ONtRAcrORs AME • /Q Lie. No. �0 UTLETS-SWITCHES-RECEP 10.00/1.00 Z/ LIGHTING FIXTURES 10.00/1.00 ORs 7 CONTRACTORS C p ` ADDRESS sv_ 03- ,�Ia% APPLIANCES - RESIDENTIAL. 4,00 PANELS IO.QO O - �� PHONE DATE OF APPLICATION RCNftscT O OR ENGINEER I � �uc. NO PANELS (OVER 200 AMP) 20.00 PLAN CHECK FEE P.C. NO. ISIGNS TRANS.' 3.00 ARCH. OR ENG. ADDRESS , SPECIALCIRCUIT 5.00 PERMIT VALIDATION - TEMP. METER OR POLE INS. 20.00 O ' tto APPLICANT'SADDRESS MOTORS SEE FEE SCH. p SERVICE CHANGE 20.00 - - I, 'LICENSED CONTRACTORS DECLARATION " I hereby affum,that 1 am licensed under provisions of Chapter 9 ISSUANCE DATE (vommencing with Section 7000) of Division 3 of the Business and Professions Code, and my license is in full force� etie t Licen,�' �lassr�- Lo NumberJd BLD ELECT. PLG. MECH. - Du0. Cn"tractor _- /f_tl- OWNER-BUILBUILDER DECLARATION L .I hereby affirm that 1 am exempt from the u Contractor's License owingreyw[iicSec. 703LS,Businessand Prafesaiens Law l:Any city Corte: Any city or cot repair any Structure Permit toconsuanc , also improve, de demolish, Or repairStructure,eprior asitO its tatement, that requires the dp pmol for such revisit to file il signed statement that he is licensed pursuant m the provisions of the License BUILDING PERMIT INFORMATION MISC.- 'REFER TO ORD VALUATION $/FT. PERMIT ISSUANCE .10.00 �' _ ELEC CONTR. LIC. NO. ELEC.10 TOTAL �� I -,,- R p QTV. PLUMBING PERMIT ' , FEE ) ofDjcer's Law (ChapternPro(commencingessionsde) r Section 7s excui ttheefrom the Business and Professions Code) or that he is exempt therefrom and SioBtES the basis for the alleged exemption. Any violation of Section 8031.5 - fora permit dollars the arplicam tea civil penalty by any more - of not more than five hundred s (my ALTER -DRAIN & VENT -WATER (EA.) 5.00 ' em): O I, as owner at the property, or my employees with wages as Sty, their sole compensation, will the work, and Ise structure is not BACK FLOW PROTECT. DEVICE 4.00 o G UP RES UNITS DRAINS -FLOOR, ROOF, AR EA,CON D. 5.00 " intended or offered for sale deur. 7044, Business and Professions (S Code: The Contractor's License Low does not apply an owner of property who builds or improves thereod, and who does such work himself or through his own employees, provided that such improve- memsamnot intended oroffamdfor sale. If, howeveq the building 2 FIXTURES -PER TRAP5.00 Q(�' a FT. FLO R AREA TOTAL ACREAGE - GAS-EA.SYSTEM-11NC.405TLETS 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 ar ch. prove for purpose of sale.). `• ❑ I, as owner of the.property, am exclusively contracting with GAS - EA. SYSTEM -OVER 4 (EA.) 2.00 BUI UrNG uSE JFA IND CON PB Omar ❑ ❑ ❑ ❑ INDUSTRIAL WASTE INTER. 30.00 LAWN SPRINKLERS - 1 INC 5 V.B. 6.00 LAWN SPRINKLERS - OVER 5 (EA.) 1.00 liccljsed contractor's 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 ASSESSORS PARCEL NO. contracts ronsuch projects with a contractorls) licensed rursuanl to the Contractor's License Law. , ';B.&P.C.for SEWER-SANITARY-STORMEA.200ft/10.00 O'- T CTNO. PARCEL NO. O lamexeniptunder Sec. this WATER HEATER W/VENT 6.00 reason Owner - Date r WATER SYSTEM 5.00 U ACC. DATE ACC. FILE NO. WORKERS'COMPENSATION DECLARATION WATER TREATING EQUIP. 5.00 I hereby, affirm that 1 have a certificate of consent to left -insure, or a certificate of Workers' Comrensddon laulo dce, or a ccrtifitd ZONING ENG. SITE NO. copy lhernoflSec. 3800 {> •r�C C,Lab.C.1__J�r� Policy N Company mu.1 J FIRE SPRINK y ❑ N ❑ FLOOD ZONE ENERGY TQ4 Y ❑ N❑ A.L.U.C. rt O Certified cop is hereby umished. j1, Ce ified o, is file R e Ty inspection division. Applicant c'do -,_J MISC.- REFER TO ORD. CB RTI F I C'ATE OF EX I'M PTION FROM WORKERS' PERMIT ISSUANCE 10.00 0 PLG. CONTR. LIC. NO. PLG. 13 7 TOTAL COMPENSATION INSURANCE This section need not be completedif tile permit is for one Y N❑ Y❑ N❑ QTY MECHANICAL PERMIT - FEE - FEE SUMMARY hundred dollars IS 100) or less.). - I certify that in the performance of the work for which this per- mit is issued, Dshall not employ any person in any manner so as to _ BUILDING 0 become subjectto the Workers'Compensation Laws of California.. Date Applicant ALTER OR ADO TO MECH. - 500 . NOTICE TO APPLICANT: If, utter making this Certificate oFIT- APPLIANCE - 5.00 PLAN CHECK FEE, e million, you should become subject to the Workers' Compensation io pravisns'of the Labor Code, you most forthwithcomplywith such provisions or this permit shall be deemed revoked. AIR HANDLING UNIT (TO 10=C.F.M) 4.00 AIR HANDLING UNIT (OVER 10=C.F,M.) 6.00 SEISMIC FEE - ]O r CONSTRUCTION LENDING AGENCY I hereby affirm that there is a construction agency for EXHAUST HOOD (WITH DUCT) 5.00 ' mit is the .Civ.mancc of the work for which Slices, permit is issued (Sec. 3097,CIv.CJ, MICROFILM ^ HEATING UNIT (TO 100,000 B.T.U.) 8.00 d HEATING UNIT (OVER 100,000 B.T.U.)9.50 ELECTRIC Lender's Name-/k-x%Ar=2�r//F/✓CO'- Lender's Address I certify that I have read this application and stale that the aboveVENTILATION information is correct. I agree to comply with all city and county ordinances and slum laws relating to building construclion, and Hereby hulhoriee representatives -of this city to enter upon the above-mentioned property for inspection purposes. FAN (SINGLE) " 4.00 '- - PLUMBING 3 7 BOILER-COMP(3 H.P. or 100,000 B.T.U.) 6.00 BOILER-COMP(Over 100,000 BTU) SEE FEESCH. MECHANICAL �7 MISC. - REFER TO ORD. CONST. TAX - . (We)- agree to Save, indemnify and keep harmless the City' of Cupertino a cost liabilities, judgments, costs and expenses which may in en way accrue against said City in consequence of the granlingof his pensliL �' PERMIT ISSUANCE '.10.00 (3 MECH. CONT. LIC. NO. MEC N. 'r �J TOTAL Gp /' TOTAL ' Signature of p Scan on rector Dae OFFICE COPY r! i POST THIS� RD NEAR FRONT OF BUILDING ^ f CIT I!OF CU•PERTINO PER M1RT NUMBER • ��+- 7 11173 m INSPECTION DIVISION ' '! � JOB INSPECT,! N RECORD ', .�� • 7 , L PERMIT' EXPIRATION JOB ADDR SS U - OT#k r^ - ' PERMIT EXPIRES•1F WORK OWNER NTRACTOR 'IS NOT STARTED WITHIN 1SODAYS OF PERMIT ISSU- ANCE OR 180 DAYS FROM LASTCALLED INSPECTION. SPECT N 'DATE. INSPECTOR INS TI NRECORD FOUN ON^. LIFER- '6hrk svG PERMIT VALIDATION , ��/�. ISSUANCE DATE ' 1 POUR NO CONCRETE UNT 1 1 ROVE HAS BEEN SIGNED f UNDERGROUND/ SLAB -•.: ' PLUMBING ELECTRICAL MECHANICAL tlL ,ELECT ,lwd I PLG. wl ,MECH. 1w 00 NOT POUR FLOOR UNTIL ABOVE HAS BEEN SIGNED " 1, BUILDING PERMIT INFORMATION' WOOD FLOOR ; VALUATION PLUMBING!,- MECHANICAL _ - ELECTRICAL.- - _1 D"Y6 . - r Y//V///��� " FRAMING • INSULATION' b _ :. r .1 STORIES TYPE CONSTR.. - " OCC. GROUP +RES. UNITS PLACE NO SUBFLOOR UNTIL ABOVE HAS BEEN SIGNED 1 J ROOF a 50. FT. FLOOR AREA TOTAL ACREAGE � DIAPHRAGM - ' dtl /K� ^ N •L b" BUILDING USE H 5 INDD' CON PB Olney ❑ ❑ ❑ ❑ APPLY,NO ROOFING NTIL ABO E HASB IGNEO ROUGH v i I. ASSESSORS PARCEL NO. - PLUMBING '%IrIO GAS TEST TRACT rvo. - PARCEL NO, MECHANICAL-�(QR ELECTRICAL FINALS DATE INSP.'' ACC. DATE ACC. FILE NO. FRAMING�g�.' SAN INSULATION Z— ��' " PLUMBING ZONING ENG. SITE NO. • GAS „- ,, ,a .T .. " ^ MECHANICAL _ FIR ESPRINK ENERGY T 24 2- S Y❑ N❑ •'Y❑ N❑. COVER NO WORK UNTIL ABO E S BEEN SI NE HEATING LATH—INTERIOR ( ELECTRICAL` _ 'FLOOD ZONE Y ❑ * N A.L.U.C., . ^ Y ❑ N❑ LATH=EXTERIOR., 7 FIRE DEPT. - SHEETROCK GRADE 0.10 Iv'7•aw FEE SUMMARY SHEAR INTERIOR - BUILDING' 3� BUILDING - SHEAR EXTERIOR �( TEMPORARY APPROVALS FIREWALLS" - ELECTRIC ; PLAN CHECK •FEE - _' , ' GAS *NO -TAPE OR PLASTER UNTIL ABOVE HAS BEEN SIGNED IOCCUPANCY - - SEISMIC FEE UCCUPANCYOF BUILDING IS NOT PERMITTED UNTIL BUILDING FINAL ISSIGNED BY BUILDINGINSPECTOR.MICROFILM ,ARRANGE FOR INSPECTION BY PHONING 252-4505, ELECTRIC wT ONE WORKING DAY BEFORE REQUIRED INSPECTION. O~� PLEASE GIVE'JOB'ADDRESS WHEN PHONING. PLUMBING • i_ Z .-SEE PERMIT FOR EXPIRATION DATE - : MECHANICAL ' CONST. TAX IMPORT,ANTI TOTAL PLEASE READ REVERSE SIDE BEFORE CALLING FOR FINAL INSPECTION.' . OFFICE COPY ,