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7138w �A LIPANT TO FILL IN INFORMATION WITHIN RED LINES- USE BALL POINT PEN. ONLY BUILDING PROJECT IDENTIFICATION UILDING -ELECTRICAL- PLUMBING -MECHANICAL PERMIT NUMBERAPPLICATION&PERMIT 7138 BUILDING Aoo� �'S S► .� ,� owNER's. "AME - Ox - PHONE A`, ' "' QTsYd e} +r .T ELECTRIC' -PERMIT H k -y `-FEEv, PLAN CHECK VALIDATION TONTAACTDH S. Z�• UTLETS-SWITCHES-RECEP 5.00/1.00 rwi iL_4 t M - C. NO, '.rJ, °I/1oO DATE OF APPLICATION LIGHTING FIXTURES 5.00/1.00 Q CONTRACTOR'S �-JQOAH13I.Ess 'f.JbOX I 4 1 PR rvE. - PPLIANCES-RESIDENTIAL 4.00 I PANELS 5.00 s� �,jj(Jp� (DLII•-si4C1� SIGNS 6.00 PLAN CHECK FEE P.C. NO. SIGNS TRANS. 3.00 HEIccR LIC. NO. ADDRESS ENc. SPECIALCIRCUIT 5.00 PERMIT VALIDATION TEMP. METER OR POLE INS. 15.00 ZIP APPLICANT s ADDRESS ' - MOTORS SEE FEE SCH. SERVICE CHANGE 10.00 ' i !�/Q 10 LICENSED CONTRACTORS DIiCLARA'pION ,J' I I hereby affirm that I am licensed under provisions of Chapter 9 (commencing with Section 7000) of Division 3 of the Business and Professions Cot`` py license is in full far t e fee Lo,en C1iU Lic. Numb Uatc_T=Contmdor. OWNER -BUILDER DECLARATION I hereby aftorn that I am exempt from The Contractor's License Law for the following reason. (Sec. 7031.5, Businessand Professions Code: Any city or county which reyuiresa permit loconstnmt, alter, ISSUANCE DATE BLDG. ELECT. PLG. MECH. ED El of CuPe�' nG MISC. - REFER TO ORD 'p-•� - BUIL NG,IPERMIT ',....a, INFOR_AfT_'N y PERMIT ISSUANCE 6.00 l VALUATION S/FT. ELEC. CONTR. LIC. NO. ELEC. /G^� TOTAL ! o / QTtYS " PLUMBING PERMIT 4 + ,; ''FEE'g` 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 ofthe Business and I'rol'essions Code) or That he is exempt therefrom and PERMIT TO �L•(�L� r the basis for the alleged exemption. Any violation of Section 7031.5 by any applicant for a permit subjects the applicant to a civil penally oft ot more than five hundred dollars f$500).). STORIES TYPE CONSTR. ALTER -DRAIN -WATER (EA.) 4.00 ❑ I, 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 2.00 OCC. GROUP RES. UNITS DRAINS -FLOOR, ROOF, AREA, GOND. 4.00 intended or Offered for sale (Sec. 7044, Business and Professions Code: The Contractor's License Law does not only to an owner of property who builds or Improves thereon, and who does such work hi nu elf or Dvough his own employees, provided that such improve- merits are not intended nr offered for sale. If, however, the building FIXTURES - PER TRAP 4.00 GAS-EA.SYSTEM-I q,00 SO. FT, FLOOR AREA TOTAL ACREAGE or improvement is sold within one year of completion, the owner- builder will have the burden of proving that he did not build 9r int- prove for purpose of sale.). 131, as owner of the property, am exclusively contracting with GAS - EA. SYSTEM -OVER 4 (EA.) 1.00 BUILDING USE RES IND WN P9 Omer ❑ ❑ ❑ ❑ ❑ INDUSTRIAL WASTE INTER. . 00 20 licensed contra.. to construct the project (Sec. 7044, Business and Professions Code:I' lie Coalitio°r'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. 5.00 LAWN SPRINKLERS -OVER 5 (EA.) 1.00 ASSESSORS PARCEL NO. contracts for such projects with a contractor(,) licensed pursuant to the Contractors License Law, ❑ I am exempt under Sec.., IL&P,C, fnr this reason SEWER -SANITARY -STORM EA. 200ft/8.00 TRACT NO, PARCEL NO. WATER HEATER W/VENT 4.00 Owner Date WATER SYSTEM 4.00 ACC.DATE - ACC. FILE NO, WORKERS'COMPENSA'I' ION DECLARATION WATER TREATING EQUIP. 4.00 1 hereby affirm that 1 have a certificate ofconsenl to self -insure, or a certificate of Workers Compensation Insurance, or a eirtified ZONING ENG. SITE NO. cOPy thcrtp-f-(SU800 I� C I( _�� ��s,.��I 1If�I F Po lic N `,j Com an1V �.a��r•�( ❑ Certified copy is hereby furnished. 's ❑ Certific py�isfIil��ed)vilh tyrinspectips`Jiaision. ;Applicant _ AvxLwx u c L(LTC 'T1CC�. FIRE SPRINK V ❑ N ❑ ENERGY Lp4 V ❑ N❑ MISC.- REFER TO ORD. CERT'IFICA'TE 017 EXEMPTION 17ROM WORKERS' COMPENSATION INSURANCE , ('Phis seelkin need not be completed if the permit is for one PERMIT ISSUANCE 6.00 FLOOD ZONE Y ❑ IN A.LU.C. Y ❑ N❑ PLG. CONTE. LIC. NO.PLG. TOTAL hundred dollers(S TOO) or less.) I certify that in the performance of the work for which this per mit Is issued, e I shall not employ any person in any manner or is to become subject to [he Workers' Compensation Laws of Calilinma. Date Applicant TO APPLICANT: If, after making Certificate Ex- y�� k A.'nkID..W. 4:" P- 7 t ' ' k QT1V. 'MECHANICAL PERMIT FEE - S� -p �. ry } - '�',;- FEE SUMMARY BUILDING ALTER OR ADD TO MECH. q-00 APPLIANCE 4.00 AIR HANDLING UNIT (TO 1Op00C.F.M) 3-00 PLAN CHECK FEE - empts°°, you should become subject In Ise Wrthwii Compensation emptier, ork sa Provisions io the Labor mit Code, you must forthwith comply with such provisions or This permit shall be deemed revoked. - AIR HANDLING UNIT (OVER 10MC.F.NL) 5.00 SEISMIC FEE CONSTRUCT ION L17NDING AGENCY I hereby affirm That there is a construction lending agency for EXHAUST HOOD WITH DUCT) 2.00 the performance of the work for which this permit is issued (Sec. 3097, Civ.C.). MICROFILM HEATING UNIT (TO 100,000 B.T.U.) 4.00 Lender's Name Lender's Address,HA ETINNI( G UT OVER 100,000 B.T.U.)7.50 ELECTRIC ee0 VENTILATION FAN (SINGLE) 3.00 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 PLUMBING BOILER- COMP 13 H.P. Or 100,000 B.T.U.) 4.00 BOILER -COMP (Over 100,000 BTU) SEE FEE SCH. MECHANICAL aboveauthorizenierepresentatives Nor ins of this city to enter upon the above io property for inspection purposes. (We) agree to one, indemnify and keep harmless the City of Cupertino against liabilities, judgments, costs andexpenses which may in any way accme against said City in consequence of the gra' sago tis pe� ! 'GJ" A.,(M .t- MISC. - REFERTOORD.1 PERMIT ISSUANCE 3.00 CONST. TAX MECH. CONT. LIC. NO. ITOTAL MECH. TOTAL - Signature of Applicant/Contractor Date OFFICE COPY w �A LIPANT TO FILL IN INFORMATION WITHIN RED LINES- USE BALL POINT PEN. ONLY BUILDING PROJECT IDENTIFICATION UILDING -ELECTRICAL- PLUMBING -MECHANICAL PERMIT NUMBERAPPLICATION&PERMIT 7138 BUILDING Aoo� �'S S► .� ,� owNER's. "AME - Ox - PHONE A`, ' "' QTsYd e} +r .T ELECTRIC' -PERMIT H k -y `-FEEv, PLAN CHECK VALIDATION TONTAACTDH S. Z�• UTLETS-SWITCHES-RECEP 5.00/1.00 rwi iL_4 t M - C. NO, '.rJ, °I/1oO DATE OF APPLICATION LIGHTING FIXTURES 5.00/1.00 Q CONTRACTOR'S �-JQOAH13I.Ess 'f.JbOX I 4 1 PR rvE. - PPLIANCES-RESIDENTIAL 4.00 I PANELS 5.00 s� �,jj(Jp� (DLII•-si4C1� SIGNS 6.00 PLAN CHECK FEE P.C. NO. SIGNS TRANS. 3.00 HEIccR LIC. NO. ADDRESS ENc. SPECIALCIRCUIT 5.00 PERMIT VALIDATION TEMP. METER OR POLE INS. 15.00 ZIP APPLICANT s ADDRESS ' - MOTORS SEE FEE SCH. SERVICE CHANGE 10.00 ' i !�/Q 10 LICENSED CONTRACTORS DIiCLARA'pION ,J' I I hereby affirm that I am licensed under provisions of Chapter 9 (commencing with Section 7000) of Division 3 of the Business and Professions Cot`` py license is in full far t e fee Lo,en C1iU Lic. Numb Uatc_T=Contmdor. OWNER -BUILDER DECLARATION I hereby aftorn that I am exempt from The Contractor's License Law for the following reason. (Sec. 7031.5, Businessand Professions Code: Any city or county which reyuiresa permit loconstnmt, alter, ISSUANCE DATE BLDG. ELECT. PLG. MECH. ED El of CuPe�' nG MISC. - REFER TO ORD 'p-•� - BUIL NG,IPERMIT ',....a, INFOR_AfT_'N y PERMIT ISSUANCE 6.00 l VALUATION S/FT. ELEC. CONTR. LIC. NO. ELEC. /G^� TOTAL ! o / QTtYS " PLUMBING PERMIT 4 + ,; ''FEE'g` 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 ofthe Business and I'rol'essions Code) or That he is exempt therefrom and PERMIT TO �L•(�L� r the basis for the alleged exemption. Any violation of Section 7031.5 by any applicant for a permit subjects the applicant to a civil penally oft ot more than five hundred dollars f$500).). STORIES TYPE CONSTR. ALTER -DRAIN -WATER (EA.) 4.00 ❑ I, 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 2.00 OCC. GROUP RES. UNITS DRAINS -FLOOR, ROOF, AREA, GOND. 4.00 intended or Offered for sale (Sec. 7044, Business and Professions Code: The Contractor's License Law does not only to an owner of property who builds or Improves thereon, and who does such work hi nu elf or Dvough his own employees, provided that such improve- merits are not intended nr offered for sale. If, however, the building FIXTURES - PER TRAP 4.00 GAS-EA.SYSTEM-I q,00 SO. FT, FLOOR AREA TOTAL ACREAGE or improvement is sold within one year of completion, the owner- builder will have the burden of proving that he did not build 9r int- prove for purpose of sale.). 131, as owner of the property, am exclusively contracting with GAS - EA. SYSTEM -OVER 4 (EA.) 1.00 BUILDING USE RES IND WN P9 Omer ❑ ❑ ❑ ❑ ❑ INDUSTRIAL WASTE INTER. . 00 20 licensed contra.. to construct the project (Sec. 7044, Business and Professions Code:I' lie Coalitio°r'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. 5.00 LAWN SPRINKLERS -OVER 5 (EA.) 1.00 ASSESSORS PARCEL NO. contracts for such projects with a contractor(,) licensed pursuant to the Contractors License Law, ❑ I am exempt under Sec.., IL&P,C, fnr this reason SEWER -SANITARY -STORM EA. 200ft/8.00 TRACT NO, PARCEL NO. WATER HEATER W/VENT 4.00 Owner Date WATER SYSTEM 4.00 ACC.DATE - ACC. FILE NO, WORKERS'COMPENSA'I' ION DECLARATION WATER TREATING EQUIP. 4.00 1 hereby affirm that 1 have a certificate ofconsenl to self -insure, or a certificate of Workers Compensation Insurance, or a eirtified ZONING ENG. SITE NO. cOPy thcrtp-f-(SU800 I� C I( _�� ��s,.��I 1If�I F Po lic N `,j Com an1V �.a��r•�( ❑ Certified copy is hereby furnished. 's ❑ Certific py�isfIil��ed)vilh tyrinspectips`Jiaision. ;Applicant _ AvxLwx u c L(LTC 'T1CC�. FIRE SPRINK V ❑ N ❑ ENERGY Lp4 V ❑ N❑ MISC.- REFER TO ORD. CERT'IFICA'TE 017 EXEMPTION 17ROM WORKERS' COMPENSATION INSURANCE , ('Phis seelkin need not be completed if the permit is for one PERMIT ISSUANCE 6.00 FLOOD ZONE Y ❑ IN A.LU.C. Y ❑ N❑ PLG. CONTE. LIC. NO.PLG. TOTAL hundred dollers(S TOO) or less.) I certify that in the performance of the work for which this per mit Is issued, e I shall not employ any person in any manner or is to become subject to [he Workers' Compensation Laws of Calilinma. Date Applicant TO APPLICANT: If, after making Certificate Ex- y�� k A.'nkID..W. 4:" P- 7 t ' ' k QT1V. 'MECHANICAL PERMIT FEE - S� -p �. ry } - '�',;- FEE SUMMARY BUILDING ALTER OR ADD TO MECH. q-00 APPLIANCE 4.00 AIR HANDLING UNIT (TO 1Op00C.F.M) 3-00 PLAN CHECK FEE - empts°°, you should become subject In Ise Wrthwii Compensation emptier, ork sa Provisions io the Labor mit Code, you must forthwith comply with such provisions or This permit shall be deemed revoked. - AIR HANDLING UNIT (OVER 10MC.F.NL) 5.00 SEISMIC FEE CONSTRUCT ION L17NDING AGENCY I hereby affirm That there is a construction lending agency for EXHAUST HOOD WITH DUCT) 2.00 the performance of the work for which this permit is issued (Sec. 3097, Civ.C.). MICROFILM HEATING UNIT (TO 100,000 B.T.U.) 4.00 Lender's Name Lender's Address,HA ETINNI( G UT OVER 100,000 B.T.U.)7.50 ELECTRIC ee0 VENTILATION FAN (SINGLE) 3.00 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 PLUMBING BOILER- COMP 13 H.P. Or 100,000 B.T.U.) 4.00 BOILER -COMP (Over 100,000 BTU) SEE FEE SCH. MECHANICAL aboveauthorizenierepresentatives Nor ins of this city to enter upon the above io property for inspection purposes. (We) agree to one, indemnify and keep harmless the City of Cupertino against liabilities, judgments, costs andexpenses which may in any way accme against said City in consequence of the gra' sago tis pe� ! 'GJ" A.,(M .t- MISC. - REFERTOORD.1 PERMIT ISSUANCE 3.00 CONST. TAX MECH. CONT. LIC. NO. ITOTAL MECH. TOTAL - Signature of Applicant/Contractor Date OFFICE COPY