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9107 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY BU I LD ING PROJECT I DENTIFIC )N PERMIT NUMBER ' BUILDING APPLICATION & PL. AIT 9107 ADDn 5 p BUILDING - ELECTRICAL-PLUMBING -MECHANICAL OWNER'S�T✓ tJ 0 PLAN CHECK VALIDATION • Me er�.o� 'F y pTY.r ELECTRIC PERMIT'• <FEE!! JG PHONE N• aNTRACTORS UTLETS-SWITCHES-RECEP 10.00/1.00 NAME LIC.NO. LIGHTING FIXTURES 10.0011.00 -� CONTRACTOR'S APPLIANCES-RESIDENTIAL 4.00 ADDRESS PHONE PANELS 10.00 GATE OF APPLICATION ARCHITECT PANELS (OVER 200 AMP) 20,00 PLANDHECKFEE P.C.NO. OR ENGINEER uc.No. SIGNS TRANS. 3.00 ADDREssARCH.OR ENG. SPECIAL CIRCUIT 5,00 PERMIT VALIDATION APPLICANT$ IIP EMP,METER OR POLE INS. 20.00 ADORE SERVICE X MOTORS SEE FEE SCH. PAID SERVICE CHANGE 20.00 VA Oo LICENSED CONTRACTORS DECLARATION TEMP.POLE 30.00 ��1 a it � I hereby affirm that I am licensed under provisions of Chapter 9 ISSUANCE DAl'E m rt y (commencing with Section 7000)of Division 3 of the Business and BLDG. ELECT. PLG. MECH. r H i Prolessions Code,and my license is in full force and effect. oro License Class Lic.Number 'ILII`I z r o Data Contractor City of Cupertino a -a B -DING PERMIT _ ¢ w a OWNER-BUILDER DECLARATION J na 5 A. y I hereby affirm that I am exempt from the Contractor's License MISC.- REFER TO ORD U. Law for the following reason.(Sec.7031.5.Businessand Professions PERMIT ISSUANCE VALUATION $/FT. - - A ` Code:Any city orcounty which requires a permit to construct,alter. E rt¢ improve,Demolish.or repair any structure,prior to its issuance,also ELEC.CONTR. LIC.NO. ELEC. fry 0 CIO¢ requires the applicant for such permit to file a signed statement that TOTAL to7 PE T TO ` w $ he is licensed pursuant to the provisions of the Contractor's License w, Law Law!Chapter 9!commencing with Section 7000)ofDivision 3 ofthe 2 c Business and Professions Code)or that he is exempt therefrom and QTY. PLUMBING PERMIT FEE CJ v X o the basis fur the Alleged exemption.Any violation of Section 7031.5 STORIES TYPE CONSTR. a ; m by any applicant for a permit subjects the applicant toe civil penalty ALTER-DRAIN&VENT-WATER (EA.) 5.00 of not more than five hundred dollars($500).): ❑ I,as owner of the property,or my employees with wages as BACK F LOW PROTECT. DEVICE 4.00 OCC.GROUP RES.UNITS their ole compensation,will do the work,and the structure is not initmkd or offered for sale (Sec. 7044, Business and Professions DRAINS-FLOOR,ROOF,AREA,COND. 5.00 • Code:'rhe 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 50.FT.FLOOR AREA TOTAL ACREAGE himself or through his own employees,provided that such improve- GAS•EA.SYSTEM-1 INCA OUTLETS'8.00 ments are not intended or offered for sale.If,however,the building or improvement is sold within one year of completion,the owner- GAS-EA.SYSTEM-OVER 4 (EA.) 2.00 BUILDING E builder will have the burden of proving that he did not build or im. RES INC PB Other prove for purpose ofsale.). INDUSTRIAL WASTE INTER. 30.00 .+,��, I,as owner of the property,am exclusively contracting with ❑ ❑ ❑ ❑ liC6nsed mmmnors to construct the project(Sec. 7044,Business LAWN SPRINKLERS-1 INC 5 V.B. 8.00 S5hSS7 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 contracts for such projects with a contractors)licensed pursuant to the Conti or's License Law. SEWER-SANITARY-STORM EA.200ft/10.00 TRACT NO. PARCEL NO. ❑ I nexemptundei Sec. ,B.&P.C.for this WATER HEATER W/VENT 6.00 reason Come Date WATER SYSTEM 5.00 ACC.DATE ACC.FILE NO. ORKERS'COMPENSATION DECLARATION! WATER TREATING EQUIP. 5.00 I hereby affirm that I have a certificate of consent to sel&insure' ZONING ENG.SITE N0. or a certificate of Workers'Compensation Insurance,or a certified copy thereof(Sec.3800,Lab.C.). Policy No. Company O ❑ Certified copy is hereby furnished. FIRE SPRINK ENERGY T-24 Z Z Cl Certified copy is riled with the city inspection division. MISC.- REFER TO ORD. O Applicant Y❑ N❑ Y ❑ N❑ ~ v) PERMIT ISSUANCE 10.00 CERTIFICATE OF EXEMPTION FROM WORKERS' FLOOD ZONE A.L.u.t. LU >_ COMPENSATION INSURANCE PLG.CONTR. LIC.No, PLG. CL O I This section need not be Completed if the permit is for one TOTAL Y❑ N❑ V [:] NF] D Z hundred dollars IS 100)or less.) - - U O 1 certify that in the performance of the work for which this per- FEE, r FEE.BUMMARI'l ��'' -vS LL I- mit is issued,I shall not employ any person in any manner so as to r U become subject to the Workers'Compensation Laws of California. G pt7 Do Date Applicant ALTER OR ADD TO MECH. 5.00 BUILDING of } m NOTICE TO APPLICANT: If,after making this Certificate of Ex Z emption,you should become subject to the Workers'Compensation APPLIANCE 5.00 PLAN CHECK provisions of the Labor Code, you most forthwith comply with FEE U such provisions or this permit shall be deemed revoked. AIR HANDLING UNIT(TO 10)[ODC.F.M.) 4.00 CONSTRUCTION LENDING AGENCY AIR HANDLING UNIT(OVER 10ADOC.F.1i 6.00 SEISMIC FEE a S= I 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(Sea MICROFILM 3097,Civ.C.). HEATING UNIT(TO 100,000 B.T.U.1 8.00 Lender's Name a HEATING UNIT(OVER• 100,000B.T.U.)9.50 Lendershat ELECTRIC 1 certiffyy that I have read this applicationcoyand state that the above VENTILATION FAN (SINGLE) 4.00 information n correct I agree to comply with all oily and county PLUMBING ordinances and state laws relating to building construction, and BOILEA-CONP(3 H.P.OF 100,000 B.T.U.1 6.00 hereby authorize representatives of this city to enter upon the 601 LER-COMP (Over 100,000BTUI SEE FEESCH. MECHANICAL above-mentioned property for inspection purposes. (Wel agree to save, indemnify and keep harmless the City of MISC.- REFER TO ORD. Luper'rfo�against liabilities,judgmenu, costs and expenses which CONST.TAX may n ty way accrue against said City in consequence of the PERMIT ISSUANCE 10.00 gr ht is permit. MECH.CONT. LIC.NO. MECH. 4r TOTAL TOTAL fApplicant/Contractor Difte OFFICE COPY POST THIS CARD NEAR FRONT OF BUILDING PE Rnilr NUMBER CI1 I OFCUPERTINO INSPECTION - Q1 QV 7 � J(�/n pJOO IB INSPECTION RECORD JOB ADDRESS �oD�-3 s-'ey2G CKeeK _ PERMIT EXPIRATION UNIT# -LOT# _/ PERMIT EXPIRES IF WORK OWNER S KS O/k oerl-/QP CONTRUVOR IS NOT STARTED WITHIN INSPECTION DATE INSPECTOR INSPECTION RECORD 180 DAYS OF PERMIT ISSU- FOUNDATION w -�-�`� Z�, ANCE OR 180 DAYS FROM 7 UFER I LASTCALLED INSPECTION. PREGUNITE PERMIT VALIDATION POUR NO CONCRETE UNTIL ABOVE HAS BEEN SIGNED UNDERGROUND /SLAB PLUMBING ELECTRICAL ISSUANCE DATE BLDG. ELECT. PLG. MECR. MECHANICAL El El _MD DO NOT POUR FLOOR UNTIL ABOVE HAS BEEN SIGNED BUILDING PERMIT WINFORMATION WOOD FLOOR VALUATION $IFT, PLUMBING MECHANICAL ELECTRICAL 'T' L 1%TO FRAMING -LnIJ egxl , STORIES TYPE CONSTR INSULATION OCG GROUP RES.UNITS PLACE NO SUBFLOOR UNTIL ABOVE HAS BEEN SIGNED ROOF 50,FT.FLOOR AREA TOTAL ACREAGE DIAPHRAGM BUILDING USE HESIND CON PB CI APPLY NO ROOFING UNTIL ABOVE HAS BEEN SIGNED ❑ ❑ ❑ ASSESSORS PARCEL No ROUGH PLUMBING GAS TEST TRACT NO. PARCEL NO, MECHANICAL ELECTRICAL FINALS DATE INSP. ACC,DATE ACC.FILE NO FRAMING 7- SAN ft ZONING ENG.SITE NO. INSULATION PLUMBING GAS FIRE SPRINK ENERGY T 24 MECHANICAL - - Y ❑ N[—] Y ❑ N� , COVER NO WORK UNTIL ABOVE HAS BEEN SIGNED HEATING op FLOOD ZONE AL.0 C. LATH-INTERIOR ELECTRICAL � J LATH-EXTERIOR FIRE DEPT, Y NCD SHEETROCK GRADE FEE SUMMARY SHEAR INTERIOR BUILDING i SHEAR EXTERIOR TEMPORARY APPROVALS BUILDING FIREWALLS ELECTRIC PLAN CHECK GAS FEE NO TAPE OR PLASTER UNTIL ABOVE HAS BEEN SIGNED JOCCUPANCY SEISMIC FEE OCCUPANCYOF BUILDING IS NOT PERMITTED UNTIL BUILDING FINAL ISSIGNED BYSUILDING INSPECTOR. MICROFILM ARRANGE FOR INSPECTION BY PHONING 252-4505, ELECTRIC o� ONE WORKING DAY BEFORE REQUIRED INSPECTION. PLUMBING Z PLEASE GIVE JOB ADDRESS WHEN PHONING. - SEE PERMIT FOR EXPIRATION DATE - MECHANICAL CONST.TAX IMPORTANT! PLEASE READ REVERSE SIDE BEFORE TOTAL CALLING FOR FINAL INSPECTION. OFFICE COPY POST THIS QARD NEAR FRONT OF BUILDING �' Cl* OF QUPERTINO RMIT NUMBER INSPECTION DIVISION J. { j JOB INSPECTION RECORD Coe PERMILEXPIRATION JOB ADDRESS goo 3 shCev Yl UNIT# _.LOT# - 1•' - - /��r/ I /1w,J O U.(' �j�f'7�� + PERMIT'EXPIRES IF WORK OWNER S YL5 6� C 0&A_ yo c'ONTR I{croR IS NOT STARTED WITHIN INSPECTION DATE INSPECTOR INSPECTION RECORD 180 DAYS OF PERMIT ISSU- . FOUNDATION '� Z _ ANCE OR.180 DAYS FROM y 7 LASTCALLED INSPECTION. UFER - �; PREGUNITE - PERMIT VALIDATION . POUR NO CONCRETE UNTIL ABOVE HAS BEEN SIGNED UNDERGROUND /SLAB PLUMBING 4i.. ELECTRICAL ISSUANCE DATE MECHANICAL 9LUG�' ELECT. •PLG.- MECN. DO NOT POUR FLOOR UNTIL ABOVE HAS BEEN SIGNED BUILDING PERMIT INFORMATION WOAD FLOOR VALUATION SIFT,;., •PLUMBING � .• MECHANICAL - T. ELECTRICAL FRAMING .. .-{!Yl7J. . G01,600 Y.•, � . , INSULATION . - STORIES TYPE CONSTW - - OCC.GROUP RES.UNITS •- PLACE NO SUBFLOOR UNTIL ABOVE HAS BEEN SIGNED , . ROOF SD.FT.FLOOR AREA 'TOTAL ACREAGE DIAPHRAGM .EDILDlrvcu E RES IND CON PB Omer APPLY NO ROOFING UNTIL ABOVE HAS BEEN SIGNED ❑ 0 El/ El ❑" ASSESSORS,PARCEL NO. ' ROUGH Jr . PLUMBING GAS TEST TRACT NO, PARCEL NO. MECHANICAL - " •. ACC.DATE ACC.FILE NO. ELECTRICAL 'j.yy.q- - FINALS DATE INSP. FRAMING 7.1.y.�� SAN # ZONING ENG.SITE NO. INSULATION PLUMBING r GAS MECHANICAL FIRE SPNINK _ ENERGY T.ZO ' Y COVER NO WORK UNTIL ABOVE HAS BEEN SIGNED HEATING • FLoO • NE v ❑ "Q P ZONE A.L.u,c. . LATH-INTERIOR ELECTRICAL 1-Fs O � LATH-EXTERIOR � FIRE DEPT. YNY,o N'[_ SHEETROCK -- GRADE - FEE SUMMARY . SHEAR INTERIOR BUILDING i SHEAR EXTERIOR TEMPORARY APPROVALS BUILDING FIREWALLS r ELECTRIC PLAN CHECK - GAS - FEE' NO TAPE OR PLASTER UNTIL ABOVE HAS BEEN SIGNED IOCCUPANCY SEISMIC FEE OCCUPANCY OF BUILDING IS NOTPERMITTED UNTIL BUILDING FINAL ISSIGNED BY BUILDING INSPECTOR. MICROFILM .� .ARRANGE FOR INSPECTION BY PHONING 252-4505, - eLEc7alc o� - ONE WORKING DAY BEFORE REQUIRED INSPECTION. PLUMBING 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 •• ' „ .,