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8146APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL P(1pNT PEN ONLY BUILDING PROJECT I DENTI FICATION APPLICATION &.PERMIT BUILDING=ELECTRICAL- PLUMBING - MECHANICAL - PERMIT NUMBER ' / Al 46 ADDRESS DING - .' AD O OWNER'S. '- NaM //A��''�x (��j_ r'•.� �'• V� I"�'V _�W�,RONE Y TV. ELECTRIC PERMIT FEE s PLA N CHECK VALIDATION - ' , NOaNrnacroRs OUTLETS - SWITCHES - RECEP- 10.00/1.00 LIGHTING FIXTURES. .10.00/1.00 - Llc. No. CONTRACTORS PPLIANCES- RESIDENTIAL 4.00 PANELS 10.00 PHONE DATE OF APPLICATION ARCHITECT - ENGINEER_ -• LIC. No.SI PANELS (OVER 200 AMP) 20.00 PLAN CHECK FEE P.C. NO. - GNS TRANS. • 3.00 ��- ADDROR ESS ENG' SPECIAL CIRCUIT 5.00 PERMIT VALIDATION a TEMP. METER OR POLE INS. 20.00 'ZIP - ! { APP❑carvra " PPLICA ADDRESS MOTORS SEE FEE SCH. SERVICE CHANGE 20.00/a/�J „J�/{yJUV 1 I FEB 2 jjj000AAA""" I ' V 155 ANCE GATE BLDG. ELECT. PLG. MECH. f Mme I Iff] 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 Lia Number TEMP. POLE '' 30,00 Date Contractor BUILDING PERMIT INFORMATION OWNER -BUILDER DECLARATION I hereby affirm that I am exempt from the Contractor's License Law for for the following reason. (Sec. 7031.5, Business and Professions Code: Any city or county which requiresa permit toconstrucN alter, _ MISC.- REFER TO ORD' - PERMIT ISSUANCE - 10.00 VALUATION ' ELEC. CONTR. LIC. NO. ELEC, TOTAL - QTY. PLUMBING PERMIT FEE 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 PERMIT TO SAP we -,ie - STORIES TYPE CONSTR. . the basis for the alleged exemption. Any violation of Section 7031.5 by any applicant for a permit subjects the applicant o a civil penalty of not mare than five hundred dollars (8500).): ALTER -DRAIN (EA.) 5.00 ❑ 1, as Owner of the property, Or my employees with wages as their. sole compensation, will do the work, and the structure is not BACK FLOW PROTECT. DEVICE 4.00 OCC. GROUP RES. UNITS DRAINS -FLOOR, ROOF, AREA, 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 FIXTURES - PER TRAP 5.00 GAS - EA. SYSTEM- 1 INC. 4 OUTLETS '6.00 SO. FT. FLOOR AREA TOTAL ACREAGE property who builds or improves thereon, and who does such work himself Or through his own employees, provided that such improve - mens am 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 im- prove for purpose of sale.).- ❑ 1, as owner of the property, am exclusively'contracting with. GAS - EA. SYSTEM - OVER, (EA.) 2.00 BUILDING USE RES IND', CON PS Other ❑ ❑ 'El Q ❑ INDUSTRIAL WASTE INTER. -30.00 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 LAWN SPRINKLERS- 1 INC 5 V.B. '6.00 LAWN SPRINKLERS - OVER 5 (EA.) 1.00 ASSESSORS PARCEL NO. - � contracts forsuch projects with a contraclods) licensed pursuant to the Contrac License Law - SEWEfl-SANITARY-STORM EA. 200ft/10.00 TRACT NO. PARCEL NO. ❑ I axe pt,BAP.C. for this ason " WATER HEATER W/VENT 6.00 - Owner Date WATER SYSTEM 5.00 ACG DATE ACC. FILE NO. WATER TREATING EQUIP. 5.00 wORKERS'COMPENSATION DECLARATION ' 1 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 thereof (Sea 3800, Lab.C.). I Policy No. Company , ' f FIRE MISC. - •, REFER TO ORD. ' SPRINK V N � -ENERGY T-24 - V N ❑ ❑ Certified COPY is hereby furnished e ❑ Certified copy is filed with, the 'city inspection division. Applicant CERTIFICATE OF EXEMPTION FROM WORKERS' PERMIT ISSUANCE 6- - FLOOD ZONE A.L.U.C. - COMPENSATION INSURANCE (This section 'need not be completed if the permit is for one v N Y Q N❑ PLG. CONTR. LIC. N0. - TLDAL ( QIa7 ' hundred dollars (8100) dr less.) I certify that in the performance of the work for which this per mit is issued, I shall not employ any person in any manner.so as to OTV. MECHANICAL PERMIT FEE FEE SUMMARY BUILDING become subject to the Workers' Compensation Laws of Califomia. Date Applicant NOTICE TO APPLICANT: If, after making (his Certificate of Ex- ALTER OR ADD TO MECH. 5.00 i APPLIANCE 5.00 PLAN CHECK' FEE emption, you should become subject to the Workers' Compensation provisions of the Labor Code, you must forthwith comply with such provisions or this permit shall be deemed revoked - AIR HANDLING UNIT (TO ICJ=CF.NL) 4.00 - AIR HANDLING UNIT (OVER 10=C.RM.) 6.00 SEISMIC FEE - ,. CONSTRUCTION LENDING AGENCY - 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 (Sec. 3097, Civ.C.). t MICROFILM HEATING UNIT (TO 10 B.T.U.) 8.00 Lender's Name Lender's Address HEATING UNIT (OVER 100,000 B.T.U.)9.50 ELECTRIC VENTILATION FAN (SINGLE) 4.00 1 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. PLUMBING - BOILER- COMP 13 H.P. or 100,000 B.T.U.) 6.00 BOILER -COMP (Over 100,000 BTU) SEE FEE SCH. ' MECHANICAL hereby authorize representatives of this City to enter upon the above-mentioned properly for inspection purposes. (We p'egree to save, indemnify and keep harmless the City of - MISC. - REFER TO ORD. Cupertino at liabilities, judgments, costs and expenses which may itn y ay accrue at said City in consequence of the gran [i o is perm' '+ 2 - PERMIT ISSUANCE 10.00 CONST. TAX CH. CONT. LIC.NO. MECH. TOTAL - TOTAL Sign ure of Ap tic nt Conlracto Date OFFICE COPY. APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL P(1pNT PEN ONLY BUILDING PROJECT I DENTI FICATION APPLICATION &.PERMIT BUILDING=ELECTRICAL- PLUMBING - MECHANICAL - PERMIT NUMBER ' / Al 46 ADDRESS DING - .' AD O OWNER'S. '- NaM //A��''�x (��j_ r'•.� �'• V� I"�'V _�W�,RONE Y TV. ELECTRIC PERMIT FEE s PLA N CHECK VALIDATION - ' , NOaNrnacroRs OUTLETS - SWITCHES - RECEP- 10.00/1.00 LIGHTING FIXTURES. .10.00/1.00 - Llc. No. CONTRACTORS PPLIANCES- RESIDENTIAL 4.00 PANELS 10.00 PHONE DATE OF APPLICATION ARCHITECT - ENGINEER_ -• LIC. No.SI PANELS (OVER 200 AMP) 20.00 PLAN CHECK FEE P.C. NO. - GNS TRANS. • 3.00 ��- ADDROR ESS ENG' SPECIAL CIRCUIT 5.00 PERMIT VALIDATION a TEMP. METER OR POLE INS. 20.00 'ZIP - ! { APP❑carvra " PPLICA ADDRESS MOTORS SEE FEE SCH. SERVICE CHANGE 20.00/a/�J „J�/{yJUV 1 I FEB 2 jjj000AAA""" I ' V 155 ANCE GATE BLDG. ELECT. PLG. MECH. f Mme I Iff] 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 Lia Number TEMP. POLE '' 30,00 Date Contractor BUILDING PERMIT INFORMATION OWNER -BUILDER DECLARATION I hereby affirm that I am exempt from the Contractor's License Law for for the following reason. (Sec. 7031.5, Business and Professions Code: Any city or county which requiresa permit toconstrucN alter, _ MISC.- REFER TO ORD' - PERMIT ISSUANCE - 10.00 VALUATION ' ELEC. CONTR. LIC. NO. ELEC, TOTAL - QTY. PLUMBING PERMIT FEE 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 PERMIT TO SAP we -,ie - STORIES TYPE CONSTR. . the basis for the alleged exemption. Any violation of Section 7031.5 by any applicant for a permit subjects the applicant o a civil penalty of not mare than five hundred dollars (8500).): ALTER -DRAIN (EA.) 5.00 ❑ 1, as Owner of the property, Or my employees with wages as their. sole compensation, will do the work, and the structure is not BACK FLOW PROTECT. DEVICE 4.00 OCC. GROUP RES. UNITS DRAINS -FLOOR, ROOF, AREA, 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 FIXTURES - PER TRAP 5.00 GAS - EA. SYSTEM- 1 INC. 4 OUTLETS '6.00 SO. FT. FLOOR AREA TOTAL ACREAGE property who builds or improves thereon, and who does such work himself Or through his own employees, provided that such improve - mens am 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 im- prove for purpose of sale.).- ❑ 1, as owner of the property, am exclusively'contracting with. GAS - EA. SYSTEM - OVER, (EA.) 2.00 BUILDING USE RES IND', CON PS Other ❑ ❑ 'El Q ❑ INDUSTRIAL WASTE INTER. -30.00 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 LAWN SPRINKLERS- 1 INC 5 V.B. '6.00 LAWN SPRINKLERS - OVER 5 (EA.) 1.00 ASSESSORS PARCEL NO. - � contracts forsuch projects with a contraclods) licensed pursuant to the Contrac License Law - SEWEfl-SANITARY-STORM EA. 200ft/10.00 TRACT NO. PARCEL NO. ❑ I axe pt,BAP.C. for this ason " WATER HEATER W/VENT 6.00 - Owner Date WATER SYSTEM 5.00 ACG DATE ACC. FILE NO. WATER TREATING EQUIP. 5.00 wORKERS'COMPENSATION DECLARATION ' 1 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 thereof (Sea 3800, Lab.C.). I Policy No. Company , ' f FIRE MISC. - •, REFER TO ORD. ' SPRINK V N � -ENERGY T-24 - V N ❑ ❑ Certified COPY is hereby furnished e ❑ Certified copy is filed with, the 'city inspection division. Applicant CERTIFICATE OF EXEMPTION FROM WORKERS' PERMIT ISSUANCE 6- - FLOOD ZONE A.L.U.C. - COMPENSATION INSURANCE (This section 'need not be completed if the permit is for one v N Y Q N❑ PLG. CONTR. LIC. N0. - TLDAL ( QIa7 ' hundred dollars (8100) dr less.) I certify that in the performance of the work for which this per mit is issued, I shall not employ any person in any manner.so as to OTV. MECHANICAL PERMIT FEE FEE SUMMARY BUILDING become subject to the Workers' Compensation Laws of Califomia. Date Applicant NOTICE TO APPLICANT: If, after making (his Certificate of Ex- ALTER OR ADD TO MECH. 5.00 i APPLIANCE 5.00 PLAN CHECK' FEE emption, you should become subject to the Workers' Compensation provisions of the Labor Code, you must forthwith comply with such provisions or this permit shall be deemed revoked - AIR HANDLING UNIT (TO ICJ=CF.NL) 4.00 - AIR HANDLING UNIT (OVER 10=C.RM.) 6.00 SEISMIC FEE - ,. CONSTRUCTION LENDING AGENCY - 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 (Sec. 3097, Civ.C.). t MICROFILM HEATING UNIT (TO 10 B.T.U.) 8.00 Lender's Name Lender's Address HEATING UNIT (OVER 100,000 B.T.U.)9.50 ELECTRIC VENTILATION FAN (SINGLE) 4.00 1 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. PLUMBING - BOILER- COMP 13 H.P. or 100,000 B.T.U.) 6.00 BOILER -COMP (Over 100,000 BTU) SEE FEE SCH. ' MECHANICAL hereby authorize representatives of this City to enter upon the above-mentioned properly for inspection purposes. (We p'egree to save, indemnify and keep harmless the City of - MISC. - REFER TO ORD. Cupertino at liabilities, judgments, costs and expenses which may itn y ay accrue at said City in consequence of the gran [i o is perm' '+ 2 - PERMIT ISSUANCE 10.00 CONST. TAX CH. CONT. LIC.NO. MECH. TOTAL - TOTAL Sign ure of Ap tic nt Conlracto Date OFFICE COPY.