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8204❑ er z F00 Q U U H Z W N Q N 0 W Z Z EA -0 W H W Y E J cc < O a U LL y LL O Q y J W Y tr <0 Q XO LL W m N ~ Z a ? x ❑ ¢1-0 W 3 m O Z P 0 = - LU CL :) Z UO_ LL Ow CL >_ rn F_ Z a, APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY BUILDING PROJECT IDENTIFICATION APPLICATION & PERMIT BUILDING - ELECTRICAL- PLUMBING - MECHANICA PE MIT NUMBER 8204 BUILDING /A /u}.U� ADD 99 OWNER'S NAME • ;V10 44,-,,/40 40 4 404 Go C". r '. - �LECTRIC.PERMIT ^ °° _ PLAN CHECK VALIDATION DATE OF APPLICATION CONTRACTOR'S NAME /� o An- AIveLIC.NO. *7/ZIf UTLET - SWITCHES - RECEP 10.00/1.00 L NG FIXTURES 10.00/1.00 CONTRACTOR 'S Q SI��� Gr A�DDRESS 101 -401 s .Se o PHONE ,.7 Z PPLIANCES - RESIDENTIAL 4.00 1PANELS 10.00 ARCHITECT OR ENGINEER Llc. No. PANELS (OVER 200 AMP) 20,00 PLAN CHECK FEE P.C. NO. SIGNS TRANS. 3.00 ARCH. OR ENG. ADDRESS ZIP SPECIAL CIRCUIT �j,QQ PERMIT VALIDATION PAID TEMP. METER OR POLE INS. 20.00 APPLICANT'S ADDRESS ,V,9 6OW4$0 C%. MOTORS SEE FEE SCH, SERVICE CHANGE 20.00 LICENSED CONTRACTORS DECLARATION TEMP. POLE 30.00 1 hereby affirm that 1 am licensed under provisions of Chapter 9 ISSUANCE DATE (commencing with Section 7000) of Division 3 of the Business and Professions Code nd m license is in full fOTCC.811A c License Class • Lic. Number L CS PLG. M1 O MECH. 1:1 Dat Contractor C -. c'pT OWNER - BUILDER DECLARATION I hereby ffirm that I am exempt from the Contractor's License y p Law for the following reason. (Sec. 7031.5. 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 Law (Chapter 9 (commencing with Section 7000) of Division 3 of the Business and Professions Code) or that he is exempt therefrom and 1©N MISC. - REFER TO ORD VALUATION 10 (/(/ $ /FT. PERMIT ISSUANCE 10.00 ELEC. CONTR. LIC. NO. ELEC. TOTAL PERMIT TO OTY/. PLUMBtNdl PERMIT STORIES TYPE CONSTR. the basis for the alleged exemption. Any violation of Section 7031.5 ALTER -DRAIN & VENT -WATER (EA.) 5.00 by any applicant for a permit subjects the applicant to a civil penalty of not more than five hundred dollars (5500).): ❑ 1, as owner of the property, or my employees with wages as their sole compensation, will do the work, and the structure is not intended or offered for sale (Sec. 7044, Business and Professions BACK FLOW PROTECT. DEVICE 4.00 OCC. GROUP RES. UNITS DRAINS - FLOOR, ROOF, AREA, 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 TOTAL ACREAGE himself or through his own employees, provided that such'Improve- ments are not intended or offered for sale. If, however, the building GAS - EA. SYSTEM -1 1 NC. 4 OUTLETS 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 im- prove for purpose of sale.). ❑ 1, as owner of the property, am exclusively contracting with licensed contractors to 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 . . GAS EA. SYSTEM -OVER 4 (EA) 200 BUILDING USE RES IND CON PB Ocher ❑ ❑ ❑ ❑ ❑ INDUSTRIAL WASTE INTER. 30.00 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 L 0 SEWER- SANITARY -STORM EA. 200ft/10.00 TRACT NO. PARCEL NO. WATER HEATER W /VENT 6.00 ❑ lam exempt under S B. &P.C. for this reason Owner Date WATER SYSTEM 5.00 ACC. DATE ACC. FILE NO. WORKERS'COMPENSATION DECLARATION WATER TREATING EQUIP. 5.00 1 hereby affirm that I have a certificate of consent to self- insure, or a certificate of Workers' �C�ompensaPion Insurance, or a certified col Polic N - AL 4:&Ama N* *201 ZONING ENG. SITE NO. y PR' y Certirpev.py is he y f ished. FIRE SPRINK ENERGY T -24 Cert' led is f t ection division. A pl;cant Y ❑ N ❑ Y ❑ N❑ MISC. REFER TO ORD. CE FICATE OF EXEMPTION FROM WORKERS' PERMIT ISSUANCE 10.00 FLOOD ZONE A.L.U.C. PLG. CONTR. LIC. NO. PLG. TOTAL COMPENSATION INSURANCE (This section need not be completed if the permit is for one v [J N ❑ v ❑ N ❑ P(erIi Fig �81t1fIMYI/tRY hundred dollars (S 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 manner so as to BUILDING Z5/. S% become subject to 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- emption, 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 LENDING AGENCY JAPPLIANCE 5.00 PLAN CHECK FEE �G'3rt T AIR HANDLING UNIT (TO 10,0MC.F.NL) 4,00 AIR HANDLING UNIT (OVER 10=C.F.M.) 6.00 SEISMIC FEE 3 EXHAUST HOOD (WITH DUCT) 5.00 MICROFILM I hereby affirm that there is a construction lending agency for the 3097. eCiv.C.jnce of the work for which this permit is issued (Sec. HEATING UNIT (TO 100,000 B.T.U.) 8.00 H EATI NG UNIT (OVER 100,000 B.T.U.) 9.50 ELECTRIC Lender's Name Lender's Address VENTILATION FAN (SINGLE) 4.00 PLUMBING 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 BOILER -COMP (3 H.P. or 100,000 B.T.U.) 6.00 BOILER -COMP (Over 10),000 BTU) SEE FEE SCH. MECHANICAL hereby authorize representatives of this city to enter upon the 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 any way accrue gainsIt said City in consequence of the anti L oft it. ��r �_Z¢�$ 5 PERMIT ISSUANCE 1000 MECH. CONT. LIC. NO. MECH. TOTAL ` TOTAL 41' 9� 56ature of Applicant /Contractor Date OFFICE.COPY -� o�z boo W U U FQ Z W N Q N 0yz ZN u F W ( Y J Cc O a U LL O Q N J W 1 Q Q O a O cc X O LL W co to � x o cc 0 a 3 m O Z Z F O CC - LLI > ao Z 0 LL U 0 >- N � Z i APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY BUILDING PROJECT I DENTI FICATION APPLICATION & PERMIT BUILDING - ELECTRICAL- PLUMBING - MECHANICA PE MIT NUMBER 8204 BUILDING i° SS2 Z>5 S 9� c 1v�. OWNER'S NAME Z ^ /y -a� DLG � JVRv C'iO PHONE aTY. : -- `' ELECTRIC PERMIT i - FEE PLAN CHECK VALIDATION DATE OF APPLICATION CONTRACTOR'S NAME //�f�� o.ov A+t,/�/ m- Aive..LIC.NO. '/?W UTLET - SWITCHES - RECEP 10.00/1.00 L NG FIXTURES 10.00/1.00 ADDRESS OR'Sra .S'alN &d GT; ADDRESS NvA71a.5 s; PHONE -7Z Z PPLIANCES - RESIDENTIAL 4.00 PANELS 10.00 ARCHITECT OR ENGINEER LIC. No. PANELS (OVER 200 AMP) 20.00 PLAN CHECK FEE P.C. NO. SIGNS TRANS. 3.00 ARCH. OR ADDRESS ENG. ZIP SPECIAL CIRCUIT 5.00 PERMIT VALIDATION i�s.rws ISSUANCE DATE EMP. METER OR POLE INS. 20.00 APPLICANT'S ADDRESS / � p�/W GiQ C7: /'/ /L���S T� MOTORS SEE FEE SCH. SERVICE CHANGE 20.00 TEMP. POLE 30.00 LICENSED CONTRACTORS DECLARATION I hereby affirm that 1 am licensed under provisions of Chapter 9 (commencing with Section 7000) of Division 3 of the Business and Professions Code nd m license is in full force �jf c1� License Class • Lic. Number ,*/� k Dat Contractor OWNER - BUILDER DECLARATION I 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 Law (Chapter 9 (commencing with Section 7000) of Division 3 of the Business and Professions Code) or that he is exempt therefrom and the 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 ($500).): ❑ 1, as owner of the property, or my employees with wages as their sole compensation, will do the work, and the structure is not intended or offered for sale (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 building 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 of sale.). ❑ 1, as owner of the property, am exclusively contracting with licensed contractors to 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 for such projects with a contractor(s) licensed pursuant to the Contractor's License L aw ❑ 1 am exempt under S B. &P.C. for this reason L .[. V PLG. O MECH. ❑ C{ F` Ot, UUPKMG PERMIT' INFORMATION MISC. - REFER TO ORD VALUATION �ij DD O� ((.� $ /FT. PERMIT ISSUANCE 10.00 ELEC. CONTR. LIC. NO. ELEC. TOTAL PERMIT TO r / %QC' % QTY. PLUMBING PERMIT' FEE, STORIES TYPE CONSTR. ALTER -DRAIN &VENT -WATER (EA.) 5.00 BACK FLOW PROTECT. DEVICE 4.00 OCC. GROUP RES. UNITS DRAINS - 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 RE S IND CON PB Other E [1 11 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/V ENT 6.00 Owner Date WORKERS'COMPENSATION DECLARATION 1 hereby affirm that I have a certificate of consent to self - insure, or a certificate of Workers' rk�Compensatpion Insurance, or ascertified copy the N ��`-/n7p'�y /�iTL Certif y is her y f fished. Certi ted is f t t in ection division. A plicant WATER SYSTEM 5.00 ACC. DATE ACC. FILE NO. WATER TREATING EQUIP, 5.00 ZONING ENG. SITE NO. FIRE SPRINK Y ❑ N ❑ ENERGY T -24 Y N� MISC. REFER TO ORD. CE FICATE OF EXEMPTION FROM WORKERS' COMPENSATION INSURANCE (This section need not be completed if the permit is for one hundred dollars ($100) or less.) I certify that in the performance of the work for which this per- mit is issued, I shall not employ any person in any manner so as to become subject to the Workers' Compensation Laws of California. Date Applicant PERMIT ISSUANCE 10.00 FLOOD ZONE Y N A. L. U. C. V N PLG. CONTR. LIC. NO. PLG. TOTAL QTY. MECHANICAL PERMIT FEE FEE SUMMARY BUILDING C 25h VOW, ALTER OR ADD TO MECH. 5.00 NOTICE TO APPLICANT: If, after making this Certificate of Ex- emption, you should become subject to the Workers' Compensation provisions of the Labor Code, you must forthwith comply with such provisions or this permit shall be deemed revoked. CONSTRUCTION LENDING AGENCY I hereby affirm that there is a construction lending agency for the performance of the work for which this permit is issued (Sec. 3097,Civ.C.). Lender's Name Lender's Address I certify that 1 have read this application and state that the above information is correct. I agree to comply with all city and county ordinances and state laws relating to building construction, and hereby authorize representatives of this city to enter upon the above - mentioned property for inspection purposes. (We) agree to save, indemnify and keep harmless the City of Cupertino against liabilities, judgments, costs and expenses which any way accrue gainst said City in consequence of the ranti g of t it. � �,, ^, 1-01ye.$ 5 V APPLIANCE 5.00 PLAN CHECK FEE �r 1103. " AIR HANDLING UNIT (TO 10=C.F.M.) 4.00 AIR HANDLING UNIT (OVER 10DWC.F.M.) 6.00 SEISMIC FEE S Oi EXHAUST HOOD (WITH DUCT) 5.00 MICROFILM HEATING UNIT (TO 100,000 B.T.U.) 8.00 H EATI NG UNIT (OVER 100,000 B.T.U.) 9.50 ELECTRIC VENTILATION FAN (SINGLE) 4.00 PLUMBING BOILER COMP (3 H.P. or 100,000 B.T.U.) 6.00 BOILER -COMP (Over 100,000 BTU) SEE FEE SCH. MECHANICAL MISC. - REFER TO ORD. CONST. TAX PERMIT ISSUANCE 10.00 MECH. CONT. LIC. NO. MECH. TOTAL TOTAL ? f 7. qa ature of Applicant /Contractor Date OFFICE COPY -�.�