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10992 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY '►- BUI LDI NG PROJECT I DENTI FICATION PERMIT NUMBER BUILDING APPLICATION & PERMIT Y aoOREss BUILDING-ELECTRICAL-PLUMBING-MECHANICAL 10992 OWNER'S PLAN CHECK VALIDATION NAMEvELECTRIC PERMIT FEE/✓1MT+^' W✓. PHONE °�• CONTRACTOR'S ['-/L JOUTLETS-SWITCHES-RECEP 10.00/1.00 NAME Gp hLcy.M,i- LIC.NO. �/ LIGHTING FIXTURES 10.00/1.00 CONTRACTOP sAPPLIANCES-RESIDENTIAL 4.00 ADDRESS "� PNONE Z;,k V7/ d'C - PANELS 10.00 GATE OF APPLICATION ARCHITECT PANELS (OVER 200 AMP). 20.00 ENPLAN CHECK FEE P.C.N0. OR GINEER LIC.No. SIGNS TRANS. 3.00 ARCHESS OR ENG SPECIALCIRCUIT 5,00 PERMIT VALIDATION Zap EMP.METER OR POLE INS. 20.00 ` APPLI SZMOTORS SEE FEE SCH. ADDRESS ✓✓✓��////// VA' SERVICE CHANGE2 .00 woo LICENSED CONTRACTORS DECLARATION a z W I hereby affirm Thal I nm licensed under provisions of Chapter 9 ISSUANCE DATE ¢ a (commencing with Section 7000)of Division 3 of the Business and BLDG. ELECT. PLG. MECH. H w i Professions Code,and my license is in full force�rrsl a t. s ❑ ❑ ❑ o o License Cha};, '- -/ Cin. ractor _a t Q Date._:-4. /7.-- Lie.Noor_ '(�`O Q y i J ` t ¢ ¢ ¢ OWNER-BUILDER DECLARATION Ot vQp BUILDING PERMIT r o a u INFORMATION X g LL r I hereby affirm that I am exempt from the Contractor's License MISC.- REF TO ORD M VALUATION $/FT. H ¢ OJ Law for The following reason.(Sec.7031.5,Businessand Professions PERMIT ISSUANCE OCA u Code:Anycily crcounty which requires a permit to construct,alter, 10.00 .(� Q a,It Q Improve,demolish,or repair any structure,prior to Its Issuance,also ELEC,CONTR. LIC.NO. ELEC. cD ¢ requires the applicant for such permit to file a signed statement that / TOTAL wm°' he is licensed pursuant to the provisions of the Contractor's License PERMIT TO H 2 a Law(Chapter 9(commencing wit it Section 7000)ofDivision3offal �LLr� Business and Professions Code)or that he is exempt therefrom and QTY , PLUMBING PERMIT FEE M I=-$ ,.the basis for the alleged exemption.Any violation of Section 7031.$ STORIES TYPE CONSTR. by any applicant for a permit subjects the applicant to a civil penalty ALTER-DRAIN&VENT-WATER (EA.) 5.00 of not more than five hundred dollars($500).): ❑ I,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, Business and Professions DRAINS-FLOOR,ROOF,AR EA,COND. 5.00 Code:The Contractor's License Law does not apply to an owner of property who builds or improves thereon,and who does such work FIXTURES-PER TRAP 5.00 SO.FT,FLOOR AREA TOTALACREAGE memsare of ugh intend, own employees,provided,Ifliow"e,ueh improve- GAS-EA.SYSTEM-1 1NC.4 OUTLETS 6.00 mems are not intended or offered for sale.If,mpleven the building or improvement is sold within one year of completion,the owner. GAS-EA.SYSTEM-OVER 4 (EA.) 2.00 builder will have the burden of proving that he Aid not buil.)or int- BUILDING USE prove for purpose of sale.). INDUSTRIAL WASTE INTER. 30.00 RES IND CON PB ower ❑ I,as owner of the property,am exclusively contracting with ❑ ❑ ❑ ❑ ❑ licensed contractors to construct the project(Sec.7044,Business LAWN SPRINKLERS-1 INC 5 V.B. 6.00 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 forsuch projects with a eontomoxis)licensed pursuant to ' the Contractor's License Law, SEWER-SANITARY-STORM EA.200ft/10.00 TRACT NO. PARCEL NO. ❑ I am exempt under Sec.-,BAP.C.for This WATER HEATER W/VENT . 6.00 reason Owner Date WATER SYSTEM 5.00 ACC.DATE ACC,FILE NO, WORK F.RS'COMPENSAI'ION DECLARATION WATER TREATING EQUIP( 5.00 I hereby affirm that I have a certificate of consent to self-insure, or a certificate of Workers'Compensation Insurunce,or a certitied ZONING ENG.SITE NO. copy thereof(Sec.3800,Lab,C.l.� {a� Policy No.-Company'' /� 47z- _71 O ❑ Certified copy is hereby furnished. TPr ..T}jyy� y ~� FIRE SPRINK ENERGY T 24 Z 2 ❑ Certified copy Is filed will, the If Inspecdod dl Isio H Applicant r: �6_fy-Q /- MISC.- REFER TO ORD. Y❑ N❑ v ❑ N❑ LU - CERTIFICATE OF EXEMPTION FROM WORKERS' PERMIT ISSUANCE 10.00 RS' FLOOD ZONE a.L.U.C. W COMP � COMPIiNSATION INSURANCE. PLG.CONTR. LIC.N0. PLG. � Z (This section need net be completed if the permit is for one TOTAL Y[:] N❑ Y[:] N❑ hundred dollars(S 100)or less.) U O I certify that in the performance of the work for which this per. QTY. MECHANICAL PERMIT FEE FEE SUMMARY LL F mit is issued,I shall not employ any person in any manner ro as to - O L) become subject In the Workers'Compensation Laws of California. a Date - Applicant ALTER OR ADD TO MECH. 5.00 BUILDING >_ N NOTICE TO APPLICANT: If,after mki ang this Certificate of Ex- _ H 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 10=C.F.M.) 4,00 CONSTRUCTION LENDING AGENCY AIR HANDLING UNIT(OVER 10,000QEM.) 6.00 SEISMIC FEE 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.C.). HEATING UNIT(TO 100,000 B.T.U.) 8.00 Lender's Name )9 U T 0 VER 1 UN IT( EATING O00,00B. . . .50 Lender's Address H ELECTRIC 60-0 1 certify That I have read this application and slot,that the above VENTILATION FAN (SINGLE) 4.00 information is correct.1 agree to comply with all city and county PLUMBING ordinancesandstate laws relating to building construction, and BOILER-COMP(3 H.P.or 100,000 B.T.U.) 6.00 hereby authorize representatives of this city to enter upon the ahove-mentioned property for inspection purposes. g01 LER-COMP(Over 100,000 BTU)SEE FEE SCH. MECHANICAL (We) agree to save, indemnify and keep handless the City of MISC.- REFER TO ORD. Cupertino against liabilities,judgments, costs and expenses which PERMIT ISSUANCE 10.00 CONST.TAX may In any way Selma against said City in consequence of the granting Ofjhis pep}1it. MECH.CONT. LIC.NO. MECH. Ix. t C0 �. .y _Z 4 G TOTAL TOTAL ignature of Applicant/Contractor - Date OFF ICE COPY-- APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY '►- BUI LDI NG PROJECT I DENTI FICATION PERMIT NUMBER BUILDING APPLICATION & PERMIT Y aoOREss BUILDING-ELECTRICAL-PLUMBING-MECHANICAL 10992 OWNER'S PLAN CHECK VALIDATION NAMEvELECTRIC PERMIT FEE/✓1MT+^' W✓. PHONE °�• CONTRACTOR'S ['-/L JOUTLETS-SWITCHES-RECEP 10.00/1.00 NAME Gp hLcy.M,i- LIC.NO. �/ LIGHTING FIXTURES 10.00/1.00 CONTRACTOP sAPPLIANCES-RESIDENTIAL 4.00 ADDRESS "� PNONE Z;,k V7/ d'C - PANELS 10.00 GATE OF APPLICATION ARCHITECT PANELS (OVER 200 AMP). 20.00 ENPLAN CHECK FEE P.C.N0. OR GINEER LIC.No. SIGNS TRANS. 3.00 ARCHESS OR ENG SPECIALCIRCUIT 5,00 PERMIT VALIDATION Zap EMP.METER OR POLE INS. 20.00 ` APPLI SZMOTORS SEE FEE SCH. ADDRESS ✓✓✓��////// VA' SERVICE CHANGE2 .00 woo LICENSED CONTRACTORS DECLARATION a z W I hereby affirm Thal I nm licensed under provisions of Chapter 9 ISSUANCE DATE ¢ a (commencing with Section 7000)of Division 3 of the Business and BLDG. ELECT. PLG. MECH. H w i Professions Code,and my license is in full force�rrsl a t. s ❑ ❑ ❑ o o License Cha};, '- -/ Cin. ractor _a t Q Date._:-4. /7.-- Lie.Noor_ '(�`O Q y i J ` t ¢ ¢ ¢ OWNER-BUILDER DECLARATION Ot vQp BUILDING PERMIT r o a u INFORMATION X g LL r I hereby affirm that I am exempt from the Contractor's License MISC.- REF TO ORD M VALUATION $/FT. H ¢ OJ Law for The following reason.(Sec.7031.5,Businessand Professions PERMIT ISSUANCE OCA u Code:Anycily crcounty which requires a permit to construct,alter, 10.00 .(� Q a,It Q Improve,demolish,or repair any structure,prior to Its Issuance,also ELEC,CONTR. LIC.NO. ELEC. cD ¢ requires the applicant for such permit to file a signed statement that / TOTAL wm°' he is licensed pursuant to the provisions of the Contractor's License PERMIT TO H 2 a Law(Chapter 9(commencing wit it Section 7000)ofDivision3offal �LLr� Business and Professions Code)or that he is exempt therefrom and QTY , PLUMBING PERMIT FEE M I=-$ ,.the basis for the alleged exemption.Any violation of Section 7031.$ STORIES TYPE CONSTR. by any applicant for a permit subjects the applicant to a civil penalty ALTER-DRAIN&VENT-WATER (EA.) 5.00 of not more than five hundred dollars($500).): ❑ I,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, Business and Professions DRAINS-FLOOR,ROOF,AR EA,COND. 5.00 Code:The Contractor's License Law does not apply to an owner of property who builds or improves thereon,and who does such work FIXTURES-PER TRAP 5.00 SO.FT,FLOOR AREA TOTALACREAGE memsare of ugh intend, own employees,provided,Ifliow"e,ueh improve- GAS-EA.SYSTEM-1 1NC.4 OUTLETS 6.00 mems are not intended or offered for sale.If,mpleven the building or improvement is sold within one year of completion,the owner. GAS-EA.SYSTEM-OVER 4 (EA.) 2.00 builder will have the burden of proving that he Aid not buil.)or int- BUILDING USE prove for purpose of sale.). INDUSTRIAL WASTE INTER. 30.00 RES IND CON PB ower ❑ I,as owner of the property,am exclusively contracting with ❑ ❑ ❑ ❑ ❑ licensed contractors to construct the project(Sec.7044,Business LAWN SPRINKLERS-1 INC 5 V.B. 6.00 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 forsuch projects with a eontomoxis)licensed pursuant to ' the Contractor's License Law, SEWER-SANITARY-STORM EA.200ft/10.00 TRACT NO. PARCEL NO. ❑ I am exempt under Sec.-,BAP.C.for This WATER HEATER W/VENT . 6.00 reason Owner Date WATER SYSTEM 5.00 ACC.DATE ACC,FILE NO, WORK F.RS'COMPENSAI'ION DECLARATION WATER TREATING EQUIP( 5.00 I hereby affirm that I have a certificate of consent to self-insure, or a certificate of Workers'Compensation Insurunce,or a certitied ZONING ENG.SITE NO. copy thereof(Sec.3800,Lab,C.l.� {a� Policy No.-Company'' /� 47z- _71 O ❑ Certified copy is hereby furnished. TPr ..T}jyy� y ~� FIRE SPRINK ENERGY T 24 Z 2 ❑ Certified copy Is filed will, the If Inspecdod dl Isio H Applicant r: �6_fy-Q /- MISC.- REFER TO ORD. Y❑ N❑ v ❑ N❑ LU - CERTIFICATE OF EXEMPTION FROM WORKERS' PERMIT ISSUANCE 10.00 RS' FLOOD ZONE a.L.U.C. W COMP � COMPIiNSATION INSURANCE. PLG.CONTR. LIC.N0. PLG. � Z (This section need net be completed if the permit is for one TOTAL Y[:] N❑ Y[:] N❑ hundred dollars(S 100)or less.) U O I certify that in the performance of the work for which this per. QTY. MECHANICAL PERMIT FEE FEE SUMMARY LL F mit is issued,I shall not employ any person in any manner ro as to - O L) become subject In the Workers'Compensation Laws of California. a Date - Applicant ALTER OR ADD TO MECH. 5.00 BUILDING >_ N NOTICE TO APPLICANT: If,after mki ang this Certificate of Ex- _ H 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 10=C.F.M.) 4,00 CONSTRUCTION LENDING AGENCY AIR HANDLING UNIT(OVER 10,000QEM.) 6.00 SEISMIC FEE 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.C.). HEATING UNIT(TO 100,000 B.T.U.) 8.00 Lender's Name )9 U T 0 VER 1 UN IT( EATING O00,00B. . . .50 Lender's Address H ELECTRIC 60-0 1 certify That I have read this application and slot,that the above VENTILATION FAN (SINGLE) 4.00 information is correct.1 agree to comply with all city and county PLUMBING ordinancesandstate laws relating to building construction, and BOILER-COMP(3 H.P.or 100,000 B.T.U.) 6.00 hereby authorize representatives of this city to enter upon the ahove-mentioned property for inspection purposes. g01 LER-COMP(Over 100,000 BTU)SEE FEE SCH. MECHANICAL (We) agree to save, indemnify and keep handless the City of MISC.- REFER TO ORD. Cupertino against liabilities,judgments, costs and expenses which PERMIT ISSUANCE 10.00 CONST.TAX may In any way Selma against said City in consequence of the granting Ofjhis pep}1it. MECH.CONT. LIC.NO. MECH. Ix. t C0 �. .y _Z 4 G TOTAL TOTAL ignature of Applicant/Contractor - Date OFF ICE COPY--