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12941APPLICANT -TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY BU I LDING PROJECT I DENTIFICATI ON APPLICATION & PERMIT, BUILDING - ELECTRICAL- PLUMBING - MECHANICAL PERMIT NUMBER 12941 RGILpINc ADOR s= - OWNER'S \^1 ��I NAME�JK-e�{ Qr"PNO i)�I DTV. ELECTRIC PERMIT FEE PLAN CHECK VALIDATION DATE OF APPLICATION NANreacrons NAME pp UC.No. G{ UTLETS-SWITCHES-RECEP 10.00/1.00 LIGHTING FIXTURES 10.00/1.00 CONTRACTOR'S RE55 \ E I-4 12C APPLIANCES - RESIDENTIAL 4.00 . PANELS 10.00 ARCHITECTPANELS OR ENGINEER uc No. (OVER 200 AMP) 20.00 PLAN CHECK FEE P.C. N0. SIGNS TRANS. 3.00 ARCH. OR ENG. ADDRESS '• ��. ZIP SPECIALCIRCUIT 5,00 PERMIT VALIDATION? I -',� TEMP. METER OR POLE INS. 120.00 APPLICANTS t - aDDRESpoaass r MOTORS SEE FEE SCH. SERVICECHANGE - 20.00 ` LIC17NSED C0N'fBACTORS DECLARATION I hereby affirm that I am licensed under provisions of Chapter 9 t$ DANCE DATE {commencing with Section 7000) of Division 3 of the Business and Professions Co •,' n y license is in full fur a n License Cl s Lic. Number BLDG. ❑ ELECT. PLC: MECH. ❑ ❑ Data 7T�Contructar7-1 _ BUIL ING PERMIT INF MATION ��- OWNER.BUILDERDECLARATION .1 hereby affirm that I am exempt from lhe Contractor's bssions Law for the following reason. {Sec 7iresa Business and Professions Code: Any city sh county which requirese permit 10 Consuanc,, al. requires. demolish, Or repair any structure, prior n its issuance, also requires the applicant for such permit to file a signed statement that he is licensed pursuant to the provisions of the Contractor's License Law (Chapter 9 (commencing with Section 7000) of Division 3 of the Business and Professions Code) or that he is exempt therefrom and MISC.- REFER TO ORD VALUATION $/FT. PERMIT ISSUANCE t?�0 E C. NT LIC: NO. L TELEC OTAL a9 TOTAL PERMIT TO /- EL er- CITY. PLUMBING PERMIT - FEE STORIES TYPE CONSTR. the basis for the alleged exemption. Any violation of Section 7031.5 by any applicant for a permit subjects the applicant m ircivil penalty of not more than five hundred dollars (S500)J: ALTER -DRAIN -WATER IEA.) 5.00 ❑ I, as owner of the property, or'my employees with wages as their sole compensation, will do the work, and the structure is not BACK F LOW PROTECT. DEVICE 4.00 OCC. GROUP RES. UNITS DRAINS -FLOOR, ROOF, AR EA, COND. 5.00 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 Bimsell' or through his own employees, provided that such improve-' mems are not intended or offered for sale. If, however, the'buili ing FIXTURES • PER TRAP 5.00 So. FT. FLOOR AREA TOTAL ACREAGE GAS•EA.SVSTEM-11NC.40UTLETS 6.00 ore improvement is sold within one year of completion, the own builder will have the burden of proving that he did not build or ie- . prove for Purpose of tare p ❑ d as owner of the property, all; exclusively . 7044, Bu Wltll licensed contractors to construct the project La does not apply Contractor's improv Law does, and who and n owner of Cn properly toanofpropertywho buildsor andwlo GAS - EA. SYSTEM -OVER 4 IEA.) 2.00 BUILDING USE RES IND CON PB Other 'x INDUSTRIAL WAST,EANTER. 30.00 LQW N'.SPRIN KLERS-11NC5 V.B. 6.00 LAWN SPRINKLERS - OVER 5(EA.) 7.00 SP ASSESSORS PARCEL NO. trimprovesensedm- with a contractor{ s) licensed pursuant to conthe Co is for such License the Contractors License Law: SEWER -SANITARY -STORM EA. 200ft/10.00 TRACT NO, PARCEL NO. ❑ lam exempt under Sec,- ,B.&flC. for this WATER HEATER W/VENT 6.00 reason - Owner Date WATER SYSTEM 5.00 ACC.DATE ACC. FILE NO. WATER TREATING EQUIP. 5.00 WORKERS' COMPENSATION DECLARATION I 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 (See. 3800, Lab.C.). Policy No. Company ❑ I led C ov rs hereby erlo✓i i. Ith t cit inspection division. Applicant Ag FIRE SPRINK Y N� ENERGY T$4 Y N� MISC.- REFER TO ORD. C17RT1171CA'I'E OF EXEMPTION FROM WORKERS' PERMIT ISSUA NCE 10.00 FLOOD ZONE A.L.U.C. PLG. CONTR. LIC. N0.PLG, TOTAL COMPENSATION INSURANCE (This section need not be completed if the permit is for one Y ❑ N[_ Y ❑ N hundred dollars IS 100) or les.) - I certify that in tiro performance of the work for which this per. mil is issued, I shall not employ any person in any manner so as to OTV. - MECHANICAL PERMIT FEE FEE SUMMARY become subject to the Workers' Compensation Laws of California. Data ApplicantBUILDING ALTER OR ADD TO MECH. 5.00 NOTICE 1'0 APPLICANT: 11, after making this Certificate of nix- emption, you should become subject to the Workers' Compensation provisions of the Labor Code, you must forthwith comply wl[h such provisions or this permit shall be deemed revoked. APPLIANCE - 5.00 PLAN CHECK FEE - AIR HANDLING UNIT (TO 10=C.F.M.) 4:00 ' AIR HANDLING UNIT (OVER 10=C.F.M.) 6.00 SEISMIC FEE CONSTRUCT ION LENDING AGENCY I hereby affina 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. 3097, Civ.C.). MICROFILM - HEATING UNIT (TO 100,000 B.T.U.) 8.00 H EATI NG UNIT (OVER 100,000 B.T.U.) 9.50 ELECTRIC 17H -Lender's Name Lenders Address - VENTILATION FAN (SINGLE) 4.00 I certify that I have read this application end state that i e ove information is correct. I agree to comply with all cite county ordinances and state laws relating to building c lr tion, and PLUMBING BOILER-COMP(3H.P.or100,000B.T.U.) 6.00 BOILER -COMP lover 100,000 BTU) SEE FEE BCH. - MECHANICAL. hereby authorize representatives of this city e r upon the above-mentioned property for in eclion pur se (We) agree to save, in Ify an armless the City of Cupertino against Iiabi' Iudgl six and expenses whi h may in any wa agar sty It conseque co e granting of I MISC. - REFER TO ORD. CONST. TAX PERMIT ISSUANCE. 10.00 ItIECRI. CONT. LIC. NO, MECH. TOTAL TOTAL Signature of Ap scant/Contractor ale OFFICE COPY POST THIS CARD NEAR'FRONT OF'BUILDING CITY OF CUPERTINO PERMIT NUMBER . 12941 INSPECTION DIVISION I ..-JOB INSPECTION RECORD I PERMIT EXPIRATION �] JOB ADDR ESS /0 �� /�"%J%L—'-X�i.A-'Ci 7V, -UNIT# LOT#` r. ``t, • -, - - -PERMIT EXPIRES IF,�WORK OWNER CONTRACTOR Afi% ,IS NOT STARTED WITHIN -180DAYSOFPERMIT1SSu- ANCE OR; 180 DAYS -FROM LAST,CALLED INSPECTION. INSPECTION DATE INSPECTOR INSPECTION RECORD FOUNDATION4� UFER PREGUNITE PERMIT VALIDATION y; y , ISSUANCE DATE POUR NO CONCRETE UNTIL ABOVE HAS BEEN SIGNED UNDERGROUND/SLAB PLUMBING ELECTRICAL MECHANICAL - - - - BLDG.' 0 ELECT. 4 FILE, MECH. 0 ❑. 00 NOT POUR FLOOR UNTIL ABOVE HAS BEEN SIGNED - BUILDING PERMIT ..INFORMATION ' WOOD FLOOR vaLuanoN slFr. " PLUMBING - - - - - - MECHANICAL ELECTRICAL- PEAJ mRMIT TO FRAMING INSULATION, � STORIES" TYPE CONSTR. , _ - - - OCC. GROUP RES. UNITS IP.LACE NO SUBFLOOR UNTIL ABOVE HAS BEEN SIGNED IROOF1 1 SO. FI,FLOUR ARE. TOTAL ACHEAGE DIAPHRAGM ' BUIITDING USE. HES . IND CON PB Ober ❑ - 0 ❑ ❑ ' ❑ APPLYAO ROOFING UNTIL ABOVE HAS BEEN SIGNED ROUGH ASSESSORS PARCEL NO. PLUMBING GAS TEST - TRACT NO, PARCEL NO. MECHANICAL'FI ELECTRICAL- NALS S DATE * INSP. ACC.DATE ACC FILE NO. FRAMING - , INSULATION G ZONING ENG. SITE NO. -I - CAL FIRE SPRINK ❑:^N❑ ENERGY T-74 ❑'- N❑ COVER NO WORK UNTIL ABOVE HAS BEEN SIGNED LATH -INTERIOR AL FLOOD ZONE, " Y ❑ N❑ A, L.0 C. Y ❑ N❑ LATH—EXTERIOR ` T, -' SHEETROCK .1 FEE SUMMARY SHEAR INTERIOR ' TEMPORARY APPROVALS BUILDING SHEAR EXTERIOR FIREWALLS ,. ELECTRIC PLAN CHECK ' FEE� ` • GASNO TAPE OR PLASTER UNTIL ABOVE—HAS BEEN SIGNED JOCCUPANCY,, I SEISMIC.FEE xjy' , OCCUPANCY OF BUILDING IS NOT PERMITTED UNTIL BUILDING FINAL ISSIGNED BY BUILDING INSPECTOR. MICROFILM. , ARRANGE FOR INSPECTION BY PHONING 252-4505„ ELECTRIC 171 �t-- w I ONE WORKING DAY BEFORE REQUIRED INSPECTION: �� PLEASE GIVE JOB ADDRESS WHEN PHONING: - Pwmewc MECHANICAL' z t=SEE PERMIT FOR EXPIRATION�DATE — CONST.TAX ` IMPORTANT! TOTAL PLEASE READ REVERSE SIDE BEFORE CALLING, FOR FINAL INSPECTION.; OFFICE COPY - ' IIIIIIIII