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2098 861 Z �d� PERMIT NUMBER 1 020 9� FOR APPLICANT TO FILL IN ONIla3d STREET ADDRESS OF PROJECT: r � .. .................................. Plans Received By....._._..._ Date ............. Legal Description: Tract....n....... ...._ Block............ Ot.. .. ..I........... REQ.: Plans_.. Survey.... Calcs: Struc..... Energy.... Elect.....Yee .... Description of Work: ...../.T..E!Qd.U/=_..cONr___,[jL(�(T___......... Plans Checked By .. . .-. . ...Date yI' tat Struct. Improvement on Parcel: Yes No..-. Area of Bldg._ ... Application Approved By .. ... Date 7 $eparate Structure ...... or Addition/Alteration to Exist Bldg ... Validated By........ .. - ...Date .. ....._.. .. No. of Stories-__ .... J uil ing _ ....... ...... r�c ... Compensation Certificate Verified By................... Date ......................... ValuatiofP.ro1'ect: $.c7, .Phone: • . • • • $ .3 9,6 0, Ownerc.LOY/}�l.L./�i2Q .r.�DR�......._...... Phone:._................ Permit Fee jus snail if a licable Contractor P_C.Zt/.... .."".! ... City Bus.Lic.#......___. (P penalty applicable') ........................$.. .....�........... Address: Q ..•G//7 Phon ........ Plan Check Fee (less deposit of $....... Rct. #.. ""-"""---"" """"""""""-'"""" ° - `�"� """��""")$""""""""�"""'��'"'��" ;111 Contractor - Electrical: ......._....... ' Energy Plan Check Fee (Dep. of $........ Rct. #........)$_.............. ....................... ......... .................... Strong Motion Fee _.................................................._....$............ .S-U City Business Liceensense #............._.._. Phone::....:................ i "' Plumbing: Plumbing Permit Fee $.._._..._........... ..._._.........icense #._............_.._.._...ne:.................... ..........._..............._...._........... City Business License #.................... Phone:.................... Electrical Permit Fee ......................................._....__....$........_............ Heating and Cooling Mach. Htg./Coolg. Permit $ ....................... ._.......#......_....................... :............_.._.. :......$.._..__............. City Business License #.................... Phone:.................... Construction Tax....................................: .......$._...............___ Architect/Designer: ._,_....... .................................... Phone:..... Sewer Conn. Fee ........:..... Water Conn. Fee .._.._...-_$....................... Engineer: ..........__........ Phone:................ Landscape Fee .................... Street Tree Fee ............$............. Lender: Q...n nown Misc. Fee _.............___.................................................$......_._...... .. "I certify that In the performance of the work for which this Permit Is • § �� issued I shall not employ any person In any manner so as to become subject • to the workman's compensation laws of California." Type Const......... Group........ Div......... Occ. Load........ No, Exits........ SIGNATURE OF Floor Loads: 1st..-. 2nd.... Other_.. Sprinklered.... Area Sep, Walls.... APPLICANT/OWNER ...... .............................._.......................... DATE ... ............ 1 certify that as the applicant I am licensed under the pIqqn��of e Contractoro Licens ew n further that my License No?(CT`jC,'bk�....... DesigEnviron Review Status: Exempt ............ Other...__...._.. Sign ............ in Classification _. .C/'............_. Is In full force and effect: or Design R8VI8W Approval: Bldg. ..:......... Site ............ Sign �"- I certify that I m exempt from the "Licensed Req.'•ad" provisions of the "' Contractors License Law. (State basis of exemption., Use . Use ............Pmit P.D. Conditions ince ......_ arki:................_..:._.__............... I hereby acknowledge that I have read this application end state that the above le Cond. Use Permit #...... Variance #...... Parking Spaces.... Load. Sp..... correct and agree to comply with all City Ordinances and State Laws regulating Approved By..............._..............._............. Date ..........-................ - building. _ I two) agree to save, indemnify and keep harmless the City of Cupertino • • s against liabilities, judgments, costs and expense hich may In any way • acture against said City in a e h gra ing of this permit. 1C/08Chm80f Permit... Grant of Easement......__........._... SIGNATURE OF Curb, Gutter, Sidewalk,. Driveway: Replace Repair APPLICANT/CONTRACTOR .. . ...... .._............... ............................ Sewer............ Conn. Fee $...._.......... Water.._........... Meter $................ NOTE: When properly vat I• form consuluNs a Sullding Permit. ,This Agreement for Completion of Public Works Improvements .................. permit expires and becomes out valid should work not be commenced within Plans Checked By........ Date........ Approved By._..... Date..........___... 120 days from validation date, or should authorized construction be suspended or abandoned for a period of 120 days after work Is commenced. APPLICATION FOR PLUMBING PERMIT PERMIT INSTALLATION NO. EACH FEE Light Outlets............ Switches............ PERMIT INSTALLATION NO. EACH FEE Fixtures............ Receptacles............ Gas Sytem with up to 5 outlets ....................................$4.00 ............. TOTAL NUMBER(less than 1000 watts).... .................$ :50 Each additional outlet .........____.....:..................... 1.00 ............. Range........ Cooking Unit........ Oven........... ___ _ __ 2.00 ............... Water System (Installation, Alt. or Repair) ....._.......... 4.00.............. Dryer....Garb. Disp..... Dishwasher.... ........ ................. 2.00 . .............. Water Closet.... Water Heater.... Ld. Tray.................... 4.00.............. SERVICE OR TEMPORARY POWER to ............ .... 2.00 . .............. Lavatory.... Shower Pan.... Bathtub.... Sink.................. 3.00".........I... . . 100 amp/$5.00, 200/$7.00, 500/$9.00 Wash. Mach..... Dishwasher.... Garb. Disp..... .............. 3.00 800/$20.00 1200/$40.00 .............____........._-...................:........... Sewer .... 8.00. .............' .......................................................................... MOTORS,Generators,Welders, Heaters, Lawn Sprinkler Sys. $6.00 Ea. add Sys. $2.00..................................... per HP-KW-KVA to 1/$2.00, 5/$3.50, Vacuum Breakers ............................................ ............. 4.50.............. 20/$6.50, 50/$10.00, 100/$12.00, Slop Sink........ Floor Sink........ Floor Drain ................ 4,00.._.......... . 500/$15.00 ............................................... ._...._.._-............................... Urinal.._ Interceptor.... Water Softener.... ................._... 4.00 ............. Signs with I XFMR .._......._.......................... ................ 2.00 -"" -"..." Plumbing Piping without fixtures ... ... 4.00 __.._.._.. Each additional XFMR/Time Clock .. .............. ... .90 .. .............. Misc. ................................................................................................---........ Annual Electrical Maintenance . ...._.......... 25.00. ..._..._..__ Permit Fee ........................................$ 8.00 Other (see Ordinance Current) ....__...__.................._........._...-............. TOTAL PLUMBING PERMIT FEE (plus penalty if app. p) $ _ _._.._ ........................................__....._._.........._................._..__._............ APPLICATION • • HEATING/COOLING Permit Fee ........................................................................ $ 6.00 PERMIT INSTALLATION NO. EACH FEE TOTAL ELECTRICAL PERMIT FEE (plus penalty,if app.❑) $ Forced Air Unit...............to 100M ................................. $ 6.00 INSPECTION RECORD over 100M ............................. 10.00 .............. Comfort Cooling Unit.....to 3 ton/HP............................ 6.00 ............... Forms / Foundation............................... By:.................. Date:................. to 15 ton/HP........................... 9.50 ............... Plumbing Ground Work'......................... ................................................... to 30ton/HP................ ..........12.00 ............... Agodl&ugh Electrical ..................................... ................................................... to 50 torl.......................... 17.00 ............... qWma - Plumbing and Heating ........................:..................................... Space Heater........ Wall Heater .......................... ............6.00 ............... ulation / Energy...............................................:......... ........................... Flues - other than above ................. ..3.00 . GasTest .................................................................................................... Vent Fan: Kitchen........ Bath ............................._............3.00 ............... Temporary Power Gas / Elect........._................................................... Commercial Range Hood ............. 6.00 Final - Electrical ........................................................................................ Misc. ........................................................................................................... Final - Building/Mechanical .................................................................. Permit Fee ..............:...-------...............................................$ 6.00 Final - Design Review / Landscaping .................................................... TOTAL Htg./ Cooig. Permit Fee (plus penalty if app, p) $ Final - Public Works................ . . .. . ............................... f) r �I5h I aheet 2 +y CITY OF CUPERTINO BUILDING PERMIT Permit No: Address: 00Love Afa elf Date: BUILDING PROJECT IDENTIFICATION - WORKERS'COMPENSATION DECLARATION Applicant's Mailing Address I hereby affirm that I have a certificate of consent to self-insure, or a certificate of Workers'Compensation Insurance,or a certified COP' thereof (Set 801),:T b.C.t r^ Address of Building Policy No. Company �� x �Certifsed copy is hereby furnished. Owner's name - �r� A � » +A / Certified copy is filed with the counh• building inspection Telephone ::o. departr/�p��q/{V,/r county ,Aep jJo Contractor's Name �217tf Fj Dated /— Applicant /f Contractors Mailing Address CERTIFICATE OF EXEMPTION FROM WORKERS' rpitg= CA-9COMPENSATION INSURANCE Lic.No. (This section need not be completed if the permit is for one Architect or Engineer hundred dollars (5100) or less.) Architect's or Engineer's Address - I certify that in the performance of the work for which this permit Lic. No. is issued,I shall not employ any person in any manner so as to become subject to the Workers' Compensation Laws of California. LICENSED CONTRACTORS DECLARATION Date Applicant NOTICE TO APPLICANT: If, after making this Certificate of I hereby affirm that I am licensed under provisions of Chapter 9 Exemption, you should become subject to the Workers' / (commencing with Section 7000) of Division 3 of the Business and Compensation provisions of the Labor Code, you must forthwith XProfessions Code nd m license is in full force and effecF-y �p comply With such provisions or this permit shall be deemed revoked. License C14F Lic. Numbe Date Contractor CONSTRUCTION LENDING AGENCY 1 hereby affirm that there is a construction lending agency for the performance of the work for which this permit,is issued (Sec.3097, OWNER-BUILDER DECLARATION Civ.C.). Lender's Name 1 hereby affirm that I am exempt from the Contractors License Lender's Address w(or the following reason (Sec.7071.5, Business and Professions 1 certify that 1 have read this application and state that the above ;ode: Any city or county which requires a permit to construct-alter, improve,demolish,or repair any structure,prior to its issuance,also ordina ces is correct. I agree to comply with all city and county requires the applicant for such permit to file a signed statement that ' ordinances and state laws relating to building construction, and he is licensed pursuant to the provisions of the Contractor's License hereby authorize representatives of this county to enter upon the Law(Chapter 9(commencing with Section 7000)of Division 3 of the above-mentioned property for inspection purposes. Business and Professions Code) or that he is exempt therefrom and the basis for the alleged exemption. Any violation of Section 7031.5 signature of Applicant or Agent Date by any applicant for a permit subjects the applicant to a civil penalty of not more than five hundred dollars (s500).): ❑ 1,as owner of the property,or my employees with wages as "OWNER-BUILDER VERIFICATION their sole compensation,will do the work,and the structure is not intended or offered for sale (Sec. 7044, Business and Professions "Attention Property Owner: Code: The Contractor's License Law does not apply to an owner of '.'An 'owner-builder' building permit has been applied for in property who builds or improves thereon,and who does such work your name and bearing your signature. himself or through his own employees, provided that such "Please complete and return this information in the envelope improvements are not int ended or offered for sale.if,however,the provided at your earliest opportunity to avoid unnecessary delay building or improvement is sold within one year of completion,the In processing and issuing your budding permit No building permit owner-builder will have the burden of proving that he did not build will be issued until this verification is received. or improve for the purpose of sale.). I. 1 personally plan to provide the major labor and materials for p ❑ 1,as owner of the property,am exclusively contracting with Construction of the proposed property improvement (yes or no) licensed contractors to construct the project (Sec.7044,Business and Professions Code: The Contractor's License Law does not apply to - 2 1- (have/have not) signed An application for a an owner of property who builds or improves thereon, and who building permit for the proposed work contracts for such projects with a contractor(s) licensed pursuant to I have Contracted with the following person(firm) to provide the Contractor's License Law.), the proposed construction: -❑ 1 am exempt under Sec. , B.h P.C. for this Name reason __ Address City Darr. Owner Phone Contractors License No. 4. f plan to provide portions of the work, but 1 have hired the following person to coordinate,supervise,and provide the major works Name Addrem City Phone Contractors License No. 5. I will provide some of the work but I have contracted(hired) the following persons to provide the work indicated: Name Address Phone Type of Work Signed: Property owner Social Security number Date: