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09619APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY BU LDI NG PROJECT I DENTI FICATI ON APPLICATION &PERMIT BUILDING - ELECTRICAL -PLUMBING -MECHANICAL PERMIT NUMBER oa�� IL UD.DIN ESS AD OWNER'S NAME CITY. ELECTRIC PERMIT FEE PLAN CHECK VALIDATION /� / /d, PHONE 5 7 44 el NAMERAcrORs UTLETS-SWITCHES -RECEP 10.00/1.00 LIGHTING FIXTURES 10.00/1.00 r T LIC. No. c CONTRACTOR ' ADDRESS ADDRESS PPLIANCES- RESIDENTIAL 4.00 l _ PHON �, I p ., _ DATE OF APPLICATION PANELS 1 O.00 p� ORX/ ' ,L A J1 ENGINEER T 'J LIC. NO. PANELS (OVER 200 AMP) 20.00 PLAN CHECK FEE P.C. N0. SIGNS TRANS. 3.00 ARCH. OR ENG ARCHER SPECIAL CIRCUIT 5.00 PERMIT �Llp'TION ,/ D ZIP AA SEP L� FFEMP. METER OR POLE INS. 20.00+ APPLICANTS ADDRESS MOTORS SEE FEE SCH. s /7 1JV5 VJ City of Cupertino SERVICE CHANGE 20.00 LICENSED CONTRACTORS DECLARATION TEMP. POLE 30.00 I hereby affirm that I am liecnsnd under provisions .(Chapter 9 (commencing with Section 7000) of Division 3 of the Business anti Professions Code, and my license is in full force and effect License Classe°Io-G.d;1 Lic. Number Dituf- - / o - A 9 -.A L. -i _Contractor ISSUANCE DATE BLDG. ELECT I PLG. MEI JJ ❑ ❑ ❑ t S9 -.3'B 0WN1: R!iL41rA) TIONBUILDING PERMIT' R- EC LA RA I hereby collo that I and exempt from the Contractor'snPrLicense Code:Law ny citylowingreason.(h requiJse perminess t tocodProfessions Code: Any city or county which rttWiresa permit to construct alter, INFORMATION MISC.- REFER TO ORD PERMIT ISSUANCE 10.00 VALUATION $/FT. ELEC. CONTE. LIC. NO. ELEC. TOTAL 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 Contractors License Law (Chapter 9 (commencing with Section 7000) of Division 3 of the E IT TO ' D Business and Professions Code) or that he is exempt therefrom and QTY. PLUMBING PERMIT FEE the basis for the alleged exemption. Any violation of Section 7031.5 STORIES TYPE CONSTR. by any applicant for a peroul subjects the applicant to a civil Pcnslly ul Rol more than five hundred d0lars($500)J: ALTER -DRAIN -WATER IEA.) 5.00 0 1, as owner of the property, or my employees wish wages as their sole compensation, will do the work, and the st nrotere is not BACK F LOW PROTECT. DEV ICE 4.00 OCC. CROUP 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 docs not apply to an owner of F IXTURES - PER TRAP 5.00 property who builds or improves thereon, and who does such work himself or through his own employees, provided that such improve- mentsarenotintendedoroffered for sale. If, however. the building SOFT. FLOOR AREA TOTAL ACREAGE GAS - EA. SYSTEM - I INC.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.).INDUSTRIAL ❑ I, as owner of the property, am exclusively contracting with GAS - EA. SYSTEM -OVER 4 (EA.) 2.00 BUILDING USE E IND CON PB Omer ❑ El ED 0 WASTE INTER. 3000 . licensed contractors to construct the project (Sec 7044, Business and Professions Code: T'he Contractor', License Low dues not apply to :in owner of properly who builds or improves thereon, and who LAWN SPRINKLERS- 1 INC 5 V.B. 6.00 ASseSSOHri PARCEL NO. LAWN SPRINKLERS - OVER 5 (EA.( 1.00 contracts for such projects with a contmctods) licensed pursuant to 11¢ Contractors License Law. SEWER -SANITARY -STORM EA. 200ft/10.00 TRACT NO. PARCEL NO. ❑ Inco exempt under Sec.-. BAP.C. for this oralmi WATER HEATER W/VENT 6.00 Owner Date WATER SYSTEM 5.00 ACC. DATE ACC. FILE NO. WORK ERS'COMPI �NSATION DECLARATION WATER TREATING EQUIP. 5.00 I hereby affirm that I have a crai ficale ofconsent to self -insure. or a Certificate of Workers' Compensation Insurance, or a certified ZONING ENG. SITE NO. copy thereof (Sec. 380QLab Cfpany . Policy No. f]y copy , nnpany ed. �� Certified copy uherehy furnished. ad' Certified copy is fled with the city inspection division. Applicant FIRE SPRINK v[] N❑ ENERGY T24 vED NE] MISC.- REFER TO ORD. Ch RTIFICATF.OF EXEMPTION FROM WORKI. RS' PERMIT ISSUANCE 10.00 FLOOD ZONE A.L.U.C. COMPF.NSAT70N INSURANCE 1' I' his. section need not be completed if the permit is for one Y NEl Y 0 IN PLG. CONTE. LIC. NO. PLG. TOTAL handfed dollars IS 100) or less.) I certify that in the performance of the work for which this per- mil is issued, I shall not employ any person in any manner so as to (ITV MECHANICAL PERMIT FEE FEE SUMMARY BUILDING beco is subject to the Workers' Compensation Laws of Calitisrnia. Dam Applicant ALTER OR ADD TO MECH. 5.00 NOTICE TO APPLICANY: If, after making this Certificate of Ex- APPLIANCE 5.00 PLAN CHECK FEE iniplion, 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. AIR HANDLING UNIT (TO 10MC.F.M.) 4.00 AIR HANDLING UNIT (OVER 10=C.EM.) 6.00 SEISMIC FEE CON'STRUCfION L17NDING AGENCY I hereby affirm that there is a construction lending agency for lire performance of the work for which this permit is issued (Sec. 3097, Civ.C.). Lender's Name Lender's Address EXHAUST HOOD (WITH DUCT) 5.00 p )j MICROFILM HEATING UNIT (TO 100,000 B.T.U.) 8.00 p Gd HEATING UNIT (OVER 100,000 B.T.U.)9.50 ELECTRIC VENTILATION FAN (SINGLE) 4.00 n„ �.r-G I certify that I have read 1 r<app kation information is correct. I agree to comply with all city anJ county ordinances and state laws relating to building construction, and PLUMBING BOILER-COMP(3 H.P. or 100,000 B.T.U.) 6.00 BOILER -COMP (Over 100,000 BTU) SEE FEE SCH. MECHANICAL 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 may in any way accrue against said City in consequence of the gramin of this permit. MISC. - REFER TO ORD. PERMIT ISSUANCE 10.00 / nn CONST. TAX MECH. CONT. LIQ NO. MECH. ' TOTAL 3 5 -0U TOTAL . Igo "I re Applicant Con Dict., ate INSPECTOR COPY 0 Z LU CL 0 V LL 0 H LIE APPLICANT TO FILL. IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY BUILDING PROJECT IDENTIFICATION PERMIT ELECTRICAL- PLUMBING - MECHANICAL PERMITNUMB£R p 9 619 BUILDINGAPPLICATION ADDRESS ' lz2, BUILDING OWNER'S NAME lLJPHONES-71 1'T. QTY. ELECTRIC PERMIT FEE PLAN CHECK VALIDATION NONTRACTbR•s - NAME OUTLETS -SWITCHES-RECEP 10.00/1.00 LIGHTING FIXTURES 10.09/1.00Ic. No. CONTRACTOR'SAPP ADDRESS LIAN_CES-RESIDENTIAL 4.00 PANELS 10.00 DATE OF APPLICATION ARCHITECT .t ' ORENGINEER LIC. No. PANELS IOVER 200 AMP) 20.00 PLAN CHECK FEE P•C. NO. SIGNS TRANS. 3.00 ARCH. OR ENG. SPECIALADDRESS CIRCUIT 5.00 PER TION TEMP. METER OR POLE INS. 20,00ZIP n ,( pSEPtil41985 CRY of Cupertino APPLICANT'S ADDRESS MOTORS SEE FEE SCH. SERVICE CHANGE 20.00 LICENSED CONTRACTORS DECLARATION TEMP, 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 Coe and my license is in full force and effect. Lic. Number 3 t S'• -Contractor ISSUANCE DATE BLDG- 0 ELECT. E PLG. M OWNER -BUILDER DECLARATION I hereby affirm that I am exempt from the Contractor's License Law for the following reason. (See. 7031.5, 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 requires the applicant (or such permit to file_ a signed statement that he is licensed pursuant to the provisions of the Contractor's License BUILDING PERMIT' INFORMATION MISC. - REFER TO ORD VALUATION PERMIT ISSUANCE 10.00 ELEC. CONTR. LIC. NO. EIEC. TOTALE 1T 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 STORIES TYPE CONSTR. the basis for the alleged exemption. Any violation of Section 7031.5 by any applicant for a permit subjects the applicant toa civil penalty of not more than five hundred dollars ($500).): ALTER DRAIN &VENT -WATER IEA.] 5:00 I, 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 properly who builds or improves (hereon, 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 FIXTURES - PER TRAP 5.00 SO. FT. FLOOR AREA TOTAL ACREAGE GAS - EA. SYSTEM - 1 INC.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 GAS - EA. SYSTEM -OVER 4 {EA.) 2,00 BUILDING USE IND CON PB Other INDUSTRIAL WASTE INTER. 30,00 LAWN SPRINKLERS - 1 INC 5 V.B. 6.00licensedcontractorstoconstructtheproject (Sec. 7044, Business and Professions Code: The Contractor's License Law docs not apply Io an owner of property who builds or improves thereon. and who ASSESSORS PARCELNO. LAWN SPRINKLERS - OVER 5 (EA.) 1.00 contracts for such projects with a contractor(s) licensed. pursuant to the Contractor's License Law. SEWER SAN ITARY-STORM EA. 200ft/10,00 TRACT NO. PARCEL NO. El I am exempt under Sec. B.&P.C. for [tis reason WATER HEATER W/VENT 6.00 Owner Date WATER SYSTEM 5.00 ACC.DATE ACC. FILE N0, WATER TREATING EQUIP, 5.00WORKERS'COMPENSATION DECLARATION 1 hereby affirm that i have a certificate of consenL to self -insure, or a certificate of Workcrs' Compensation Ins u ce, or a cern lied ZONING ENG. SITE NO. copy thereof (Sec. 3800, Lab.C.). Polic o.P Ompany FIRE SPAINK Y E] N ENERGY T-24 Y N[] t ertified copy is hereby furnished. Certified copy is Filed with the city inspection division. Applicant MISC. - REFER TO ORD. CERTIFICATE OF EXEMPTION FROM WORKERS' PERMIT ISSUANCE 10-001 FLOOD ZONE A.LUX. PLG. CONTR. LIC. NO. PLG, TOTAL COMPENSATION INSURANCE This section need not be completed if the permit is for one Y N 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 become subject to the Workers' Compensation Laws of California. Date Applicant BUILDINGALTERORADDTOMECH. 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 10,13M C.F.M.) 4.00 AIR HANDLING UNIT (OVER 10=C.F.M,) 6.00 SEISMIC FEECONSTRUCTIONLENDINGAGENCY I hereby affirm that there is a construction lending agency for EXHAUST HOOD (WITH DUCT) 5.00 p0 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 cf-zV UNIT (OVER 100,000 B.T.U.)9.5D ELECTRIC Lender's Name. HEATINGLender's Address certify that I have read This application and state that the above VENTILATION FAN (SINGLE) 4.00 ap information is correct. I agree to comply with all city and county ordinances, and state laws relating to building construction, and PLUMBING BOILER -COMP (3 H.P. Or 100,000 B.T.U.) 6.00 BOILER -COMP lover 100,000 BTU) SEE FEE SCH. MECHANICALherebyauthorizerepresentativesofthiscitytoenteruponthe above-mentioned property for inspection purposes. MISC. - REFER TO ORD. We) agree to save, indemnify and keep harmless the City of Cupertino against liabilities, judgments, costs and expenses which' may in any way accrue against said City in consequence of the, CONST. TAXPERMITISSUANCE10.00 /0.00 gr nti of this permit. MECH. CONT. LIC- NO, MECH. 9 , TOTAL 3 6--ve TOTAL Sign Applicant(Contractor Date OFFICE COPY