Loading...
70886CERTIFICATION OF COMPLIANCE DATE PERMIT NUMBER ISSUED BY DATE APPLICATION FOR BUILDING PERMIT VALUATION r SANTA CLARA COUNTY AND MECHANICAL PERMIT FEES. PERMIT EXPIRES IF WORK L� a BUILDING INSPECTION DIVISION INSPECTION RECORD 1. FOUNDATION FORMS 70 W. HEDDING ST., SAN JOSE, CA 95110 TEL. 299.2351 ti {1 LAND DEVELOPMENT EN NE ING & SURVEYING JOB ADDRESS: - CLEARED FOR ISSUANCE BY DATE 3. HEATING DUCTS / 141 idng In cv�lmmana with applieaNa wcGondl nI Ina Snnta Clare Co—Y Ordi— Codd. STREET NUMBERdMA CRECK 6130 ❑ COMPLETE PRIOR TO OCCUP Y. FOR INSPECTION CALL 299.2871 �.V VVVVV NEAREST CROSS STREET PERMIT '�1., �• 1�� ��D/� ❑ RD. IMP. CLEAR DATE ❑ OWY. APPA. CLE B / DATE POST OFFICE (CITY) O P` El ql5 CLEARE Y DATE n� �KW 10. PRESSUREiO�D' L1 OWNER PHONE-,i'.� 11. ROOF FRAME FLUES FRAME MADORESAILING$ ,�e I#N3 `FOS 2eF-7 R 12 AOUGH WIRING ELEC TRANSP R ATION AGENCY SERVICE: I + I V BONOING: DO NOT INSULATE UNTIL ABOVE HAS BEEN SIGNED gip/ 4# 9 CLEARED FOR ISSUANCE BY DATE UA-dtvV-twL-7-2--k7 CITY - • -� • / ZIP u PHONE El COMPLETE PRIOR TO OC NCY. FOR INSPECTION CALL 299.2591 ARCHITECT , OR ❑ ENGINEER ADDRESS LIC. N0. no. IMP. CLE BY DATE CONTRACTOR _ SELF ❑ pWY, APPR. rl AD GATE ' 19.ENERGY FINAL { r9m BUILDING D - C.OMPLET� 3• —.�8 LIC. NO. CLASS NO UTI LITIf7 WILL BE CLEARED UNTIL "BUILDING COMPLETE^ HAS BEEN SIGNED MAILING PHONE ADDRESS ENVIRONMENTAL HEALTH y�q CITY 14f ZIP SANIT. DIST. NO. BE TK PERMIT NO. FOR INSPECTION CALL /11?299.6060 BUILDING INSPECTION DIV. If I LOT TRACT PLAN CLEARED FOR ISSUANCE BY .S.DAT.- �] a g (/CHECK -j110, 7 BLOCK A.P.N. / L l� • ✓ CLEARED FOR OCCUPANCY BY RS. DATE TYPE OF IMPROVEMENT •FIRE MARSHA T. BUILD REMODEL C ADOTO REPAIR MOVE CONVERT DEMOLISH FORINSPECT NCALI SG.FT /A�(je No. al No. al 2 -2351 �l Si aL� FAMILIES IS I PER IT B USE CLEARED FOR ISSUANCE BY STRUCTURE CLEARED FOR OCCUPANCY BY DATE E $ PLANNING BET FRONT SIDFV $E /� /yONE BACK$ /j�I ,�/ N 'et / %'/C� FEET 0`%^ "?/,g DEV. REO. COMv, VARIANCE OR SPEC. REO. _ uB /� _ 3 /� �� FOR INSPECTION CALL APPROVAL BY: / 2+99-2521 CLEAREDFOR ISSUANCE BY .ATE CLEARED FOR OCCUPANCY BY: DATE APPROVED BY CERTIFICATION OF COMPLIANCE DATE NOTE: TOTAL FEES EXCLUDE APPLICABLE ELECTRICAL, PLUMBING VALUATION TOTAL FEES AND MECHANICAL PERMIT FEES. PERMIT EXPIRES IF WORK SEPTIC TANK INSPECTION RECORD 1. FOUNDATION FORMS COMPLETE BACK OF FI RST PAGE ti {1 FIRE RaRuaal for rNuiWf or adluttmenH in law wid mwt be mode [ In puildln0 offkial In C.P.O.ISSUANCE FEE 3. HEATING DUCTS MARSHALL PLAN 141 idng In cv�lmmana with applieaNa wcGondl nI Ina Snnta Clare Co—Y Ordi— Codd. LAST CALLED INSPECTION. CRECK 6130 FORM 379783 �.V VVVVV ` 1 iii PERMIT '�1., �• 1�� FOR BUILDING INSPECTION CALL 299-2351 MINIMUM 24 HOURS NOTICE PERMIT EXPIRATION PERMIT EXPIRES IF WORK INSPECTION RECORD 1. FOUNDATION FORMS A 1P ti 2. FORMS 180 DAYS OF PERMIT ISSU- POUR NO CONCRETE UNTIL THE ABOVE HAS BEEN SIGNED 3. HEATING DUCTS CS ' 4. COMFORT COOLING LAST CALLED INSPECTION. 6. GIRDERS 6130 6. ROUGH FLOG. PARTIAL J !J O DO NOT LOVER FLOORS UNTIL THE ABOVE HAS SEEN SIGNED 7: BONO BEAMS ICONC. SLK.) B. ROUGH FLOG. COMPLETE 9. SEWER INSPECT WATER SERVICE 10. PRESSUREiO�D' )/// 11. ROOF FRAME FLUES FRAME 12 AOUGH WIRING ELEC P, �P- �T/, !(( V VV V SERVICE: I + I V BONOING: DO NOT INSULATE UNTIL ABOVE HAS BEEN SIGNED 13.INSULATION UA-dtvV-twL-7-2--k7 1d. ROCK ROCKCK u 15. STUCCO WIRE OR LATH I&PLUMBING FINAL IFIMFraal g. I 3^� \`'a 17•GAS APPLIANCES -3 1B.ELECTRtCALI FINAL CFI.,—) V 3`,'�-�-.$ ' 19.ENERGY FINAL { r9m BUILDING D - C.OMPLET� 3• —.�8 NO UTI LITIf7 WILL BE CLEARED UNTIL "BUILDING COMPLETE^ HAS BEEN SIGNED PERMIT EXPIRATION PERMIT EXPIRES IF WORK IS NOT STARTED WITHIN n ti a 180 DAYS OF PERMIT ISSU- ANCE OR 180 DAYS FROM CS LAST CALLED INSPECTION. THIS PERMIT SHALL EXPIRE SY LIMITATION AND BECOME NULL AND VOID IF WORK IS NOT COMMENCED WITHIN 180 DAYS. "REFUND: WHERE NO PORTION OF THE WORK OR CONSTRUCTION COVERED BY THIS PERMIT HAS BEEN COMMENCED BEFORE THE EXPIRATION DATE HEREOF, REQUESTS FOR REFUNDS MUST BE MADE IN WRITING TO THE DfRECTOR OF THE BUILDING INSPECTION DIVISION ON OR BEFORE ONE HUNDRED -TWENTY (120) DAYS FROM THE DATE OF ISSUANCE OF THIS PERMIT." GRADE LINES AS SHOWN ON DRAWING ACCOMPANYING THIS APPLICATION ARE ASSUMED TO BE CORRECT. IF ACTUAL GRADE LINES ARE NOT THE SAME AS SHOWN, REVISED DRAWINGS SHOWING CORRECT GRADE LINES, CUTS AND FILLS, TOGETHER WITH COMPLETE DETAILS OF RETAINING WALLS AND WALL FOOTINGS REQUIRED, MUST BE RESUBMITTED TO THIS DIVISION FOR APPROVAL. INSPECTOR MUST B INIMUM 24 HOURS NOTICE FOR EACH INSPECTION. i. WORKERS' COMPENSATION DECLARATION LICENSED CONTRACTORS DECLARATION ` I hereby affirm that 1 am licensed under provisions of Chapter 9 (Commencing with Section 7000) of Division 3 of the Business and Professions Code, and my license is in full force and effect. License Class Lic, Number Date Contractor OWNER -BUILDER DECLARATION I hereby affirm that I am exempt from the Contractor's License Law for the follow- ing reason (Sec, 7031.5, Business and Professions Code: Any city or county which requires a permit to construct, alter, improve, demolish, or repair any structure, prior to its issu- ance, also requires the applicant for such permit to file a signed statement that he is licensed pursuant to the r p provisions of the Contractor's License Law (Chapter 9 (com- mencing with Section 7000) of Division 3 of the Business and Professions Code) or that he is exempt therefrom and the'basis for the alleged exemption. Any violation of Section 7031.5 by any applicant for a permit subjects the applicant to a civil penalty of not more than five hundred dollars ($500).): 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 improvements 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 improve for the purpose of sale. l. ' k ❑ 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 theieon, and who contracts for such projects with a contractors) licensed pursuant to the Con- tractor's License Law.').; i❑ I am exempt under,Sec, j 0. & P,C, for this reason I �- C � Date ,:• mss, n . t> I hereby affirm that I have a certificate of consent to self -insure, or a certificate of Workers' Compensation Insurance, or a certified copy thereof (Sec. 3810, Lab. C.). Policy No. Company ❑Certified copy is hereby furnished. ❑Certified copy,is filed with the county building inspection department or county department. Date Applican*l� CERTIFICATE OF EXEMPTION FROM WORKERS' COMPENSATION INSURANCE (This section need not be completed if the permit is for one hundred dollars ($100) or less.) I certify that in the performance of the work for which this permit is issued,'I shall not a employ any persgn in any manner so as to become subject to the Workers' Compensation 'Laws of California.. Date Applicant NOTICE TO AAPLICANT: If, after making this Certificate of Ei emption, you should \become subject tb the Workers' Compensation provisions of the Labor Code, you must forthwithycompfy 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. 3097, Civ. C.). Lender's Name t Lender's Address I certify that I have read this application and state that the above information is correct. I agree to comply with all city and county ordinances and state laws relating to building construction, and hereby authorize representatives of this county to enter upon the above- mentioned property for inspection purposes. Signature of Applicant or Agent Date 1'4 COMPLETE BACK OF FIRST PAGE Request for refunds or adjustments in fees paid must be made to the building official in wrhrg in conformance with applicable section(s) of the Santa Clara County Ordinance Code. THIS SPACE FOR INSPECTOR'S USE MECHANICAL PERMIT PARTIAL OK.(SIGNATURE) DATE ROUGH OK (SIGNATURE) DATE FINAL OK (SIGNATURE) DATE PLUMBING PERMIT PARTIAL OK (SIGNATURE) DATE ROUGH OK (SIGNATURE) DATE FINAL OK (SIGNATURE) DATE ELECTRICAL PERMR PARTIAL OK (SIGNATURE) DATE ROUGH OK (SIGNATURE) DATE FINAL OK (SIGNATURE) DATE APPLICATION FOR SUPPLEMENTAL PERMITS SANTA CLARA COUNTY FOR BUILDING INSPECTION CALL 299-2351 BUILDING INSPECTION OFFICE MINIMUM 24 HOURS NOTICE 70 W. HERDING ST, SAN JOSE., CA 95110 TEL 299-2351 ELECTRICAL PERMIT FEE MECHANICAL PERMIT FEE PLUMBING PERMIT FEE ITEM NO. FEES REM NO. FEES ITEM NO. FEES ISSUANCE FEE 5.00 ISSUANCE FEE s�� 5.00 ISSUANCE FEE 5.00 SURVEY FEE O SURVEY FEE SURVEY FEE PERMIT FEE PERMIT FEE Complete Plumbing System for new single LAST SIGNED INSPECTION. PERMIT FEE Complete Electrical System for new single Complete Mechanical System for new single and multiple family structures and multiple family structures and multiple family structures Installation, relocation, repair or alteration of each forced -air or gravity -type furnace or burner, c Including ducts and vents alt to Each plumbing fixture or trap or set of fixtures on one trap Temporary pole or meter set < Light oNiets 1 - 10 min (Minimum fee) appudinge, up to end U' 0 0 B.T.. Each building sewer Over 100.000 B.T.U: s r• Receptacles Soo OP Each on site sewer system Switches Over 10, each additional s Domestic type Incinerator Each water service Ugnt fixtures 1 - 10 (Minimum fee) Over 10, each additional Soo Commercial or industrial type Incinerator Each on site water service system Hoer furnance, suspended heater, recessed wall Moved building Heat (Per kw) Each water heater and/or any gas ventww ven/dryer/water heater heater or floor mounted unit heater, Including vent (Or replacement of) appliance vent installed and Propane tank Panel/panel board/switchboard Each gas piping system, natural or LPG Service: change, repair, or well 100 amp or less / 200 amp not included in an appliance permit Regislem diffusers and grilles (inti. duct'sye $1.00 each One to into outlets Over five, each additional y 400 amp or more ✓✓✓ ,Alteration or repair of Moved Wilding Each installation or repair of water, soil waste, and vent system 1 / Motors -14 hp or less transformers -'h kva or less I 1 '/ l0 2 hp 2 o 2 kva I l0 2 to 6 hp 2 to 5 kva forced air ducts Installation or relocation of each boiler or Compressor To and including 3 hp 5 l0 15 hD 5 to 15 kva Each industrial waste pre-treatment Interceptor, Over 3 hp to and including 15 hp over 15 hp to and Incl Wing 30 hp 15 to 25 hp 15 l0 25 kva Over 30 hp and Including 50 hp including its trap and vent, excepting kitchen type Interceptors functioning as fixture 25 to 50 hp 25 Io 50 kva 50 to 100 hp 60 to 100 kva Or absorption system - to and including 100,000 aT.U.'s grease Iraps Over 100 hp Over 100 kva Over 100,000 to and including 500,000 Over 500,000 to and including 1,000,000 Over 1,000,000 to and including 1,750,000 Each rainwater system -per drain Solar system (Refrigeration compressor over 50 hp or Each lawn sprinkler system or arty one meter, including back flow protection devices therefor Swimming pools - Private absorption system over 1,750,000 B.TU: s) Public Heat pump To and including 3 tons Vacuum breakers or back flow protective devices on Signs r Over 3 tons tanks, vats, etc., or for installation on unprotected PWio frvxeturea on. Over five, each additional Sign transformers Solar as heating system Festoonlightinglamps or less 10 t to 200 lamps Over 200 lamps Special circuits Trailer spaces Moved building Air handling unit war 10,000 od.m. Swimming pools Prorate Public at Eveponalive cooler other than portable type Vent fan connected to a single duct, Ventilation which is not a of Solar system Electric welder (per kva) system portion any healing or air conditioning system ...d d by a permiL AMercury vapor lamp Installation of each hood which is served by ,I y1 'A/ o SUB TOTAL- SUB TOTAL mechanical exhaust, including ducts for hood 11 Appliance or piece of equipment not classed in other Ky appliance catagones, or for which no other fee 'b` -tit r•*� PERMIT EXPIRATION SUBTOTAL- PERMIT EXPIRES IF WORK 4 s�� Cep IS NOT STARTED WITHIN pkS O 180 DAYS OF PERMIT ISSU- ANCE OR 180 DAYS FROM LAST SIGNED INSPECTION. I THIS PERMIT SHALL EXPIRE BY LIMITATION AND BECOME NULL AND VOID IF WORK IS NOT COMMENCED WITHIN 180 DAYS. "REFUND: WHERE NO PORTION OF THE WORK OR CONSTRUCTION COVERED BY THIS PERMIT HAS BEEN COMMENCED BEFORE THE EXPIRATION DATE HEREOF, REQUESTS FOR REFUNDS MUST BE MADE IN WRITING TO THE DIRECTOR OF THE BUILDING INSPECTION OFFICE ON OR BEFORE ONE HUNDRED -EIGHTY (180) DAYS FROM THE DATE OF ISSUANCE OF THIS PERMIT." LICENSED CONTRACTORS DECLARATION I hereby affirm that I .am licensed under provisions of Chapter 9 (Commencing with Section 7000) of Division 3 of the Business and Professions Code, and my license is in full force and effect. License Class Lic. Number, Date Contractor - OWNER -BUILDER DECLARATION I hereby affirm that I am exempt from the Contractor's License Law for the following reason (Sec. 7031.5, Business and Professions Code: Any city or county which requires a permit to construct, alter, improve, demolish;. or repair any structure, prior to 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 the basis for the' alleged exemption. Any violation of Section 7031:5 by any applicant for a permit subjects the applicant to a civil penalty of not more than five hundred dollars ($500).): ,;!!.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, Busi- ness 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 improvements 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 improve for the purpose of sale.). 0 1, 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,contractor(s) licensed pursuant to the Contrac- tor's License Law.). D I am exempt under Sec.. B. & P.C. for this reason f•'1: r. V. WORKERS' COMPENSATION DECLARATION , I'here6y affirm that I have a certificate of consent to self -insure, or a certificate.,of . Worker's Compensation Insurance, or a certified copy thereof (Sec. 3800, Lab. C.). ' Policy No. Company f� Certified copy is hereby furnished. O Certified copy is filed with the county building inspection department or county department. Date Applicant CERTIFICATE OF EXEMPTION FROM WORKERS' COMPENSATION INSURANCE (This section need not be completed'if the permit is for one hundred dollars ($100) or less.) I certify that in the performance of. the work for which this permit is issued, I shall not employ any person in any manner so as to become subject to the Worker's Compen- sation Laws of California. Date Applicant NOTICE TO APPLICANT: If, after making this Certificate of Exemption, you should become subject to the Worker's 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. 3097, Civ. C.). Lender's Name Lender's Address l certify that I have read this application. and state that the above information is correct. I agreetto comply with all cite and county ordinances and state laws relating to building construction, and hereby authorize representatives of this county to enter upon the abovementioned property for inspection purposes, 1', Signature of Applicant or Agent Date 11) o JOB ADDRESS: PARTIAL OK (SIGNATURE) DATE I STREETNUIBER DATE FINAL OK (SIGNATURE) DATE NEAREST CROSS STEET ©PAN%QCT PARTIAL OK (SIGNATURE) ISSUANCE FEE SURVEY FEE OWNER MAILING ARCHITECT n ZIP PHONE I.C. NO. CLASS MAILING PHONE ADDRESS GITY ZIP COMPLETE BACK OF FIRST PAGE Request for refunds or adjustments In fees paid must be made to the building official In writlrg In conformance with applicable aeotion(s) of the Santa Clara County Ordinance Cade. THIS SPACE FOR INSPECTOR'S USE MECHANICAL PERMIT PARTIAL OK (SIGNATURE) DATE ROUGH OK (SIGNATURE) DATE FINAL OK (SIGNATURE) DATE PLUMBING PERMIT PARTIAL OK (SIGNATURE) DATE ROUGH OK (SIGNATURE) DATE FINAL OK (SIGNATURE) DATE ELECTRICAL PERMIT PARTIAL OK (SIGNATURE) DATE ROUGH OK (SIGNATURE) DATE FINAL OK (SIGNATURE) DATE APPLICATION FOR SUPPLEMENTAL PERMITS SANTA CLARA COUNTY BUILDING INSPECTION OFFICE 70 W. HEDDING ST., SAN JOSE., CA 95110 TEL 299-2351 MECHANICAL PERMIT FEE PLUMBING PERMIT FEE ITEM I NO. I FEES ITEM Complete Mechanical System for new single and muldple family structures Installation• relocation, repair or alteration of each forced -air or gravity -type furnace or bumer, including ducts and vents attached to each appliance. up to and including 100,000 B.T.U.'s Over 100.000 BTU.'. - Domestic type incinerator Commercial or industrial type incinerator Floor furnance, suspended healer, recessed wall heater or floor mounted unit heater, Including vent (Or replacement of) appliance vent installed and not included in an appliance permit Registers diffusers and grilles (incl duct's): $1.00 each Alteration or repair of forced air ducts Installation ....location of each boiler or Compressor. To and including 3 hp Over 3 hp to and Including 15 hp Over 15 hp to and including 30 hp Over 30 hp and including 50 hp Or absorption system - to and including 100,000 BTU.'. Over 100,000 to and Including 500,000 Over 500,000 to andincludir� 1,000,000 Over 1,000,000 to and including 1.750,000 (Refrigeration compressor over 50 hp or absorption system over 1,750,000 BTU's) Heat pump To andincluding 3 tons Over 3 tons ea to a In whlcfn Or airs ry a parr 5.00 ISSUANCE FEE SURVEY FEE PERMIT FEE Complete Plumbing System for new single and multiple family structures Each plumbing fixture or trap or set of fixtures on one trap Each building sewer Each on site sewer system Each water service Each on site water service system Moved building Each water heater and/or any gas vent Propane tank Each gas piping system, natural or IPG One to five outlets over five, each additional Each installation or repair of water, soil waste, and vent system Each Industrial waste pre-treatment Interceptor, Including Its trap and vent, excepting kftchen type grease interceptors functioning as fixture traps Each rainwater system - per draln Each lawn sprinkler system or any one mater. Including back flow protection devices therelor Vacuum breakers or back flow protective devices on tanks, vats, etc., or for installation on unprotected plumbing fixtures One to five Over five, each additional Swimming pools Private Public Solar system FOR BUILDING INSPECTION CALL 299-2351 MINIMUM 24 HOURS NOTICE ELECTRICAL PERMIT FEE VO. FEES ITEM 5.00 ISSUANCE FEE SLIMY FEE for new single emperary ol" a mater set ✓ Ught outlets 1 - 10 min (Minimum fee) Receptacles Switches Over 10, each additional Light fixtures 1 - 10 (Minimum fee) Over 10, each additional Heater (Per kw) 55a/oxen/dryer/water heater nal/ nal board/switchboard Service: change, repair, or well 100 a less 40C imp or more Moved building Motors -'h hp a less transformers -'h kva or less 'h 10 2 hp'h to 2 kva 2 to5hp 2 t 5kva 5 to 15 hp 510 15 kva 15 to 25 hp 15 to 25 We 25 to 50 hp 25 l0 50 kva 50 to 100 hp 50 to 100 kva Over 100 hp Over 100 kva Solar system Swimming pools Private Public Signs Sign transformers Festoon lighting 100 lamps or less 101 to 200 lamps Over 200 lamp. Special Circuits Trailer spaces Electric welder (per kva) Mercury vapor lamp 1 FEES 5.00 mechanical exhaust,lncluding ducts for hood SUB TOTAL - SUB TOTAL Uei Appliance or piece of equipment not classed in other appliance allegories, or for which no other fee is listed ` `suBTOTAL- '` - � ' _ PERMIT EXPIRATION M PERMIT EXPIRES IF WORK Iffi IS NOT STARTED WITHIN 180 DAYS OF PERMIT ISSU- GU ANCEOR 180 DAYS LAST SIGNED INSPECTION. THIS PERMIT SHALL EXPIRE BY LIMITATION AND BECOME NULL AND VOID IF WORK IS NOT COMMENCED WITHIN 180 DAYS. "REFUND: WHERE NO PORTION OF THE WORK OR CONSTRUCTION COVERED BY THIS PERMIT HAS BEEN COMMENCED BEFORE THE EXPIRATION DATE HEREOF, REQUESTS FOR � REFUNDS MUST BE MADE IN WRITING TO THE DIRECTOR OF THE BUILDING INSPECTION OFFICE ON OR BEFORE ONE HUNDRED -EIGHTY (180) DAYS FROM THE DATE OF ISSUANCE OF THIS PERMIT." WORKERS' COMPENSATION DECLARATION LICENSED CONTRACTORS DECLARATION I hereby affirm that I am licensed under provisions of Chapter 9 (Commencing with Section 7000) of Division 3 of the Business and Professions Code, and my license is in full force and effect. License Class Lic. Number Date Contractor OWNER -BUILDER DECLARATION 1 hereby affirm that I am exempt from the Contractor's License Law for the following reason (Sec. 7031.5, Business and Professions Code: Any city or county which requires a permit to construct, alter, improve, demolish, or repair any structure, prior to 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 the basis for the alleged exemption. Any violation of Section 7031.5 by any applicant for a permit subjects the applicant to a civil penalty of not more than five hundred dollars ($500).): ED 1, 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, Busi- ness 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 improvements 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 br improve for the purpose of sale.). 0 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 taw'does not apply to an owner of property who builds or improves thereon, and who contracts for such projects with contractor(s) licensed pursuant to the Contrac- tor's License Law.). O 1 am exempt under Sec. B. & P.C. for this reason Date Owne ' K11 2at__ 1 hereby affirm that I have a certificate of consent to self -insure, or a certificate of , Worker's Compensation Insurance, or -a certified copy thereof (Sec. 3800, tab. C.). Policy No. Company O Certified copy is hereby furnished. © Certified copy is filed with the county building inspection department or county department. Date Applicant CERTIFICATE OF EXEMPTION FROM WORKERS' COMPENSATION INSURANCE (This section need not be completed if the permit is for one hundred dollars ($100) or less.) I certify that in the performance of the work for which this permit is issued, I shall not employ any person in any manner so a to b e subject to the Worker's Compen- sation Laws of California. Date Appl ican NOTICE TO APPLICANT: If, after making is deritTfi.ate of Exemption, you should become subject to the Worker's 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. 3097, Civ,. C.). Lender's Name Lender's Address I certify that I have read this application and state that the above information is correct. I agree to comply with all city and county ordinances and state laws relating to building construction, and hereby authorize representatives of this county to enter upon the abovemen ions op ty for inspection purposes. �/I ignature of Applicant or Agent Date Permit 1987-70886-00 Inspection Data Sheet - Issued 512211987 Location 21836 Lomita Ave., Cupertino, CA 95014 Zone 2 Cross Street Owner Richards F&EI Self Contractor Owner Phone Job Desc Addition To Residence 2561280° Fees ❑ Geology ❑ Land Develop ❑ Planning ❑ Roads / Airports ❑ Environ Health ❑ Fire Marshal printed 12/15/2015 9:09:48 AM page 1 Called Date Insp Phone Code 1 2 3 4 5 Request Note Code Comments Date Insp Disposition ST02 FOUNDATION FORWREBAR 7/9/87 Approved ST14 SHEETROCK NAILING 11/10/87 Approved F101 PROJECT COMPLETED 3/24/88 Approved printed 12/15/2015 9:09:48 AM page 1