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8145APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY BUILDING PROJECT IDENTIFICATION APPLICATION & PERMIT BUILDING - ELECTRICAL- PLUMBING - MECHANICAL PERMIT NUMBER 1 45 mIILDING shkAooREss � 0 � A OWNER'S "ME q9(.-37Zz_ CITY ELECTRIC PERMIT FEE PLANCHEC VAUDATON ilErirzrwwrd HONE NOME Acr s $-35.26 j�Z UTLETS-SWITCHES -RECEP 10.00/1.00 1JnOW Ni LIC.No. LIGHTING FIXTURES 10.00/1.00 r-ONrRACr R's ADDRESS 021 g PPLIANCES- RESIDENTIAL 4.00 PANELS � 10.00 [3 rzkw /-I PHONE q9 -37a DATE OF APPLI TIO ARRCHITECT ENGINEER LIC. no. PANELS (OVER ZOO AMP) 20.00 PLAN CHECK FEE NO. SIGNS TRANS. 3.00 ADDRRess ENG ' SPECIAL CIRCUIT 5.00 PERMIT VALIDATION TEMP. METER OR POLE INS. 20.00 ZIP APPLICANTS 6 ADDRESS MOTORS SEE FEE SCH. SERVICE CHANGE R A W LICENSED CONTRACTORS DECLARATION TEMP. POLE W-00 1 hereby affirm that I am licca wd under provisions of Chapter 9ISSUANCE (commencing with Section 7000)of Division 3 of the Business and Professions Co and my license is in full fort a 'RLcl. License Class Lic. Number ) �• L Y L Date Contmctm OWNER -BUILDER D17CLIRATION 1 hereby affirm that I am exempt from the Contractor's License Law for the following mason. (Ste. 7031.5, Businessand Professions Cale: Any city or county which mquires 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 (Chaplet 9(commencingwilh Section 7000) of Division 3 oftlse Business and Professions Code) or that he is exempt therefrom and DATE BLDG. ELECT. I PLG. MECH. ❑ ❑ ❑ ❑ _ a- , City of Cupertino `ISG.- BUILDING PERMIT INFORMATION REFER TO ORD PERMIT ISSUANCE 10.00 VALUATION f/FT. ELED, CONTR. LIC. NO. ELEC. '1 TOTAL PERMIT TO /t•MPa E L GTY. PLUMBING PERMIT FEE STORIES TYPE CONSTR. the basisforthc alleged exernpan, Any violation of Seclion703L5 by any applicant for a permit subjects the applicant Lou civil penalty of not more than five hundred dollars (5500).): ALTER-DRAIN&VENT -WATER (EA.) 5.00 ❑ 1, as owner of the property, or my employees with wages as their wit 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. 7144, Business and Professions Code: The Contractor's License Law does not apply to an owner of property who builds or improves thereon, and who docs such work himself or through his own employees, provided that such improve- ments are not intended or offered for sale. If, however, the building FIXTURES - PER TRAP 5.00 SO. FT. FLOOR AREA TOTAL ACREAGE GAS- EA. SYSTEM- 1 INC.4 OUTLETS 6.00 wner or improvement is sold within one year of completion, the owner- builder builder will have the burden of proving that he did not build or im- prove for purpose ofsale.).INDUSTfl ❑ I, as owner of the property, am exclusively contracting with . - GAS EASYSTEM -OVER 4 IEA:1 2.00 BUILDING USE RES IND CON PB Omer ❑' ❑ ❑ ❑ ❑ IAL WASTE INTER. 30.00 liconsd cont rectors to emutruct the project (Sec. 7144, Business and Pro fcssiom Code: The Contractor's License Law docs not apply to an owner of properly who builds or improves thereon, and who LAWN SPRINKLERS- 1 INC 5 V.B. 6.00 LAWN SPRINKLERS - OVER 5 (EA.) 1.00 ASSESSORSPARCELNO. '. contracts for such projects with a contractotls) licensed pursuant to the Contractnis Lic.. Law, SEWER-SANITAR V -STORM EA. 200ft110.00 TRACT NO. PARCEL NO. ❑ lam exempt under Sec,-. BAP.C. for this Reason WATER HEATER W/VENT 6.00 owner Dale - WATER SYSTEM 5.00 ACC. DATE ACC. FILE NO. WATER TREATING EQUIP. 5.00 WORKERS'COMPENSATION DECLARATION 1 hereby affirm that I have a certificate of consent to soli i....c, or a certificate of Workers' Compensation Insurance. or a certified ZONING ENG. SITE NO. copy thereof (Sec. 3800, W b.C.). Policy No. Company ❑ Certified copy is hereby furnished. - O Certified! ..spy is tiled with th' city aspen ion division. Applicant 1. Pillow W FIRE SPRINK Y❑ N❑ ENERGY T la Y❑ N❑ MISC.- REFER TO ORD. CERTIFICATE 017 EXEM 1R ORKERS' PERMIT ISSUANCE 10.00 FLOOD ZONE A.L.U.C. COMPENSATION I URANCE 1'rids section used not be completed if the permit is for one Y ❑ N ❑ Y ❑ N ❑ PLG.CONTR. LIC. NO. pLG, TOTAL hundred dollars IS 100) or Tess.)' I certify that in the performance of the work for which this per- mit is issued, 1 shall not employ any person in any manner so as to OTY. MECHANICAL PERMIT FEE FEE SUMMARY BUILDING become subject to the Worker' Compensation Laws of California. Date Applicant ALTER OR ADD TO MECH. 5.00 NOTICE TO APPLICANT: If, after making this Certificate of Ex- APPLIANCE 5.00 AIR HANDLING UNIT (TO 10,00DC.F.M.) 4.00 PLAN CHECK FEE emption, you should become subject to the Workers Compensation ,oird, mt of the Labor Code, you must forthwith comply with such provisions or this permit shall be deemed revoked. AIR HANDLING UNrf(OVER I0,000GF.M.) 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 perlormance of the work for which this permit is issued (Sec. 3097, Civ.C.). MICROFILM HEATING UNIT (TO 100,000 B.T.U.) 8.00 Lcedur's Name Lender's Address HEATING UNIT (OVER 100,000 B.T.U.)9.50 ELECTRIC _] tel. I certify that I have read this application and state that the above VENTILATION FAN (SINGLE) 4.00 information is correct. 1 agree to comply with all city and county ordinances and slate laws rclaling to building conMruclion, and PLUMBING BOILER-T!13,H.P.or100,000B.T.U.) 6.00 BOILER -COMP IOva, 100,000 BTU) SEE FEE SCH. MECHANICAL hereby authorize representatives of this city to error upon the above-mentioned property for inspection purposes. (We) agree to save, Indemnify and keep harmless the City of MISC. - REFER TO ORD. Curse ino against liabilities, judgments, costs and expenses which may in any way accrue against said City in consequence of the PERMIT ISSUANCE 10.00 CONST: TAX granting of this permtit. aria nu MECH. CONT: LIC. NO. MECH. TOTAL TOTAL Signature of App Gee I tractor Ua[e OFFICE COPY i APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY BU LDI NG PROJECT I DENT] FICATI ON APPLICATION &PERMIT BUILDING - ELECTRICAL- PLUMBING - MECHANICAL PERMIT NUMBER g� 45. SG ADD ADDRESS E _ PLAN CHECK VALIDATION AME 99-3 72 L QTY. ELECTRIC PERMIT FEE CONTRACTolls NAME yz OUTLETS -SWITCHES -RECEP 10.00/1.00 It LIGHTING FIXTURES 10.00/1.00 yLLIC NO DATE OF APPLICATION roNraacT R'SPPLIANCES-RESIDENTIAL DD ARESS 1 8 PRONE 4.00 PANELS 10.00 ARCHITECT OR ENGINEER uc. Na. PANELS (OVER 200 AMP) 20.00 PLAN CHECK FEE P.C. NO. SIGNS TRANS. 3.00 ADDRESS ENG. SPECIALCIRCUIT 5.00 PE STRIP VALIDATION EMP. METER OR POLE INS. 20.00 ZIP j J APPLICANT'S ADDRESS MOTORS ) SEE FEE SCH. SERVICE CHANGE 20.00 LICENSED CONTRACTORS DECLARATION TEMP. POLE 30.00 r I hereby affirm that 1 ant licensed under provisions ofChapmr 9 (commencing with Section 7000) of Division 3 of the Business and Professions Code and my license is in full force and effect. Liccase Class Lic. Number ;F a f it 7 ISSUANCE DATE BLDG. El ELECT. L1 PLG. MECH. 1:1❑ Date Contractor OWNER -BUILDER DECLARATION 1 hereby affirm that I am exempt from the Contractor's License nt Law forlhe following reoson. (Sec. 703L5, Businessand Prolessiovs Code: Any city or county which rcquiresa permit toconstTucl,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(contmencingwith Section 7000)of Division 3 ofthe Business and Professions Code) or that lie isexempt therefrom and BUILDING PERMIT INFORMATION MISC. REFER TO ORD . VALUATION $/FT. PERMIT ISSUANGE 10.00 ELEC. CONTR. LIC. NO, ELEC. TOTAL .K7/ b " PERMIT TO �, m �'�� OTY. PLUMBING PERMIT FEE STORIES TYPE CONSTR. Bre 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 ($5001.).. ALTER -DRAIN & VENT -WATER (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 F LOW PROTECT. DEV ICE 4.00 OCG GROUP RES. UNITS DRAINS -FLOOR, ROOF, AREA,COND- 5.00 intended or offered for sale (Sec. 7044. Business and Professions Code: The Contmdar's License Law does ,,it apply to an owner of properly who builds or improves thereon, and who does such work himself or Omough his own employees, provided that such in.provr ments.are not intended or offered for sale. If, however, the huilding FIXTURES -.PER TRAP 5.00 SO. FT. FLOOR AREA TOTALACREAGE GAS-EA.SYSTEM-11NC.4OUTLETS 6.00 or improvement is sold within one year of completion, the owner- builder will have the burden of proving that he did not build or int- for purpose ofsale.). ❑ 1, as owner of the property, am exclusively contracting with GAS - EA. SYSTEM - OVER 4 (EA.) 2.00 BUILDING USE RES IND ' CON PB Omer ❑ ❑ ❑ ❑ ❑ INDUSTRIAL WASTE INTER. 30.00 licensed contractors to construct the project (Sec. 7044, Business and Professions Code, The Contractor's License Law docs not apply to an owner of property who builds or improves thereon, and who LAWN SPRINKLERS -11 INC 5 V.B. 6.00 ASSESSORS PARCEL NO. LAWN SPRINKLERS - OVER 5 (EA.) 1.00 contracts for such projects with a contractors) licensed pursuant to the Contractor's License Law, SEWER -SANITARY -STORM EA. 200tt/10.00 TRACT NO. PARCEL NO. ❑ taro rxempt under Sec. ,B.&P.C. for this reason WATER HEATER W/VENT 6.00 Owner Date. WATER SYSTEM 5.00 ACC.DATE ACC. FILE NO. WATER TREATING EQUIP. 5.00 WORK ERS'COMPENSATION DECLARATION 1 hereby affirm that 11have a certif irate of UmMR t to elf-iranic, or a ce,til'icale of Workers' Compensation Insurance, or a certified ZONING ENG. SITE NO. copy thereof (Sec. 3800, Lab.C.). - Policy No,Company ❑ Certified copy is hereby furnished ❑ Certified copy is filed with the city 'sped ion division. Applicant FIRE SPRINK Y ❑ N ❑ ENERGY T24 Y ❑ N❑ REFER TO ORD MISC. - . /')W N CERTHlc! EOI'EXEMP IO ( O S PERMIT ISSUANCE 10.00 FLOOD ZONE A. L. U.C. PLG. CONTR. UC. NO. PLG. TOTAL COMPENSA7'[ON I RANCE. This section need not be completed -if the permit is for one Y ❑ N ❑ Y ❑ N ❑ hundred lona.. ($100) or 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 mann,, so as to CITY. MECHANICAL PERMIT FEE FEE SUMMARY BUILDING become subject to the Workers' Compensation Laws of California. Date Applicant ALTER OR ADD TO MECH. 5.00 ALTER NOTICE TO APPLICANT: If, after making this Certificate of 1: yen should become object to the Workers'' Compensalion APPLIANCE 5A0 PLAN CHECK provisions of the Labor Code, you must forthwith comply with such provisions or this permit shall be deemed revoked. FEE AIR HANDLING UNIT (TO 10)000C.F.M.) 4.00 AIR HANDLING UNIT (OVER 10MC.F.M.) 6.00 SEISMIC FEE CONSTRUCT ION LENDING AGENCY I hereby affirm that the,e 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 HEATING UNIT (OVER 100,000 B.T.U.)9.50 ELECTRIC L`'d Lender's Name Lender's Address I certify that l have read this application and slate that the above VENTILATION FAN (SINGLE) 4.00 imommtion is correct. I agree to comply with all city and county ordinances and state laws relating to building construction, and PLUMBING BOILER- COMP(3 H.P. or 100,000 B.T.U.) 6.00 BOILER -COMP Over 100,000 BTU) SEE FEE SCM- MECHANICAL hereby authorize representatives of this city m enter upon the above mentioned property for inspection purposes. MISC. - REFER TO ORD. (We) agree to save, indemnify and keep harmless the City of Cupertino against liabilities, judgments, costs and expenses which may in any way averue against said City in consequence of the CONST. TAX PERMIT ISSUANCE 10.00 granting of this permit. MECH. CONT. LIC. NO. MECH. TOTAL ' TOTAL y1ftatto, Ume Signature ou'Applicamr/V INSPECTOR COPY