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09565• O ZZ F- O = - LU > a 0 UO U_ I- 0 W } u F_ Z A APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY gx-1 BUILDING PROJECT IDENTIFICATION APPLICATION & PERMIT BUILDING —ELECTRICAL— PLUMBING —MECHANICAL PERMIT NUMBER 09565 BUILDING AppRES= OWNER'S is E \ 7I IRON� 162, QTY. ELECTRIC PERMIT FEE PLAN CHECK VALIDATION DATE OF APPLICATION CONTRACTOR'S NAME Cao LIc. No. OUTLETS -SWITCHES -RECEP 10.00/1.00 LIGHTING FIXTURES 10.00/1.00 coNTRAoR� v*A-e-_qel appRESG fyfh erc PHONE�3�'� APPLIANCES - RESIDENTIAL 4.00 PANELS iQ,QQ AOR RCHITECTPANELS(OVER ENGINEER LIC.NO. 200 AMP) 20.00 PLAN CHECK FEE P.C. NO. SIGNS TRANS. 3.00 AR H. OR CADDRESS ENG, ZIP SPECIAL CIRCUIT ,rj,QQ PERMIT A Nov 71985 �ryr of CaPe�i170 ISSUANCE DATE BLDG. ELECT. PLG. MECH. ❑ ❑ ❑ TEMP. METER OR POLE INS. 20.00 APPLICANTS appREss MOTORS SEE FEE SCH. SERVICE CHANGE 20.00 LICENSED CONTRACTORS DECLARATION 1 hereby affirm that I am licensed under provisions of Chapter 9 (commencing with Section 7000) of Division 3 of the Business and Professions Co p license is in full f J l PLice,rofessions Class VV Lia Nwellf Date ` Contractor tl_ ( OWNER -BUILDER DECLARATION 1 hereby affirm that I am exempt from the Contractor's License Law for the following reason.(See. 703 1.5, Businessand Professions Code: Any city or county which requires a permit to construct, alter, improve.demolish, or repair any Structure, prior to its issuance, also the applicant for such permit to file a signed statement that requires ilicensed he is licensed pursuant to the provisions of the Contractor's License of Division 3 of the Law (Chapter dr 9 (commencing with Section 7s exempt or that he is exempt Therefrom and Business and Professions exemption. oto -cion 703 1.5smaby by basis for (lie ant fora exemption. Any applicant by any applicant fora permit subjects th-applicmlt toacivil penalty of not more than five hundred dollars (8500).): ❑ 1, as owner of the properly, or myemployees with wages as their sole compensation, will do the work, and the structure is no[ intended or offered for sale (Sec. 7044, Business and Professions Codc: The Contractor's License Use 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 - mentsare not intended orOffered for Sale. If, however, the budding 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 ofsale.). ❑ I, as owner of the property, am exclusively contracting with licensed contractors in 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 contracts fur such projects with n contractor(.,) licensed pursuant to the Contractor's License Law. ❑ I am exempt under Sec.., B &p,C, for this rcasnn TEMP. POLE 30.00 BUILDING PERMIT INFORMATION MISC. — REFER TO ORD PERMIT ISSUANCE 10.00 VALUATION S/FT. ELEC. CONTR. LIG NO. ELEC. TOTAL / PERMIT TO / /L�ly/(///`/// OTV. PLUMBING PERMIT FEE ALTER-DRAIN&VENT-WATER(EA.) 5.00 STORIES TYPE CONSTR. BACK FLOW PROTECT. DEVICE 4.00 OCC. GROUP RES. UNITS DRAIN$ -FLOOR, ROOF, AREA, COND. 5.00 FIXTURES - PER TRAP 5.00 SQ FT. FLOOR AREA TOTAL ACREAGE GAS - EA. SYSTEM -1 INC.4 OUTLETS 6.00 GAS - EA. SYSTEM -OVER 4 (EA.) 2.00 BUILDING USE E HND CON PB 011ier INDUSTRIAL WASTE INTER. 30.00 LAWN SPRINKLERS - 1 INC 5 V.B. 6.00 ASSESSORS PARCEL NO. LAWN SPRINKLERS - OVER 5 (EA.) 1.00 SEWER -SANITARY -STORM EA. 200ft/10.00 TRACT NO. PARCEL NO. WATER HEATER W/VENT 6.00 Owner Date WATER SYSTEM 5,00 WORKIi MPENSATION DECLARATION that I I hereby affirm that have a certificate ol'consent m sdGinsure. copy a cer lyaje�p o ke�S�Cogzp prion I uran e r a rot' jed I s i. e �pFFCCSy„JJ. d��L(I,,vv ! lec� ' I'oompanY i Cl❑ Cer" tted copy is hereby furnished. ❑ Cerifmd co y IS filed wit the ' itytinspection division. Applicant nI _ �P i CI?RTIRCATEOF EXEMPTION PROMWOR'ERS' COMPENSATION INSURANCE (This seclidn need not be completed if the permit is for one hundred dollars ($100) or less.) I certify that in the performance of the work for which this per- alit is issued, I shall not employ any person in any manner so as to become subject to the Workers' Compchmtion Laws of California. NOTApplicant NOTICE TO APPLICANT: If, after making this Certificate of Ex- -option, 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 CONSTRUCTION CONSTRUCTION LENDING AGENCY I hereby affirm (flat there is a construction lending agency for the performance of the work for which this permit is issued (Sec 3097, Civ.C.). Lender's Name Lender's Address I certify that I have read this up,heatiml and State Om( the above information is correct. 1 agree to comply with all city and county Ordinances and state laws relating to building construction, Joel hereby authorise representatives of this city to enter upon the above Rient ioned property for inspection purposes. (We) agree to save, indemnify and keep harmless the City of Cupertino against liabilities, judgments, costs and expenses which m m any ay accrue against said City in consequence of the g nit ;Mt, em'L t —lys� ACC.DATE ACO. FILE NO. WATER TREATING EQUIP. 5.00 ZONING ENG. SITE NO. FIRESPRINK Y� N[ ENERGY T-24 v0 N[] MISC.- REFER TO ORD. PERMIT ISSUANCE 10.00 FLOOD ZONE Y ❑ N� A.L.UC. V [] N� PLG. CONTR. LIC. NO. PLG. TOTAL OTV MECHANICAL PERMIT FEE FEE SUMMARY BUILDING ALTER OR ADD TO MECH. 5.00 APPLIANCE 500 . AIR HANDLING UNIT (TO 10)==C4.00 PLAN CHECK FEE AIR HANDLING UNIT (OVER IOp00C.F.M.)6.00 SEISMIC FEE EXHAUST HOOD (WITH DUCT) 5.00 MICROFILM ELECTRIC HEATING UNIT (TO 100,000 B.T.U) B00 . . HEATING UNIT (OVER 100,000 B.T.0 9.50 VENTILATION FAN (SIN LE) 4.00 PLUMBING BOILER-COMP(3 H.P. r10 6.00 BOILER -COMP ver 0 )S EE SCH. MECHANICAL MISC , EFER TO ORD. CONST. TAX PE ISSUANCE 1000 O . MECH. C/O/NT. LIG NO. I� �`c l MECH. TD�� �� TOTAL Signature of AppbcaN/Contractor Date OFFICE Cur i