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09539V. 0 2 Z N_ W 7LU — t1 0 UO LL U 0 a N F., z APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY BUILDING PROJECT IDENTIFICATION PERMIT BUILDING —ELECTRICAL— PLUMBING —MECHANICAL PERMITNUMBER 09539AQQ53 0--agi c OWNER'S NAME PIIS — PHONE QTY. ELECTRIC PERMIT FEE PLAN CHECK VALIDATION CONTRACTOR'S NAME. OUTLETS -SWITCHES -RECEP 10.0011.00 LIGHTING FIXTURES 10.0011.00I .Ne. CONTRACTOR'S ADORE APPLIANCES - RESIDENTIAL 4.00 PHONE PANELS 10.00 DATE OF APPLICATION ARCHITECT ENGINEER Lnc. Ne. PANELS ROVER 200 AMP) 20,00 PLAN CHECK FEE P.C. NO. SIGNS TRANS. 3.00 AARCH. ORDDRESS ENG. ZIP SPECIAL CIRCUIT 5.00 PERMIT VALIDATION PAID q gAUG :Z 3 7985 Aaertino TEMP. METER OR POLE INS. 20,00 APPLICANT'S ADDRESS MOTORS SEE FEE SCH. SERVICE CHANGE 20.00 LICENSED CONTRACTORS DECLARATION 1 hereby affirm that I am licensed under provisions of Chapter 9 TEMP. POLE 30.00 commencing with Section 7000) of Division 3 of the Business and amt F feProfessionsCoajilicenseisinfullforeells 7LicenseasLic. Number Date Contractor BLDG. ELECT, PL MECH. BUILDING RMIT INFORMATIONOWNER -BUILDER DECLARATION 1 hereby affirm that I am exempt from the Contractor's License 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 arty 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 MISC. — REFER TO ORD vaLuaTION SIFT. PERM IT ISSUANCE 10.00 ELEC. CONTR. LLC. NO. ELEC. TOTAL T TO QTY, PLUMBING PERMIT FEE1Law (Chapter 9 (commencing with Section 7000) ofDivision 3 of the Business and Professions Code) or that he is exempt therefrom and 4ESTYP CNSTR. 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).): ALTERDRAlN&VENT-WATER(EA} 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 BACK F LOW PROTECT. DEVICE 4,00 OCC GROUP RES. UNITS DRAINS -FLOOR, ROOF, AREA, COND. 5.00intendedorofferedforsale (See. 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 workTGAS-EA.SYSTEM-1 himself or through his own employees, provided that such improve- ments are not intended or offered for sate. If, however, the building F IXTUR ES - PER TRAP 5.0 SO. FT. FLOOR AREA TOTAL ACREAG9 INCA 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.). D 1, as owner of the property, am exclusively contracting with GAS - EASYSTEM -OVER 4 (EA) 200 BUILDING USE 5 IND CON PR Omer INDUSTRIAL WASTE INTER. 30,00 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 ASSESSORS PARCEL NO. LAWN SPRINKLERS - 1 INC 5 V.B. 6.00 LAWN SPRINKLERS - OVER 5 (EA.) 1,00 contracts for such projects with a contractor(s) licensed pursuant to the Contractor's License Law. SEPI=R-SANITARY-STORM EA, 200h/10.DD O TRACT NO. PARCEL NO. 1 am exempt under Sec. B.&P.C. for this WATER HEATER WIVENT 6.00 [7reason Owner Date I WATER SYSTEM 5.00 ACC. DATE ACC. FILE NO. WATER TREATING EQUIP. 5.00WORKERS'COMPENSATIONDECLARATION I 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 N0. copy thereof (Scc. 3800, Lab.C.). Policy No. Company FIRE SPRINK YE] N ENERGY T-24 Y N 7 Certl<ed copy is hereby furnished. rb( Certified ry is filed withrlbe city inspection division. Apph ant I I!CQ iiL-h -t] M15C. - REFER TO ORD. CERTIFICATE 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 Y N 0 Y N QTY. MECHANICAL PERMIT FEE FEE SUMMARY 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 become subject to the Workers' Compensation Laws of California. Date Applicant ALTER OR ADD TO MECH500 NOTICE TO APPLICANT: If, after making this Certificate of Ex- emption, you should become subject to the Workers' Compensation APPLIANCE 5.00 PLAN CHECK provisions of the Labor Code, you must forthwith comply with such provisions or this permit shall be deemed revoked. FEEAIRHANDLINGUNIT (TO 10=C.F.M.) 4.00 AIR HANDLING UNIT (OVER 10=C,RM.) 6.00 SEISMIC FEECONSTRUCTIONLENDINGAGENCY l 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. 3097,Civ.C.). MICROFILM HEATING UNIT (TO 100,000 B.T.U.) 8.00 HEATING UNIT (OVER 100 000 B.T.U.) ELECTRIC 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 stale laws relating to building construction, and VENTILATION FAN (SINGLE) 4.00 PLUMBING 60 BOILER -COMP (3 H.P. or 100,000 B.T.U.) 6.00 BOILER -COMP ,(Over 100,000 BTU) SEE FEE SCH. MECHANICALherebyauthorizerepresentativesofthiscitytoenteruponthe above-mentioned properly for inspection purposes. MISC. - REFER TO ORD. We) agree to save, indemnify and keep harmless the City of Cupertino liabilities, judgments, costs and expenses which may ' graTf tngrmit. Xyaccrue a ' st said ity in consequence the CONST. TAX PERMIT ISSUANCE 10.00 MECH-CONT. .LIC. NO. MECH, J / TOTAL TOTAL Signature of Applicant( ontractar f Date OFFICE COPY APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY BU LDI NG PROJECT IDENTIFICATION APPLICATION &PERMIT BUILDING - ELECTRICAL- PLUMBING - MECHANICAL PERMIT NUMBER 09539. LDIN MAADDRESS ,. s O NER'S rvnmE y�s - ` PTY. ELECTRIC PERMIT FEE PLAN CHECK VALIDATION ONE NAME Acro UTLETS- SWITCHES -RECEP 10.00/1.00 LIGHTING FIXTURES 10.00/1.00 12 a a NQ. DoRx REss ADDRESS PPLIANCES- RESIDENTIAL 4.00 PANELS 10.00 FHONE C _ C DATE OF APPLICATION ORRCHI Ec ENGINEER LIC. No, PANELS (OVER 200 AMP) 20.00 PLAN CHECK FEE P.C. N0. SIGNS TRANS. 3.00 ADDRESS ENG, SPECIAL CIRCUIT 5.00 PERMIT VAIjflP2111b EMP. METER OR POLE INS. 20.00 ZIP AUG�-J„� G 23 1985 ADDRESS APPLICANT'S MOTORS SEE_ FEE SCH. SERVICE CHANGE 20.00 City Of Cupertino ISSUANCE DATE BLDG. ELECT. PLG. MECH. LICENSED CON TRACTORS 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 Cod y and my license is in full force un fleet. License Class Lic. Number - TEMP. POLE 30.00 Datc�COntmctor PILDING RMIT BUILDINGA ION INFOR OWNER -BUILDER DECLARATION 1 hereby affirm that 1 am exempt from the Contractor's License Law for the following reason, (Ser. 7031.5, Business and ProfessionsPERMIT Code Any city or county which requires a Permit to constn¢L alter, MISC. - REFER TO ORD ISSUANCE 10.00 VALUATION $/FT. ELEC. CONTR. LIC. NO. ELEC. TOTAL Improve, demolish, Or repair any structure, prior In Its Issuance, alio requires the applicant for such permit to file a signed statement that he is licensed pursuant to the provisions of the Contractor's License E IT TO QTY. PLUMBING PERMIT FEE Law (Chaco, 9 (commencing with Section 7000) of Division 3 of the Business and Professions Code) or that he is exempt therefrom and I, the basis for the alleged exemption. Any violation of Section 7031.5 STORI TYPE CONSTR. by any applicant for a permit subjectsthe applicant to a civil penalty of not more than five hundred dollars (5500).1: .ALTER-DRAIN&VENT-WATER (EA.) 5.00 ❑ 1, as owner of the property, or my employees with wages as their sole compensation, will do the work, and the st... time is not BACK F LOW PROTECT. DEVICE 4.00 OCC. GROUP RES. UNITS DRAINS -FLOOR, ROOF, AREA, COND, 5.00 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, pvided that such improve- ro mentsareriotimendedoroffered for sale. If, however, the building F IXTUR ES - PER TRAP 5.00 C V SQ. FT FLOOR AREA TOTAL ACREAGE GAS - EA. SYSTEM -1 INC.4 OUTLETS 6.00 00 or improvement is sold within one year of completion, the owner- builder will have the burden of proving that he did not huild or im- provefor purpose ofsals.). ❑ I, as owner of the property, am exclusively contracting with GAS - EA. SYSTEM -OVER 4 IEA.) 2.00 'BUILDING USE IND CON PB Omer INDUSTRIAL WASTE INTER. 30.00 licensed contractors to construct the project (Sec. 7044, Ifusiness 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 LAWN SPRINKLERS - OVER 5 (EA.) 1.00 ASSESSORS PARCEL NO. contracts for such projects with a contractors) licensed Pursuant to the Contrac'tor's Licence Law. SEWER -SANITARY -STORM EA. 200ft/10.00 U O TRACT NO. PARCEL NO. ❑ lamexc'mPtunder See .B.&P.C,I,nthis WATER HEATER W/VENT 6.001 - OO reason Owner Date WATER SYSTEM 5.00 - (� ACF GATE ACG FILE N0, WATER TREATING EQUIP. 5.00 WORKERS'COMPF-N'SATION DECLARATION I hereby affirm that I have a certificate of consent to self -insure, or a certificate of Workers' Compensation Insunu cc, or a certified ZONING ENG. SITE NO. ropy thercof(Scc. 3800, Lab.CJ. Policy No. Company ❑ C.taifed copy is hereby furnished L enifcd vtpZas� 194wi�rt�e city inspclion division. Abp dant d FIRE SPRINK Y� N� ENERGY T 24 v� N� MISC- REFER TO ORD. CF: R' I'I PICATF, OF'EXF,m v rlON FROM WORKERS' PERMIT ISSUANCE 10.00 DO "OOD ZONE A.L.U,C. COMPIiNSA1'ION INSURANCE IThis section need not be completed if the permit is for one v N Y N PLG. CONTR. LIC. NO. PLC. TOTAL CV hundred dollars (5100) or less.) I c,Rify turn in the performance of tire work for which this per mit is issued, I shall not employ any person in a iy Inanner so as to QTY. MECHANICAL PERMIT FEE FEE SUMMARY BUILDING become subject to the Workers' Compensation Laws of California. Date ApplicantALTER OR ADD TO MECH. 5.00 NOTICE: TO APPLICANT: If, after making this Certificate of lix- emplion, you should become subject to the Workers' Compensation provisions of the Labor Code, you most forthwith comply with such provisions or this permit shall be deemed revoked. APPLIANCE 5.00 AIR HANDLING UNIT (TO 10MC.F.M.) 4.00 PLAN CHECK FEE AIR HANDLING UNIT(OVER 10=C.F.M.) 6.00 SEISMIC FEE CONSTRUCTION LENDING AGENCY 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. 3097, Civ.C.). MICROFILM HEATING UNIT (TO 100,000 B.T.U.) 8.00 Lender's Nam. Lender's Address HEATING UNIT (OVER 100,000 B.T.U.)9.50 ELECTRIC VENTILATION FAN (SINGLE) 4.00 I certify flirt l 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 vL/ BOILER -COMP (3 H. P. Or 100,0006.T.U.) 6.00 BOILER -COMP Mini, 100,000 BTUI SEE FEE SCH. MECHANICAL hereby authorize representatives of this city to enter upon the above-mentioned property for inspection purposes. MISC. - REFER TO ORD. PERMIT ISSUANCE 10.00 CONST. TAX (We) agree to save, indemnify and keep harmless the City of Cupertino against liabilities, judgments, costs and expenses which may in any IWy recruit .1 sl said ity m consequence of the granting f th' pernit. MECH. CONT. LIC. NO. MECH. TorAL TOTAL SaWarcrF.1 l pp hCant/ -o o / D'atC, INSPECTOR COPY V. 0 2 Z N_ W 7LU — t1 0 UO LL U 0 a N F., z APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY BUILDING PROJECT IDENTIFICATION PERMIT BUILDING —ELECTRICAL— PLUMBING —MECHANICAL PERMITNUMBER 09539AQQ53 0--agi c OWNER'S NAME PIIS — PHONE QTY. ELECTRIC PERMIT FEE PLAN CHECK VALIDATION CONTRACTOR'S NAME. OUTLETS -SWITCHES -RECEP 10.0011.00 LIGHTING FIXTURES 10.0011.00I .Ne. CONTRACTOR'S ADORE APPLIANCES - RESIDENTIAL 4.00 PHONE PANELS 10.00 DATE OF APPLICATION ARCHITECT ENGINEER Lnc. Ne. PANELS ROVER 200 AMP) 20,00 PLAN CHECK FEE P.C. NO. SIGNS TRANS. 3.00 AARCH. ORDDRESS ENG. ZIP SPECIAL CIRCUIT 5.00 PERMIT VALIDATION PAID q gAUG :Z 3 7985 Aaertino TEMP. METER OR POLE INS. 20,00 APPLICANT'S ADDRESS MOTORS SEE FEE SCH. SERVICE CHANGE 20.00 LICENSED CONTRACTORS DECLARATION 1 hereby affirm that I am licensed under provisions of Chapter 9 TEMP. POLE 30.00 commencing with Section 7000) of Division 3 of the Business and amt F feProfessionsCoajilicenseisinfullforeells 7LicenseasLic. Number Date Contractor BLDG. ELECT, PL MECH. BUILDING RMIT INFORMATIONOWNER -BUILDER DECLARATION 1 hereby affirm that I am exempt from the Contractor's License 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 arty 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 MISC. — REFER TO ORD vaLuaTION SIFT. PERM IT ISSUANCE 10.00 ELEC. CONTR. LLC. NO. ELEC. TOTAL T TO QTY, PLUMBING PERMIT FEE1Law (Chapter 9 (commencing with Section 7000) ofDivision 3 of the Business and Professions Code) or that he is exempt therefrom and 4ESTYP CNSTR. 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).): ALTERDRAlN&VENT-WATER(EA} 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 BACK F LOW PROTECT. DEVICE 4,00 OCC GROUP RES. UNITS DRAINS -FLOOR, ROOF, AREA, COND. 5.00intendedorofferedforsale (See. 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 workTGAS-EA.SYSTEM-1 himself or through his own employees, provided that such improve- ments are not intended or offered for sate. If, however, the building F IXTUR ES - PER TRAP 5.0 SO. FT. FLOOR AREA TOTAL ACREAG9 INCA 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.). D 1, as owner of the property, am exclusively contracting with GAS - EASYSTEM -OVER 4 (EA) 200 BUILDING USE 5 IND CON PR Omer INDUSTRIAL WASTE INTER. 30,00 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 ASSESSORS PARCEL NO. LAWN SPRINKLERS - 1 INC 5 V.B. 6.00 LAWN SPRINKLERS - OVER 5 (EA.) 1,00 contracts for such projects with a contractor(s) licensed pursuant to the Contractor's License Law. SEPI=R-SANITARY-STORM EA, 200h/10.DD O TRACT NO. PARCEL NO. 1 am exempt under Sec. B.&P.C. for this WATER HEATER WIVENT 6.00 [7reason Owner Date I WATER SYSTEM 5.00 ACC. DATE ACC. FILE NO. WATER TREATING EQUIP. 5.00WORKERS'COMPENSATIONDECLARATION I 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 N0. copy thereof (Scc. 3800, Lab.C.). Policy No. Company FIRE SPRINK YE] N ENERGY T-24 Y N 7 Certl<ed copy is hereby furnished. rb( Certified ry is filed withrlbe city inspection division. Apph ant I I!CQ iiL-h -t] M15C. - REFER TO ORD. CERTIFICATE 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 Y N 0 Y N QTY. MECHANICAL PERMIT FEE FEE SUMMARY 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 become subject to the Workers' Compensation Laws of California. Date Applicant ALTER OR ADD TO MECH500 NOTICE TO APPLICANT: If, after making this Certificate of Ex- emption, you should become subject to the Workers' Compensation APPLIANCE 5.00 PLAN CHECK provisions of the Labor Code, you must forthwith comply with such provisions or this permit shall be deemed revoked. FEEAIRHANDLINGUNIT (TO 10=C.F.M.) 4.00 AIR HANDLING UNIT (OVER 10=C,RM.) 6.00 SEISMIC FEECONSTRUCTIONLENDINGAGENCY l 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. 3097,Civ.C.). MICROFILM HEATING UNIT (TO 100,000 B.T.U.) 8.00 HEATING UNIT (OVER 100 000 B.T.U.) ELECTRIC 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 stale laws relating to building construction, and VENTILATION FAN (SINGLE) 4.00 PLUMBING 60 BOILER -COMP (3 H.P. or 100,000 B.T.U.) 6.00 BOILER -COMP ,(Over 100,000 BTU) SEE FEE SCH. MECHANICALherebyauthorizerepresentativesofthiscitytoenteruponthe above-mentioned properly for inspection purposes. MISC. - REFER TO ORD. We) agree to save, indemnify and keep harmless the City of Cupertino liabilities, judgments, costs and expenses which may ' graTf tngrmit. Xyaccrue a ' st said ity in consequence the CONST. TAX PERMIT ISSUANCE 10.00 MECH-CONT. .LIC. NO. MECH, J / TOTAL TOTAL Signature of Applicant( ontractar f Date OFFICE COPY