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09532 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY BU EDI NG PROJECT I DENTI FICATI ON PERMIT NUMBER BADDRESS UILDING APPLICATION & PERMIT. 09532BUILDING -ELECTRICAL-PLUMBING -MECHANICAL C NER5 I PLAN CHECK VALIDATION NAME / 'I - QTY. ELECTRIC PERMIT FEE PHO. NAME OUTLETS-SWITCHES-RECEP 10.00/1.00 // ,uc.NO. C'_ LIG HTI NG FIXTURES 10.00/1.00 ADDRESGTDFs PPLIANCES-RESIDENTIAL 4.00 ADDRESS PRIORI PANELS 10.00 DATE OF APPLICATION ORcwTEcR - PANELS (OVER 200 AMP) 20.00 PLAN CHECK FEE P.C.NO. C ENGINEER LIC NO SIGNS TRANS. 3.00 ADDRESS Eos e.c. SPECIALCIRCUIT 5.00 PEra q° T�Y9DATION ZIP EMP.METER OR POLE INS. 20.00 !��'11 APPLICANTS MOTORS -SEE FEE SCH. AUG 23 ADDRESS SERVICE CHANGE 20.00 /t♦ 1985 0.0 LICENSED CONTRACTORS DECLARATION TEMP.POLE 30.00 y(ly Qf CUPeµ' Q u v I hereby affirm that I am licensed under provisions of Chepfer 9 ISSUANCE,OAI H a (commencing with Section 7000)of Doisian 3 of the Business and BLDG. ELECT. PLG. MECH. r :z Professions Code,and my license is in full force and effect P5 � License Class Lia.Numhcr z O - o/OXI 9 y t Data GX - �Contractor �'� a m 2 BUILDING-PERMIT ¢ 0 i a .OWNER-BUILDER DECLARATION INFORMATION w ; y I hereby affirm that I am exempt from the Contractors License MISC.- REFER TO ORD LLa- Law for the following reason. 7031.5.Businessand Professions PERMIT ISSUANCE 10.00 VALUATION � - w Code:Any city or county which requires a permit to construct,alter, IS 2 ¢ 2 improve,demolish.or repair any structure,prior to its issuance,also ELEC.CONTR. LIC.NO. ELEC. ¢ requires the applicant for such permit to file a signed statement that TOTAL P HMTTO ww u he.is licensed pursuant to the provisions of the Contractor's License HZQ Law(Chapter9(eommencingwith Secti"n 7000)of Division3ofthe 4 O Business'and Professions Code)or that lie is exempt therefrom and QTY. PLUMBING PERMIT FEE ¢ r o the basis for the alleged exemption.Any violation of Section 70315 STORTEs /T PE CONSTR. by anyapplicant for a permit subjects the applicant toa civil penalty ALTER-DRAIN& VENT-WATER IEA.) 5.00 of not more than five hundred dollars($500),) . ❑ .1,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 structure is not intended or offered for sale(Sec. 7044, Rusiness and Professions DRAINS-FLOOR,ROOF,AREA,COND. 5.00 - .. A Code: The Contractors License Law does not apply to an owner of pro Pcrty who builds or improves thereon,and who docs such work FIXTURES-PER TRAP 5.00 V6 SO.FT.rLOOR AREA TOTALACREAGE himself or through his own employees,provided[hut such improve- , merits are not intended or offered for sale.If,however,the building GAS-EA.SYSTEM-1INC.4 OUTLETS 6.00 06 or improvement is sold within one year of completion, the owner- GAS EASYSTEM OVER 4 IEA) 200 builder will have the burden of proving that h - . - . . ime did not build or - BUILDING USE prove for purpose of sale.). INDUSTRIAL WASTE INTER. 30.00 tND CON PB Other O 1,as owner of the property,am exclusively contracting with R ❑ ❑ ❑ ❑ licensed contractors In construct the project(Sec. 7044,Business LAWN SPRINKLERS-1 INC 5 V.B. 6.00 r I ASSESSORS PARCEL NO. 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-OVER 5(EA.) 1.00 contracts for such projects with a coniruclorl s)licensed pursuant to the Contractor's License Law. SEWER-SANITARY-STORM EA.200ft/10.00 W TRACT NO. PARCEL NO. ❑ lam exempt under Sec. ,B.&PC.for this WATER HEATER W/VENT 6.00 �CU mason Owner Date WATER SYSTEM 5.00 Wig) ACC.DATE ACC.FILENO. WORK ERS'COMPENSATION DECLARATION WATER TREATING EQUIP. 5.00 v 1 hereby affirm that 1 have a certificate of consent to self-insure. or a certificate of Workers'Compensation Insumnec,or a certified ZONING ENG.SITE NO. copy thereof(Sec 3800,Lab.C.L Policy No. Company 0 ❑ Certified copy is hereby furnished. Z Z �@ Certified -rpy Is Bled will the city inspection division. FIRE SPRINK . ENERGYT24 O Applicantrarlr�,q/� MISC.- REFER TO ORD. r ❑ ,N❑ v ❑ N❑ jrD CERTIFICkTEOF EXEMPTION FROM WORKERS' PERMIT ISSUANCE 10.00 W FLDUDZONE A.L.U.C. LU > COMPENSATION INSURANCE? PLG.CONTR. LIC.N0. PLG. Q' 0 11 his section need not be completed if the permit is for one TOTAL �� Y❑ N❑ y❑ N❑ Z) 2 hundred dollars($100)or Icss.) U O 1 certify that in the performance of the work for which this per- QTY. MECHANICAL PERMIT FEE FEE SUMMARY LL F mit is issued,1 shall not employ any person in any manner so as to 0 ED become subject to the Workers'Compensation Laws of California. BUILDING G. Date Applicant ALTER OR ADD TO MECH. 5.00 } W NOTICE TO APPLICANT- It,after making this Certificate of Ex- F. 2 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 U such provisions or this permit shall be deemed revoked AIR HANDLING UNIT(TO 1Op00C.F.M.) 4.00 CONSTRUCTION LENDING AGENCY AIR HANDLING UNIT(OVER I0,000C.EM.) 6.00 SEISMIC FEE t 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 MICROFILM 3097;Civ.CA HEATING UNIT(TO 100,000 B.T.U.) 8.00 Lender's Name H EATING UNIT(OV ER 100,000 B.T.U.)9.50 Lender's Address ELECTRIC 1 certify that 1 have read this application and state that the above VENTILATION FAN (SINGLE) 4.00 information is correct. I agree to comply with all city and county PLUMBING UO ordinances and state laws relating to building construction, and 130ILER-COMP(3H.P.or100,000B.T.U.) 6.00 110hereby authorize representatives of this city to enter upon the BOILER-COMP Over 100,0009TUI 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 PERMIT ISSUANCE 10.00 CONST.TAX may in eny way accrue against said City in consequence of the Era of hrs permit MECH.CONT. LIC.NO. Ni ji r ���� �� / TOTAL TOTAL Si Be"/ure oP'A man Co mei r' Dae /uTV�I INSPECTOR COPY - S'PPLI.CANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLYit Irzw00 q Z UF,2w N Q N Z U Z0 N F JJ S 0 W U60SFxWwo F w J CO2LU w O 0 a X o w w m u, za IrQ F- o a 3 O Z_ 2 H0 LU W — EL O Z Z C) o W U Om tot Z U BUI LD1 NG PROJECT I DENTI FICATION APPLICATION & PERMIT BUILDING — ELECTRICAL—PLUMBING — MECHANICAL PERMIT NUMBER 09532 BUILDING, ADDft NAMER [ Ifs jj QTY.ELECTRIC PERMIT FEE PLAN CHECK VALIDATION PHON f Vn GONTRACTGR' NAMEn c. NG. UTLETS-SWITCHES -RECEP 10.0011,00 LIGHTING FIXTURES 10,00/1.00 CONTRACTOR'S A DRESS APPLIANCES - RESIDENTIAL 4.00 PAN ELS 10,007 (., PHONE DATE OF APPLICATION ARCHITECT r ORENGINEER LIC. NO. PANELS (OVER 200 AMP) 20,00 PLAN CHECK FEE P.C. NO. SIGNS TRANS. 3.00 aooaEss ENG' SPECIAL CIRCUIT 5,00 P,ERMtrjl tEpl 7101 ii'11:i EMP. METER OR POLE INS. 20.00ZIP AUG 2y g85APPLICANT'SMOTORS ADDRESS SEE FEE SCH, SERVICE CHANGE 20.00 City of CupertinoLICENSEDCONTRACTORSDECLARATIONTEMP. POLE 30.00 I hereby affirm that I am licensed under provisions of Chapter 9 commencing with Section 7000) of Division 3 of the Business and Professions nseCodendliceis in full fore. a Ita e((ee License lass Lie. Number -(3 ISSUANCE DATE BLDG. I ELECT. I PLG.A MECH, Date Date — Contractor BUI7_DING ERM IT INFOR ATIONOWNER -BUILDER DECLARATION hereby affirm that I am exempt from the Contractor's License Law for the following reason. (Sec. 703 1.5, 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 DMISC. — REFER TO OR VALUATION SIFT. PERMIT ISSUANCE 10.00 ELEC. CONTR. LIC. NO, ELEC. TOTAL RMIT TO QTY. PLUMBING PERMIT FEE Law (Chapter 9 (commencing with Section 7000) of Division 3 of the Business and Professions Code) or that he is exempt therefrom and ST RIES PE,CONSTR. the basis for the alleged exemption. Any violation of Section 7031.5 by any apphcani for a permit subjects the applicant to a civil penalty Of not morethan five hundred dollars (S 500).): ALTER -DRAIN 81 VENT -WATER {EA.) 5.OD O [,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. 5.00intendedorofferedforsale (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 improve- ments are not intended or offered for sale. If, however, the buitding FIXTURES - PER TRAP 5,00 Qb SO. FT. FLOOR AREA TOTALACREAGE GAS - EA. SYSTEM- l INC.4 OUTLETS 6.00 GOO or improvement is sold within one year of completion, the owner, builder will have the burden of proving that he did not build or (m- prove for purpose of sale.). CI 1, as owner of the. property, am exclusively contracting with GAS EASYSTEM •OVER 4 (EA.) 2.00 BUILDING USE R IND CON PB Other ElEl 1:1 E] licensed INDUSTRIAL WASTE INTER. 30.00 contractors to onstruct 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 ASSESSORS PARCEL NO, LAWN SPRINKLERS - OVER 5 (EA.) 1,00 contracts for such projects with a contractor(s) licensed pursuant to the Contractor's License Law. SEWER -SANITARY -STORM EA. 200ft11000. ( TRACT NO. PARCEL NO. 1 am exempt, under Sea. B.&P.C. for this reason WATER HEATER W/VENT 8.00 Owner Date WATER SYSTEM 5.00 ACC. DATE ACC. FILE NO. WATER TREATING EQUIP. 5.00WORKERTCOMPENSATIONDECLARATION l hereby affirm that I have a certificate of consent to self -insure: or a certificate of Workers' Compensation Insurance, or a certified ZONING ENG. SITE NO. copy thereof (Sec. 3800, Lab.C.). Policy No. Company FIRE SPRINK Y N ENERGY T-24 Y N Certified c y is filed wit the city inspection division. AACertified copy is hereby furnished, pp IT `a/RdL q,? MISC. - REFER TO ORD. CERTIFICATE OF EXEMPTION FROM WORKERS' PERMIT ISSUANCE 10,00 FLOOD ZONE A.L.U.C. COMPENSATION INSURANCE This section need not be completed if the permit is for one Y N Y N PLG. CONTR. LIC. NO. PLG. qr TOTAL 7w hundred dollars ($100) or less.) I certify that in the performance of the work for which this per. Mit is issded, i shall not employ any person in any manner so as to QTY. MECHANICAL PERMIT FEE FEE SUMMARY BUILDING become subject 10 the Workers' 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 PLAN CHECKemption, 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. FEEAIRHANDLINGUNIT (TO 1000 C.F.M.) 4.00 AIR HANDLING UNIT(OVER 10=C.F.M.) 6.00 SEISMIC FEECONSTRUCTIONLENDINGAGENCY 1 hereby affirm that there is a construction lending agency for EXHAUST HOOD (WITH DUCT) 5.00 lie 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 Lender's dame Lender's Address I certify that I have read this application and stale that the above information is correct. I agree to comply with all city and county ordinances and stale laws relating to building construction, and VENTILATION FAN (SINGLE) 4,00 PLUMBING 0 BOILER -COMP(3H.P; or 100,000 B.T.U.) 6.00 BOILER -COMP (over 100,000 BTU) SEE FEE SC H. MECHANICALherebyauthorizerepresentativesofthiscitytoenteruponthe above-mentioned property for inspection purposes. MISC, - REFER TO ORD. CONST. TAX We) agree to save, indemnify and keep harmless the City of Cupertino against liabilities, judgments, costs and expenses which may in an way accrue against said City in consequence of the gra t f is permit, PERMIT ISSUANCE _ 10.00 MECH. CONT. LIC. NO. MECH, flnjTOTAL TOTAL Signature o Applicant/Contractor Date OFFICE COPY