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5634 CITY OF CUPERTINO INSPECTION RECORD (OFFICE COPY) • 5634 6191 Bollin er Rd. S PMa terror PERMIT ISSUED DATE ELECTRICAL DATE INSP.' ui in ectri cal Plumbing Power Pole Meechianicaler oun emp as ec ou 1rin _ � i bolar Walls . Fl—re rin er CeilingP bign Pixtures Int/Ext otors Misc. Grounding e ower Uther FINAL INSPECTIONS DATE INSP, Not :Approved Gas Electric 2_ Plumbing a -12;R s- PLUMBING DATE INSP. mechanical 57- Backflow Backflow Jo � un i er -Grading er oor Planning Partia ou �. Fire Dept. ou on . et he t. So ou ar ui t in z-vv e r Call water -4Insulation t er Main Drain oDrain Gas t eitTT—r — BUILDING DATE INSP, Not rove Pad Certification '�� o/� C°'•U U- a t Yf'W' oun at�on ELECTRICAL DATE INSP. re- rte a - rane Underfloor S:M. Bond eam cts nsu ation Underfloor it ers Fire Dampers FloorSteel— Pare lace ie owns Grease nuct oo — is ramsOne Hour a t eismec Bracing 7-,j'L' Condensate rain a s _ � _ ui mom` ent Anci_6ra e rame ues 4 Comb. Air 't Other er l�Ilboards Int/Ext. y-<< _ Not Approved -'irewalls Other MI,, 4 lig et rove e K APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY BU I LDING PROJECT I DENTIFIC, PERMIT NUMBER a°ILDING /— APPLICATION & PEI .E. f AooREss ,i!� 5634 BUILDING —ELECTRICAL—PLUMBING—MECHANICAL OWNER'$ nSS Y`.`Is.4S 'ys�rV.' rJ. 41 v} �l�' H f� 7a ¢ PLAN CHECK VALIDATION NAME r tt "IF i�1 R[f, 'xt' E u.. • War V d' ` cI1 •C zSz—I 6SHLECTRIGQE f( t s� {� I tsGL PHONE NAME ACTORS p p UTLETS-SWITCHES-RECEP 5.00/1.00 LIC,NO. 1- LIGHTING FIXTURES 5.00/1.00 CONTRACTOR'5 ADDRESS PPLIANCES-RESIDENTIAL 4.00 PHONE PANELS 5.00 DATE OF APPLICATION ARCHITECT PLAN CHECK FEE .C.NO. OR SIGNS 6.00 ENGINEER LIC.No. SIGNS TRANS. 3.00 ADDRESS ENc' SPECIAL CIRCUIT 5.00 V PERMIT VALIDATION A ZIP TEMP.METER OR POLE INS. 15.00 ^ /� ASMOTORS SEE FEE SCH. `U7JhLF/� ADDRESS SERVICE CHANGE 10.00 �� w o 2 LICENSED CONTRACTORS DECLARATION a i.u I hereby affirm that I am licensed under provisions of Chapter 9 PAI ISSUANCE DATE N z a leommencin with Section 7000)of Division 3 of the Business and a g SLOG. ELECT. PLG. MECH. O i Professions Code,and my license is in full force and effect z O License ClassLic.Number x t1 , 9 r w Dam sJ Contractor I" 2 A. OWNER BUILDER DECLARATION 1JC-Pn.`.,n. 71 - Q�jfii.1R T{t w0 w . I hereby affirm that I am exempt from the Contractor's License MISC.— 89ER ' r u O a Law for the following reason.(Sec.7031.5,Business and Professions PERMIT ISSUANCE 6.00 Vdll2ryry01� r i - :jFT. f Code:Any city or county whichrequiresa permit to construct,alter, - v ' Z S ¢ FO improve,demolish,or repair any structure,prior to its issuance,also ELEC.CONTR. LIC.NO. ELEC. •( s�r, i a. O u requires the applicant for such permit to file a signed statement that TOTAL 7a Lob X $ he is licensed pursuant to the provisions of the Contractor's License I Lt! &tIf10 z a Law(Chapter 9(commencing with Section 7000)ofDivision 3 ofthe -t "•j - )`•" xsT"r x .c.-_Fr7 t>'Cklr�ODe(� �Nr�, F z O Business and Professions Code)or that he is exempt therefrom and 0 ,yP,LUMBING PERMLT,- ,.'� t Pl c er H $ the basis for the alleged exemption.Any violation OI Section 7031.5 //// s . } Pji. } F`A, ,a,y;<? STORIES TYPE CONSTR. n ; _ by any applicant fora permit subjects the applicant toacivilpena0y ALTER-DRAIN -WATER (EA.) 4.00 of not more than five hundred dollars Imy employees 174 ❑ I,as owner at the property,or my employees with wages as BACK FLOW PROTECT. DEVICE 2.00 OCC.GROUP RES.UNITS their sole compensation,will Ifo the work,and the structure is not , intended or offered for Sale (Sec. 7044, Business and Professions DRAINS-FLOOR,ROOF,AREA,COND._4.00 Code:The Contractor's License Law does not apply to an owner of property who builds or improves thereon,and who does such work 2 FIXTURES-PER TRAP PR/AaK. U 4.00 SO,FT.FLOOR AREA TOTAL ACREAGE • himself or through his own employees,provided that such improve- mentsarenot intended or offered for sale.l L however.the building GAS-EA.SYSTEM-1 INC.4 OUTLETS 4,00 or improvement is sold within one year of completion, the owner- GAS-EASYSTEM-OVER 4(EA.) 100 BUILDING USE builder will have the burden of proving that he did not build or Lor' . . . - RES IND CON PR Otner contracting for purpose of sale.). INDUSTRIAL WASTE INTER. 20.00 13 IN 11❑ I,as owner of the property,am exclusively conteting with Cl 1:1 licensed contractors to construct the project(Sec. 7044,Business LAWN SPRINKLERS-1 INC 5 V.B. 5.00 ASSESSORS PARCEL NO. and Professions Code:The Contractors 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 commetons)licensed pursuant to the Contractor's License Law. SEWER-SANITARY- A.200ft/8.00 TRACT NO. PARCEL NO. ❑ ,B,&P.C.forthis WATER HEATER W/VENT 4,00 reason Ownertem xempt under Sec. Date WATER WATER SVSTE(iA r I C, 4.00 ACC.DATE ACC,FILE NO. WORK ERS'COMPENSATION DECLARATION WATER TREA11rTd EQUIP. 4.00 I hereby affirm that I have a certificate of consent to self-insure, (. ZONING ENG.SITE NO. or a certificate of Workers'Compensation Insurance,or a certified copy there°f(Sec.3600,Lab.C.). Policy No. Company O ❑ Certified Copy is hereby furnished. FIRE SPRINK ENERGY T-24 Z ZO Applicant❑ Certified copy is filed with the city inspection division. MISC.- REFER TO ORD. Y NO Yo N XT CERTIFICATE OF EXEMPTION FROM WORKERS' PERMIT ISSUANCE 6.00 F -- FLOOD ZONE A.L.U.C. W a COMPENSATION INSURANCE PLG.CONTR. LIC.NO. PLG. )� ..., Y� N� Y � NC] Q. Cl( This section need not be completed if the permit is for one TOTAL aC hundred dollars IS 1001 or less.) J' Sv'j"psr4?ra s4:. A`was'L Q,sy yyip U O 1 certifythat in theperformance of the work for which this r y+ S ►E11N1 F,g7; R">y'c. e' LL F roti is issued.1 shall nt employ any person in any manner so as to s4 ia; PAN, LL >q}'; L! t'a5.u',='{. a A * Q w become subject to the Workers'Compensation Laws of California. BUILDING Q. Date Applicant ALTER OR ADD TO MECH. 4.00 t } ro NOTICE TO APPLICANT: If,after making this Certificate of Ex- F. z emplion,you should become subject to the Workers'Compensation APPLIANCE 4.00 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 10,00DC.F.M.) 3.00 CONSTRUCTION LENDING AGENCY AIR HANDLING UNIT(OVER 10,0MCRIM 5.00 SEISMIC FEE p2 73 I hereby affirm that there is a construction lending agency for 1 EXHAUST HOOD(WITH DUCT) 2.00 the performance of the work for which this permit is issued ISec. MICROFILM 3097,Civ.C.). I HEATING UNIT(TO 100000 B.T.U.) 4.00 Lender's Name HEATING UNIT OOB.T.U.)7.50 Lender's Address ELECTRIC • 1 certify that I have read this application and state that the above VENTILATION FAN Is 3.00 — information is correct. I agree to comply with all city and county --PLUMBING Z ordinances and state laws relating to building construction, and BOILER-COMPI�IIf, Or .T.U.) 4.00 hereby authorize representatives of this city to enter upon the BOILER-COMP(Dw1100,000 BTU $EE FEE SCH. MECHANICAL (P above-mentioned property for inspection purposes. (We) agree to save, indemnify and keep harmless the City of MISC.- 1 sf 0 R 0 ORD. Cupertino against liabilities,judgments,costs and expenses which CONST.TAX may in any way accrue against said City in consequence of the PERMIT ISSUANCE 3. granting Ilhis permit. MECH.CONT. UC.NO. MECH. �r t w`. k / TOTAL // — TOYAL 70 Signature of ApplicanljCammctor OFFICE COPY APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY BUILDING PROJECT IDENTIFICATION BUILDING PERMIT NUMBER ADORESa n APPLICATION & PERMIT BUILDING -ELECTRICAL-PLUMBING- ON WrNEE RSI^'I-�.J({f Iy,y,(��G�G • /V�TMdui yg{ • 6y+RC'�YrHy,.�r+F�A�paF�!IjyMECHANICAL ZS Lam!let p Bw,+ Q 8 � + PLAN CHECK VA LIGATIONRIG PHONE • CONTRACT fly 1'"' B T. ry }� 1' n3.i O�'D NAME / UTLETS-SWITCHES-RECEP 5.00/100 r LIC NO. LIGHTING FIXTURES 5.00/1.00 .DOT ACTORS 196A ADOREss APPLIANCES-RESIDENTIAL 4,00 AUG 22yV(�T PHONE PANELS ARCHITECT ,rj,DQ OR ENGINEER SIGNS S.UU PLANCTE F C NO. ARCH.OR ENG, LUNO. SIGNS TRANS. 3,00 ADDRESS SPECIAL CIRCUIT 5,00 PERMIT VAL DATION APPLICANT ZIP EMP.METER OR POLE INS. 15,00 77 ADDRESS MOTORS SEE FEE SCH. SERVICE CHANGE 10.00 w D B LICENSED CONTRACTORS DECLARATION a w I hereby affirm Thal I am licensed under provisions of Chapter 9 m < (commencing with Section 7000)Of Division 3 Of the Business and ISSUANCE DATE y i Professions Code,and my license is in full force and effect. g 2 D m License Class LiC.Number ELECT. PLG. MECH. Z w Date Contractor ❑ a ¢ ¢ OWNER-BUILDER DECLARATION n 0 W ;n m I hereby affirm that I am exempt from the Contractor's License MISC.— REFER TO ORD F LL O J Law for the following reason.(Sec.7031.5,Businessand Professions a Code:An Cit or Count whichre uiresa PERMIT ISSUANCE VALUATION S/FT. u, 4 0 Y Y Y 9 permit to conslrucL alteq 5.00 ¢ ¢o p improve,demolish,or repair any straClure,prior to its issuance,elan ELEC.CONTR, LIC.NO. u requires the applicant for such permit to file a Signed statement that ELEC. n w he is licensed pursuant to the Provisions of the Contractor's License TOTAL I- Law(Chapter 9(Commencingwith Section 7000)crDivision 3 ofthe PERMIT TO 4 x o Business and Professions Code)or that he is exempt Iherefrom andi- Cx E the basis for the alleged exemption.Any violation ofSectian 7031.5 bY any applicant For a permit subjects the applicant to civil penalty ST ES PE CONSTR. of not more than five hundred dollars($500).): ALTER-DRAIN&VENT-WATER (EA.) 4.00 an the sole Co.Pensalion1,as owner of e will do the work�a Plloye structure wages nal BACK FLOW PROTECT.DEVICE 2,00 intended or offered for Sale(Sec. 7044, Business and ProFinuacr RDUP ES.UNITS Code:The Cantmctar's License Law does not apply to an owner of DRAINS-FLOOR,ROOF,AREA,COND. 4.00 Property who builds Cr improves thereon,and who does Such work FIXTURES-PER TRAP himself or through his own employees,provided that such improve. SO .FLOO AREA AL ACR menta are not intended or offered for mi. If,however,the building GAS-EA.SYSTEM-1 INC.4 OUTLETS • or improvement is Bold within one year of mmpletion,the owner- 4.00builder w21 have the burden of proving that he did not build or im. GAS-EA.SYSTEM-OVER 4 IEA,) 1.00 prove for purpose of sale.). BUILDIN USE ❑ I,as owner of the property,am exclusively contracting with INDUSTRIAL WASTE INTER. 2000 RES IND Pa Otnw licensed Contractors to construct the project(Sec. 7044,Business ❑ ❑ and Professions Code:The Contractors License law dcea not apply LAWN SPRINKLERS-1 INC 5 V.B. 5,00 to an owner of property who builds or improves(hereon,and who AWE 5 PgRCEL NO. Contracts forsuch projects with acomractids)licensed pursuant to LAWN SPRINKLER$-OVER 51EA.) 1,00 the Contractor's License Law. SEWERSANITARV$TORM EA.200ft/8.00 ❑ 1 a axe p under Sec. ,B.AP.C.for this TRACT N PggCEL NO. reason WATER HEATER W/VENT q•00 Owner Dale F,s.ZA; Y -G LY WATER SYSTEM 4 00 W RKER 'COMPENSATIONDECLARATIONACOOATE ACC.FILE NO. I hereby affirm that I have a Certificate Ofconsent to self-insure, WATER TREATING EQUIP. 4,00 or a cerlificale of Workers'Compensation Insurance,or a certified COPY thercoflSec.3800,Lab.C.). ZONING ENG.SITE NO. Policy No. Company O ❑ Certified copy is hereby furnished. Z Z Cl Certified copy is filed with the City inspection division. FIRE SPRINK ENERGY T-Z4 F- O Applicant MISC.- REFER TO ORD. N CERTIFICATE OF EXEMPTION FROM WORKERS' PERMIT ISSUANCE Y ❑ N v N� W COMPENSATION INSURANCE 5'� FLOOOZONE A.L.U.C. CL O - PLG.CONTR. LIC.NO. PLG. 0 (This section need not be completed i!the permit is for one TOTAL Y IN y N❑ V O hundred dollars(E 100)or le s I Certify that in the Performance of the work for which this per I ? ° LL U mit is issued, I shall not employ any person in any manner So as to v C) lU become subject to the Workers Compensation Laws of California 0. Date_ Applicant i } to NOTICE TO APPLICANT: If after making thin Certificate of Ex- ALTER OR ADD TO MECH. q,L10 BUILDING ? CmVlion,you should become subject to the Workers'Compensation APPLIANCE U InGlIs ,osi' the this bor Comitd, y u Most forthwith deemed revoked comply with 4.00 PLAN CHECK AIR HANDLING UNIT ITO 10—C.F.M.) 3.00 FEE CONSTRUCTION LENDING AGENCY AIR HANDLING UNIT(OVER 104MC.RM.) 5.00 SEISMIC FEE 1 hereby affirm that there is a construction lending agency for EXHAUST HOOD(WITH DUCT) 2,00 the Perlonnance of the work for which this permit is issued(Sec. Land,r'S Na). HEATING UNIT(TO 100,000 B.T.U.) 4.00 MICROFILM 3097, iName Lender's Address HEATING UNIT(OVER 100,000 B.T.U.M50 I Certify that 1 have read this application end state that the above VENTILATION FAN (SINGLE) 300 ELECTRIC information is Correct. 1 agree to comply with all city and county Ordinances and stale laws relating to budding construction, and BOILER-COAT 13 H.P.Dr 100,000 B.TU.) 4.00 PLUMBING hereby authorize representatives of this city to enter upon the above-mentioned property for inspection purposes. BOILER-COMP (Over 100,0008TU1 SEE FEE SCM. (We) agree to save, indemnify and keep harmless the City of MISC.- MECHANICAL Cupertino against liabilities,judgments, costs and expenses which REFER TO ORD. maY in any way accrue against acid City in consequence of the PERMIT ISSUANCE 3.00 CONST.TAX grantin of is permit. 9 (�(� MELH.CONT, LID.NO. MECH. —Z��d l TOTAL ptS(cgi.3' .. Signature of ApplicantICOnlractor• `, )"M I. OFFICE COPY rva I I rlla CARD NEAR FRONT OF BUILDING CITY OF CUPERTINO FFRUIT NUMBER INSPECTION DIVISION 111 f 70 JOB INSPEC N RECORD . JOB ADDRESS PERMIT EXPIRATION INNER UNIT# LOT 4* O CONTRACTOR PERMIT EXPIRES IF WORK IN PECTION DATE INSPECTOR IS NOT STARTED WITHIN FOUNDATION INSPE TI RECORD 180 DAYS OF PERMIT ISSU. I UFER ANCE OR 180 DAYS FROM PREGUNITE -LAS�TCAyLLED INSPECTION. / its / rT1l}]fj�ALIDATION POUR NO CON HE E UNTIL ABOVE HAS BEE SIGNED UNDERGROUND /SLAB EC 2 d iw PLUMBING ELECTRICAL City Of Cupertino MECHANICAL ISSUANCE DATE BLDQJ ELECT. PLG, MICH, 00 NOT POUR FLOOR UNTIL ABOVE HAS BEEN SIGNED 0 0 ❑ WOOD FLOOR BUILDING PERMIT PLUMBING INFORMATION MECHANICAL VALUATION $IFT, ELECTRICAL FRAMING PERMIT TO INSULATION STO IES TYPE CONSTR. PLACE NO SUBFLOOR UNTIL ABOVE HAS BEEN SIGNED OCC.GROUP RES,UNITS ROOF DIAPHRAGM SO FT FLOOR AREA TOTAL ACREAGE • APPLY NO ROOFING UNTIL ABOVE HAS BEEN SIGNED REsINDUILDCN N USE PB ❑ 13 ❑ o' ROUGH PLUMBING ASSESSO PARCEL NO. GAS TEST MECHANICAL TRACT NO. PARCEL NO ELECTRICAL FRAMING FINALS DATE INSP. ACC.OATE ACC FILE NO. INSULATION SAN a PLUMBING ZONING ENG.SITE NO. GAS COVER NO WORK UNTIL ABOVE HAS BEEN SIGNED HEAT NGICAL RE SPRINK ENERGY i ZA LATH—INTERIOR `' ❑ N❑ Y ❑ N❑ LATH—EXTERIOR ELECTRICAL FLOOD ZONE A.LD C. SHEETROCK FIRE DEPT. v❑ N❑ , v ❑ N❑ SHEAR INTERIOR GRADE BUILDING FEE SUMMARY SHEAR EXTERIOR .. FIREWALLS TEMPORARY APPR VALS BUILDING ELECTRIC PLAN CHECK NO TAPE OR PLASTER UNTIL ABOVE HAS BEEN SIGNED OCCUPANCY FEE MIC FEE OCCUPANCY OF BUILDING IS NOT PERMITTED UNTILBUILDING FINAL ISSIGNED BY BUILDING INSPECTOR, SEIS MICROOFILMFILM LU ARRANGE FOR INSPECTION BY PHONING 252-4505 LE O� ONE WORKING DAY BEFORE REQUIRED INSPECTION. crRlc ~ Z PLEASE GIVE JOB ADDRESS WHEN PHONING. PLUMBING • — SEE PERMIT FOR EXPIRATION DATE — MECHANICAL IMPORTANT! CONST.TAX PLEASE READ REVERSE SIDE BEFORE CALLING FOR FINAL INSPECTION. TOTAL OFFICE COPY APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY BUILDING PROJECT IDENTIFICATION FERMI r NUMBER f SU LOING APPLICATION & PERMIT 1017 0 ADDRESS ^� � rJd LL ,/ 'c�- BUILDING — ELECTRICAL—PLUMBING—MECHANICAL DANE 'S "��P C` + r:+ - .�t �" PLAN CHECK VALIDATION NAME PI"'G .. P` •.. ....e 'S., Dl'11: - ELECTRIC PERMIT r'^f-,-',.'1 y rFEE V" RONE • ONTRACTOR'S AME UTLETS-SWITCHES-RECEP 10.00/1.00 LIC.NO. LIGHTING FIXTURES 10.00/1.00 CONTRASDDRESS ORs APPLIANCES-RESIDENTIAL 4.00 PHONE PANELS 10,00 DATE OF APPLICATION ARRCHITECT PANELS (OVER 200 AMP) 20,00 PLAN CHECK FE7 P.C.NO. ENGINEER LIC.No ISIGNS TRANS. 3.00 ARCHDRESOR S ENG SPECIAL CIRCUIT 5,00 PERMIT PJDATION AD ZIP EMP.METER OR POLE INS. 20.00 PryD AT's ADDRESSDDRESS MOTORS SEE FEE SCH.SERVICE CHANGE 20.00 DEC 2 0 loss D o 2 LICENSED CONTRACTORS DECLARATION TEMP.POLE 30.00 of CnperNno u u 1 hereby affirm that 1 am licensed under provisions of Chapter 9 ANCE DATE N z "' (commencin with Section 7000)of Division 3 of the Business and ¢ a B BL ELECT. PLG. MECH. H z Professions Code,and my license is in full force and effect. ❑ ❑ ❑ 0 0 t W License Class Lic.Number Date Contractor 1- N 5 J a , J .°'",BUILDING'PERMIT,:3;' M a W a OWNER-BUILDER DECLARATION !:';y-`A'7i ^ r U a:+i1NFORMAT10Nl`s ?i e H I hereby collo That I em exempt from the Contractor's License MISC.— REFER TO ORD guy J Law for the following reason.(Sec.703L5.Businessand Professions PERMIT ISSUANCE 1000 VALUATION SIFT. m0 Code:Any city or county which mquiresa permit to construct,alter, ¢ a ¢ improve,demolish,or repair any structure,prior to its issuance,also ELEC.CONTR. LIC.NO. ELEC. DLL requires the applicant for such permit to file a signed statement that TOTAL PERMIT Tp E 2 w he is licensed pursuant to the provisions of the Contractor's License ,, .. _ H > Law(Chapter 9(commencing with Section 7000)of Division 3 of the '*" ,, '" t ' ,.,�:$, °•.:'v>LL+L o Business and Professions Coder or that he is exempt therefrom and DTY:' `'3PLUMBINO PERMIT::-'"L Y FEE M H E the basis for the alleged exemption.Any violation or Section 7031.5 �'F'� + .:i - "' STORIES TYPE CONSTR. n ; _ by any applicant fore permit subjects SSOO).licant toe civil penalty ALTER-DRAIN& VENT-WATER (EA.) 5.00 of not more than five hundred dollars(S5001.): ❑ I,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 nructure is not intended or offered for tele(Sec. 7044, Business and Professions DRAINS-FLOOR,ROOF,AREA,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 SD FT.FLOOR AREA TOTAL ACREAGE himself or through his own employees,provided that such improve- men,,are not intended or offered for sale.If,however,the building GAS-EA,SYSTEM•I INC,4 OUTLETS 6,00 or improvement is sold within one year of completion,the owner- GAS•EA.SYSTEM-OVER 4 (EA.) 2.00 BUILDING USE builder will have the burden of proving that he did not build or im- RES IND CON PB Other prove for 1,aso neerose of sale.). INDUSTRIAL WASTE INTER. 30.00 0 ❑ ❑ d as owner of the property,he exclusively contracting with licensed contractors to construct the project(Sec. 7044,Business LAWN SPRINKLERS-1 INC 5 V.B. 6.00 Jaime550 RCEL NO. and Professions Code:The Contractor's License Law does not apply to owownerof property who builds or improves thereon,and who LAWN SPRINKLERS•OVER 5(EA.) 1.00 contracts for such projects with a contractor(s)licensed pursuant to SEWER-SANITARY-STORM EA.200ft/10.00 the Contractor's License Law. TRACT NO. PARCEL NO. ❑ Iamexemplunder Seca ,B.&P.C.for this WATER HEATER W/VENT 6.00 reason Owner �.�p` Date/ WATER SYSTEM 5.00 ACC.DATE ACC.FILE NO. WORKERS'COMPENSATION DECLARATION WATER TREATING EQUIP. 5.00 1 hereby affirm that 1 have a certificate of consent to self-insure, ZONING ENG.SITE NO. 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 ❑ Certified copy is filed with the city inspection division, F 0 Applicant MISC.- REFER TO ORD. Y M N Y ❑ No X T CERTIFICATE OF EXEMPTION FROM WORKERS' PERMIT ISSUANCE 10,00 FLOOD ZONE A.L.U.O. W COMPENSATION INSURANCE PLG.CONTR. LIC.NO. PLG 1 . � Y ❑ N❑ 0 (This section need not be completed if the permit is for one TOTAL Y N D Z hundred dollars(S100)or less.) _ - V O 1 certifythat in the performance of the work for which this per. _ ;t LL F mit is issud,I shall noemploy any person in any manner so ato DTV. `MECHANICAL PERMIT '� FEE' 7+!+'FEE SUMMARY ./ OW become subject to the Workers Compensation Laws of California. BUILDING d Date Applicant ALTER OR ADD TO MECH. 5.00 } 14 rn NOTICE TO APPLICANT: If,after making this Certificate of Ex- 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 V such provisions or this permit shall be deemed revoked. AIR HANDLING UNIT(TO 10=C.F.M.) 4.00 CONSTRUCTION LENDING AGENCY AIR HANDLING UNIT(OVER 10PMC.F.M.) 6.00 SEISMIC FEE I hereby affirm that there is a construction lending agency for EXHAUST HOOD (WITH DUCT) 5.00 the perform mance of the work for which this permit is issued(Sec HEATING UNIT(TO 100,000 B.T.U.) 6.00 MICROFILM Lender's Name HEATING UNIT(OVER 100,000 B.T.U.)9.50 Lender's Address 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 cityand county BOILER-OOIVR(3 H.P.Or 100,000 B.T.U.) 6.00 PLUMBING • ordinances and state laws relating to building construction,terupon and hereby authorize representatives ec this city to enter upon the BOILER-COMP (Over 100,000 BTU)SEE FEE SCH. MECHANICAL above-mentioned property for inspection purposes, (We) agree to save, indemnify and keep harmless the City of MISC.- REFER TO ORD. Cupertino against liabilities,judgments, costs and expenses which CONST.TAX may.im any way accrue against said City in consequence of the PERMIT ISSUANCE 10.00 m of this p it_ MECH.CONT. LIC.NO. MECH. TOTAL &gneturc of Applicant/Contractor Date `••'"e" OFFICE COPY