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11236 POST THIS CARD.NEAR FRONT OF BUILDING •. 1• PE1111IT NON18ER CITY OF CUPERTINO11236, INSPECTION DIVISION a JOB INSPECTION RECORD /"'/ PERMIT EXPIRATION JOB ADDRESS cSiAel a✓Z D�\C I m UNIT# LOT# PERMIT EXPIRES IF WORK OWNER . C e G CONTRACTOR IS NOT STARTED WITHIN INSPECTION' DATE INSPECTOR INSPECTION RECORD 180 DAYS OF PERMIT ISSU- FOUNDATION �:` - ANCE OR 180 DAYS FROM UFER �,q---7 p K- LAST CALLED INSPECTION. PREGUNITE PERMIT VALIDATION POUR NO CONCRETE UNTIL ABOVE HAS BEEN SIGNED UNDERGROUND /SLAB PLUMBING ELECTRICAL ISSUANCE DATE ,MECHANICAL - 64DG. ELECT. PLG. MECH. DO NOT POUR FLOOR UNTIL ABOVE HAS BEEN SIGNED BUILDING PERMIT INFORMATION WOOD FLOOR VALUATION $/FT. PLUMBING MECHANICAL ERIT TO - ELECTRICAL ski"' �% %t FRAMING ' INSULATION STORIES YPE CONSTR. EXPIRED - OCC.GROUP RES.UNITS PLACE NO SUBFLOOR UNTIL ABOVE HAS BEEN SIGNED - 50,IT.FLOOR AREA TOTAL ACREAGE lie DIAPHRAGM ROOF aull.owC usE 'a oN o a' APPLY NO ROOFING UNTIL ABOVE HAS BEEN SIGNED ASSESSORS PARCEL NO. ROUGH '' PLUMBING _ .TRACT NO. PARCEL NO. GAS TEST .''qq yy MECHANICAL 6 ?j,y� tps.cA,p�UVa—.f,O� - ELECTRICAL — MHEATING S DATE INS ACC,DATE acc.FILENO FRAMING ' I ' ZONING ENG SITE NO. INSULATIO FIRE SPRINK ENERGY TQ< COVER NO WORK UNTIL ABOVE HAS BEEN SIGNED Yo "� N❑ LATH-INTERIOR PLooD zoNE aL.0c. ATH—EXTERIOR Y ❑ IN SHEETROCK FEE SUMMARY SHEAR INTERIOR BUILDING SHEAR EXTERIOR TEMPORARY.APPROVALS BUILDING f r a FIREWALLS ELECTRIC PLAN CHECK GAS FEE NO TAPE OR PLASTER UNTIL ABOVE HAS BEEN,SIGNED IOCCUPANCY SEISMIC FEE OCCUPANCY OF BUILDING ISNOTPERMITTED UNTIL BUILDING.FINAL ISSIGNED BY BUILDING INSPECTOR. MICROFILM - 5 ARRANGE FOR INSPECTION BY PHONING 252-4505, ELECTRIC Lu ONE WORKING DAY BEFORE REQUIRED INSPECTION. PLUMBING PLEASE GIVE JOB ADDRESS WHEN PHONING. \� Z - SEE PERMIT FOR EXPIRATION DATE MECHANICAL IMPORTANT! , ENALX]PLEASE READ REVERSE SIDE BEFORE CALLING FOR FINAL INSPECTION. i OFFICE COPY ,-APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY w BFI I LDI NG PROJECT IDENTIFICATION PERMIT NUMBER ` BUILDING -3 APPLICATION & PERMIT ADDRESS n 11236 BUILDING-ELECTRICAL-PLUMBING-MECHANICAL OwN 'BI PLAN CHECK VALIDATION NAME-. �" 5/0� ,� - QTY. ELECTRIC PERMIT FEE 7 T:( PHONE r 3 n �� Y � • croRs NAME UTLETS-SWITCHES-RECEP 10.00/1.00 ,...[ NAME !i( s .1C.N0 ILiGHTING FIXTURES10.00/1.00 CONTRACTOR'S ADDRESS p _0 �. PPLIANCES-RESIDENTIAL '4.00 OS ,rl PyD/ d PANELS 10.00 DATE APPLICATION ARCM T PANELS (OVER 200 AMPI 20.00 PLAN CHECK FEE P.C.NO. OR ENGINEER LIC.No. SIGNS TRANS. 3.00 AR H. ENG. SPECIAL CIRCUIT 5.00 PERMIT VALIDATION AOORESS ESa � 'ZIP TEMP.METER OR POLE INS. 20.00 APPLICANT'S rs MOTORS SEE FEE'SCH. SERVICE CHANGE 20.00 w a 2 LICENSED CONTRACTORS DECLARATION Q U I hereby affirm that 1 am licensed under provisions of Chapter 9 ISSUANCE DATE Z<w"i (commencing with Section 7000)of Division 3 of the Business and BLDG. ELECT. PLG. MECH. r w Professions Code,and my license is in full fore ec. as 0 y � License Class 7j Lie Number - ❑. ❑ ❑ Q L L w/ ' Date Contractor a y 3 � nvF 1 I1 r BUILDING PERMIT rc ¢w u OWNER-BUILDER UECLAR 1 � INFORMATION K p u I hereby affirm that I am exempt from the Contractor's License MISC.- REFER TO ORD 3 rl P ALUATION $/FT. wa- Law for the following reason. 7031.5,Busineasand Professions PERMIT ISSUANCE 10.00 �- Code:Any city or county which requires a permit to construct,alter, l MYf� ¢ Q 0 improve,demolish,or repair any structure,prior to its issuance,also ELEC.CONTR. LIC.NO. ELEC. at ¢ requires the applicant for such permit to file a signed statement that TOTAL ERMIT TO w$ he is licensed pursuant to the provisions of the Contractor's License H z i Law(Chapter 9(commencing with Section 7000)of Division 3 ofthe �„- Q Business and Professions Code)or that he is exempt therefrom and QTY. PLUMBING PERMIT FEE $ the basis for the alleged exemption.Any violation of5ection 7031.5 STORIES TYP ONSTR. by any applicant for a permit subjects lheapplicant toa civil Penalty ALTER-DRAIN&VENT-WATER (EA.) 5.00 of not more than five hundred dollars($500).: ❑ 1,as owner of the property,or my employees with wages as BACK FLOW PROTECT.DEVICE 4.00 OCC.GROUP RES.UNITS licit sole compensation,will do the work,and the structure is not intended or offered for sale(Sec. 7044, Business and Professions DRAINS-FLOOR,ROOF,AREA,COND. 5.00 Code:The Contractor's License Law does not apply to an owner of properly who builds or improves thereon,and who does such work F IXTUR ES-PER TRAP 5.00 BD.FT.FLOOR AREA TOTAL ACREAGE himself or through his own employees,provided that such improve- mentsamnotintended or offered for sale.If,however,the building GAS-EA.SYSTEM-11NC.40UTLETS 6.00 On improvement is sold within one year of completion,the owner- GAS-EA.SYSTEM-OVER 4 (EA.) 2.00 BUILDING USE builder will have the burden of proving that he did not build or im- E IND CON PB Omer prove for purpose of sale.). INDUSTRIAL WASTE INTER. 30.00 13I,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 Cade: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 for such projects with a contractors)licensed pursuant to SEWER-SANITARY-STORM EA.200ft/10.00 the Contractors License Law. TRACT NO. PARCEL NO. ❑ l am exempt under Sec. ,B.&BC.for this WATER HEATER W/VENT 6.00 reason Owner Dale WATER SYSTEM 5.00 ACC.DATE ACC.FILE NO. WORKERS'COMPENSATION DECLARATION WATER TREATING EQUIP. 5.00 - - I hereby affirm that I have a certificate of consent to sel6insure, ZONING ENG.SITE NO. or a certificate of Workers'Compensation Insurance,or a cierlifted copy thereof(Sec.3800,Lab.C.). Policy No. Company O ❑ Certified Copyisherebyfamished. FIRE SPRINK ENERGY T 24 z ZO V Certified py fled with the city inspection division. MISC.• REFER TO ORD. ❑ ❑ ❑ ❑ App ant b V N V N G CERTIFICATE OF EXEMPTION FROM WORKERS' PERMIT ISSUANCE 10,00 FLOOD ZONE A.L.u.C. LU > COMPENSATION INSURANCE. PLG.CONTH. UC.NO. PLG, IL 0 (This section need not be completed if the permit is for one TOTAL - Y❑ N❑ Y❑ N❑ :D Z hundred dollars($100)or less.) U O 1 certify that in the performance of the work for which this per. OTY. MECHANICAL PERMIT FEE FEE SUMMARY LL F mit is issued,I shall not employ any person in any manner so as to Ow become subject to the Workers'Compensation Laws of California. BUILDING Date Applicant ALTER OR ADD TO MECH. 5.00 } lora NOTICE TO APPLICANT: If,after making this Certificate of Ex- H ? emotion.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 1 CONSTRUCTION LENDING AGENCY AIR HANDLING UNIT(OVER 10=C.F.M.) 6.00 SEISMIC FEE r 1 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.) 6.00 Lender's Name HEATI NG UN IT(OV ER 100,000 B.T.U.)9.50 ELECTRIC Lender's Address •� I certify that 1 have read this application and state that the above VENTILATION FAN (SINGLE) 4.00 information is correct.1 agree to comply with all city and county QMECHANICAL BOILER-COUP(3 H.P.or 100,000 B.T.U.) 6.00 ordinances and state laws relating to building Construction, and hereby authorize representatives of this city to enter upon the BOILER-COMP IOvdr 100,000 BTU)SEE FEE SCH. above-mentioned properly for inspection purposes. (We) agree to save, indemnify and keep harmless the City of MISC.- REFER TO ORD. Cupertino against liabilities,judgments, costs and expenses which PERMIT ISSUANCE 10.00 may in a way accrue against said City in consequence of thegra0tlIt Is p mil MECH.LONT. LIC.NO. MECHTOTAL lure ofA lican 'ontrac[or Dete - OFFICE COPY .-APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY BUILDING PROJECT I DENTI FICATION PERMIT NUMBER BUILDING . APPLICATION & PERMIT ADDRESSG! BUILDING-ELECTRICAL-PLUMBING-MECHANICAL 11357 'A OWNER'a PLAN CHECK VALIDATION ELECTRIC PERMIT FEE • Y\ e C4 0 e! PHONE G'S^ corvrRAcr R's . UTLETS-SWITCHES-RECEP 10.00/1.00 Na E/ LIGHTING FIXTURES Qy r fS 10.00/1.00 0 - �( CONTRACTO - PPLIANCES-RESIDENTIAL 4.00 / ' aooREss PHONE �y9_�o� PANELS 10.00 DATE OF APPLICATION ARCHITECTPANELS (OVER 200 AMP) 20.00 PLAN CHECK FEE P.C,NO. OR ENGINEER _ Llc.NO. SIGNS TRANS. 3.00 ADR. Ery � SPECIAL CIRCUIT 5.00 PERMIT VALIDATION ADDRESS ss ZIP EMP.METER OR POLE INS. 20.00 ADDDRESSDRESS AMOTORS SEE FEE SCH. - SERVICE CHANGE 0 f-1 Y T rFJ woo LICENSED CONTRACTORS DECLARATION l� a u u I hereby affirm that I am licensed under provisions of Chapter 9 s 1 ISSUANCE DATE m< w (commencing with Section 7000)of Division 3 of the Busiuw and - _ BLDG. ELECT. PLG. MECH. o Professions Code,and my license is in full to a ff ❑ ❑ ❑ 2 0 H icense Cl.. _Lic.Number O w F D Data Contractor City of CuDert no a Y s d BUILDING PERMIT ¢ ¢w4 OWNER-BUILDER DECLARATION INFORMATION ado I MISC.- REFER TO ORD X3: LL hereby affirm that I am exempt from the Contractor's License VALUATION SIFT. F n O at Law for the following reason.(Sec.7031.5,Businessand Professions PERMIT ISSUANCE 10.00 Q-- w Code:Any city or county which requires a permit to conslruct,alter, ¢ rt 4 2 improve,demolish,or repair any structure,prior to its issuance,also ELEC.CONTF. LIC.NO. ELEC. -C u requires the applicant for such permit to file a signed statement that TOTAL oc-d PERMIT TO i w m he is licensed pursuant to the provisions of the Contractor's License HI> Law(Chapter 9(commencing with Section 7000)ofDivision3oflhe ELG-�T - a Business and Professions Code)or that he is exempt therefrom and QTY. PLUMBING PERMIT FEE ¢f the basis for the alleged exemption.Any violation of Section 7031.5 STORIES TYPE CONSTR. by any applicant for a permit Subjects the applicant toa civil penalty ALTER-DRAIN III VENT-WATER (EA.15.00 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,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 g6 FT.FLOOR AREA TOTAL ACREAGE himself or through his own employees,provided that such improve- memsarenotintended or offered for sale.If,however,the building GAS-EA.SYSTEM-11NC.40UTLETS 6.00 or improvement is sold within one year of completion,the owner- GAS-EA.SYSTEM-OVER 4(EA.) 2.00 BUILDING USE builder will have the burden of proving that he did not build or am- RES IND CON PB Omar Piave for purpose of sale.). INDUSTRIALWASTE INTER. 30.00 ❑ 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 ASSESSORSPARCELNO. and Professions Code:The Contractor's License Law does not apply' to an owner of property who builds or improves thereon.and who iLAWN SPRINKLERS-OVER 5(EA.) 1.00 contracts forsuch projects with a corRraco ms)licensed pursuant to the Contractor's License Law. SEWER-SANITARY-STORM EA.200ft/10.00 TRACT NO. PARCEL NO. ❑ lam exempt under Sec. ,B.&P.C.for this WATER HEATER W/VENT 6.00 reason Owner - Date WATER SYSTEM 5.00 ACC.DATE ACC.FILE NO. WORK E.RS'COMPENSATION DECLARATION WATER TREATING EQUIP. 5.00 1 hereby affirm that 1 have i certificate of consent to self-insure, ZONING ENG.SITE NO. or a certificate of Workers'Compensation Insurance,or a certified copy thereof(Sec.3800,Lab.C.). Policy No. Company 0 ❑ Cerlifed opyis hereby furnished. FIRE SPRINK ENERGY T-24 Z Z� ❑ Certifepco Iled with the city inspection division. O APplicant 1F/_ REFER TO ORD. Y C] NE] Y [] N[] CCyCERTIPIPIiXF:MPTION FROM WORKERS' PERMIT ISSUANCE 10.00 FLOOD ZONE A.L.U.C. LU > COMPENSATION INSURANCE. PLG.CONTR. LIC.NO. PLG, a- O 11 his section need not he completed if the permit is for one TOTAL Y❑ N Y ❑ N D Z hundred dollars(S 100)or less I U O I certify that in the performance of the work for which this per- FEE SUMMARY LL F mil is issued,I shall not employ any person in any manner so as to QTY. MECHANICAL PERMIT FEE U become subject to the Workers'Compensation Laws of California. O w Data Applicant ALTER OR ADD TO MECH500 BUILDING } in . . NOTICE TO APPLICANT: If,after making this Certificate of Ex- F Z 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 - V such provisions or this permit shall be deemed revoked. AIR HANDLING UNIT ITO 10=C.F.M.) 4.00 CONSTRUCTION LENDING AGENCY AIR HANDLING UNIT(OVER 10MC.RM.) 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.CJ. HEATING UNIT(TO 100,000 B.T.U.) 8.00 Lender's Name HEATING UNIT(OVER 100,000 B.T.U.)9.50 ELECTRIC - �^' - \ Lender's Address 1 I certify that l have read this application and state that the above VENTILATION FAN (SINGLE) 4.00 information is correct. I agree to comply with all city and county PLUMBING ordinances and state laws relating to building construction, and BOILER-COMPOH.P.or.100,000B.T.U.) 6.00 hereby authorize representatives of this city to enter upon the BOILER-COMP(Over 100,000BTU)SEE FEESCH. MECHANICAL _ above-mentioned property for inspection purposes. (We) agree to save, indemnify and keep harmless the City of MISC.- REFER TO ORD. Cum, gairest liabilities,judgments, costs and expenses which I CONST.TAX may " i w rue against said City in consequence of the PERMIT ISSUANCE 10.00 gr ing t er IL MECH.CONT. LIC.NO. MECH. IC TOTAL TOTAL ratAzylIGa t Contractor fUate OFFICE COPY �j CITY OF CUPERTINO INSPECTION RECORD (OFFICE COPY) hs / PEFMI_;;NO. ADDRESS 7 OWN7 PERMIT ISSUED ELECTRICAL DATE INSP. Uui n ctrica Plumbing Power*Pole Mectian3.cal Lindeund Temp as ec u irin Solar walls Fire Sprinkler Ceiling Sign eixtures Int/Ext tors Misc. Grounding e ower uttier FINAL INSPECTIONS DATE INSP, Not Approved Gas Electric Plumbing PLUMBING DATE INSP. anica ��o ar Backflow 0o r Md Grad:Lng underfloor Planning Partialu Fire Dept. u ete eat t. ar ugh Building water *4 ns ation eraln Worazn Gas Mer BUILDING DATE INSP. Not Approved Pad Certification Foundation ELECTRICAL DATE INSP. re- rte Slab-NLnbrane Underfloor S.M. Bond am Mcts nsulation Undertloor i rsirF'eD Dampers Floor Steel Fireplace Tiedowns Grease Duct -'Tood — ia rams One Hour Shaft eismecracin Condensate Drain s- ane s Anchorage Tram s r �a ter a oars nt xt. of rove irewa s er Met Approved i BUILDING ELECTRICAL PLUMBING MECHANICAL NUSCELLANEOUs '. •-'APPLICANT TO'FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY, BUILDING PROJECT I DENTI FICATION PERMITNUMBER - eDILDIND - - APPLICATION & PERMIT ^ n I� .ADDRESS e b I r � A BUILDING-ELECTRICAL-PLUMBING-MECHANICAL OWNER'S - }' " '"i', gyp ' Fe g�' A"a j"�' S' .I$ k � PLAN CHECK VALIDATION NAME ... F kP$I'� ++ a.pk 1 §5 R .+ , - OTVy' ', ELEC'1'IRICPERMIT, 3 fa, FEE.,: .E..IVA/L�/ PNDNE�KJ�Wa 1 ` k •. A'�• 4 CONTRACTOR'Sf , NA E Q -/ • UTLETS-SWITCHES-RECEP 5.00I1.00 uc N041 OSg5LIGHTING FIXTURES;. 5.00/1.00 ' CONTRACTOR'S APPLIANCES-RESIDENTIAL - 4.00 ' ADDRESS ..�.C/ .J.�.,cfr SAJY�K+V• HON�Iry'-,sw�J PANELS 5.00 DATE OF APPLICATION ARCHITECT - SIGNS 6.00 PLAN CHECK FEE P.C.NO. ENGINEER- • '-- '. LIC.NO, SIGNS TRANS. 3.00 AARCH OR DDRESS ENG. '�. r SPECIALCIRCUIT' .S.00 PERMIT VALIDATION ;IP TEMP..IMETER OR POLE INS. 15.00 ADDRESS MOTORS SEE FEE SCH. ��' APPLICA '. SERVICE CHANGE 10.00 ��p I'd /S)", 0 Z2 LICENSED CONTRACTORS.DECLARATION " rt ca E,' '.I hereby affirm that I am licensed under provisions of Chapter 9 ISSUANCE DATE t;'a m (commencing with Section 7000)of Division 3 of the Business and BLDG. ELECT. PLG. MECH.: H m z Professions Code nd y license Is in full Por eff L� • ' O "z o w License Class - Lic.Number S b El E 13 2 z t-ea Date_(p �-�r Contractor " H.N � J ¢ y a, J .BUILDING•PERMIT Nvv, z ¢w ¢ OWNER-BUILDER DECLARATION - Al INFORMATION* �1 ... wOno MISC.- REFER TO ORD - - - ac n y I hereby.affirm that Lam exempt from the Contractor's Pr License UATION S/FT. ' H LL Law for the following reason.(Sec.7031.5,Business and Professions PERMIT ISSUANCE 6.00 Code:Any city orcounty which requires a permit to construct,alter, C 5 ¢ 4 , improve,demolish,or repair any structure,prior to its issuance,also ELEC.CONTR.' LIC.NO. ELEC. e_g m LL requires the applicant for such permit to file a signed statement that TOTAL PERMIT TO INf7 he is licensed pursuant to the provisions of the Contractor's License La H Z a Law,(Chapter 9(commencing with Section 70000of Division 3 of the - #.`u yG,� i o Business and Professions Code)or that he is exempt therefrom and DTV. v "PLUMBING PERMIT' ;Feel - ¢ H o the basis for the alleged exemption.Any violation of Section 7031.5 STORIE6 TYPE CONSTR. dgw' by any applicant Join permit subjects the app licanttoacoupena0y ALTER-DRAIN -WATER IEA.) 4.00, of nounce ore than five hundred dollars(S500).1: ❑ I,as,owner of the property,or my employees with wages as BACK FLOW.PROTECT.DEVICE 2.00 OCC.GROUP PES.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,AREA,COND.'4.00 Code:The Contractor's License Law don not apply to an owner of property who builds or improves thereon,and who does such work FIXTURES-PER TRAP 4.00 SQ.FT.FLOOR AREA TOTAL ACREAGE himself or through his own employees,provided that such improve- mentsarenotintendedorofferedforsale.If,however,the building GAS or 4.00 or improvement is sold within one year of completion,the owner. GAS-EA.SYSTEM-OVER 4(EA.) LOO BUILDING'USE - builder will have the burden of proving that he did not build or im. qES IND CON PB Other prove for purpose of sale.). INDUSTRIAL WASTE INTER. 20.00 ❑' 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. 5.00 ASSESSORS PARCEL NO. and Professions Code:The Contractors 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 for such projects with a contractor(s)licensed pursuant to the Contractor's License Law. SEWER-SANITARY-STORM EA.200ft/8.00 TRACT NO. PARCEONO. ❑ lam exempt under Sec. _ ,B.&P.C.for this WATER HEATER W/VENT 4.00 reason Owner Date' WATER SYSTEM 4.00 ACC.OATS - ..ACC.,F ILEA NO. WORKERS'COMPENSATION DECLARATION WATER TREATING EQUIP. 4.00 1.1hereby affirm that 1 have a certificate of consent to self-insure, „ ZONING ENG.SITE NO: or a cerlificu a of Workers'Compensa ion Insurance a certified copy thereof b.C.). , PDIICY No. - sp ❑ �.tlified c P s eby to i tied. FIRE SPRINK ENERGY T-24 Z Z B'Certifie y.is d with city ins MISC.- REFER TO ORD. O APPlicant _ ' Y❑ N❑ _ Y ❑ •N❑ ' - - PERMIT ISSUANCE 6.00 FLOOD ZONE A.L.U.C. - CE RTIFICATEAFE-XEMPTION FR W ERS' W > - - .COMPENSATION INSURANCL PLG.CONTH. 1 LIC.NO. PLG. 1 O (This Section need not be completed if the permit is for one TOTAL Y❑ N❑ Y❑ N❑ Z hundred delta.IS 100)or less.) V O I cert if that in tire e erformance of the work for which this per s i * =FEE'6UMMARV"°•exp' U. F mit is issued,I shall not employ any person in any manner an as to QTY,.,.t x .»MECHANICAL PERMIT, U become subject to the Workers'Compensation Laws of California ` y Date Applicant - ALTER OR ADD TO MECH. 4.00 BUILDING } rn NOTICE'TO APPLICANT: If,after making this Certificate of Ex- F ? emptiun;you should become suhject to the Workers'Compensation APPLIANCE 4.00 PLAN CHECK '3� provormus'ol' the,Labor Code,.you.must forthwith complywithFEE // U such provisions or this permit shall be deemed revoked. AIR HANDLING UNIT(TO 10=1C.F.M.) 3.00 CONSTRUCTION LENDING AGENCYAIR HANDLING UNIT(OVER IQOOOC.EM.) 5.00 SEISMIC FEE _ I hereby affirm that lhcre is a construction lending agency for EXHAUST HOOD (WITH DUCT) . 2.00 ' the performance of the work for which this permit'is issued(Sec. MICROFILM ' 3097.Civ.CJ. HEATING UNIT(TO 100;000 B.T.U.) .4.00 Lender's Name Lender's Address HEATING UNIT(OVER 100,000 B.T.U.)7.50 ELECTRIC I certify that l have read this application and stale that the above VENTILATION FAN (SINGLE) 3.00 Information-is correct. I agree to comply with all city and county BOILER-DOW(3 H.P.Or 100,000 BT.U.), 4.00 PLUMBING ordinances and state laws relating to building construction,and hereby authorize representatives of this city to enter upon the BOILER-COMP to.,IC1,000 BTU)SEE FEE SCH. MECHANICAL above-mentioned.property tonna ection purposes. I (We) agree to save;-mde an keep harmless'the City of ,� MISC.- - REFER TO ORD: Cupertino 'lit' 1 gen costs and expenses which CONST.TAX - GR y y way ' a nst i City in conseq nce f the PERMIT ISSUANCE 3.00 ling oft ' TOTAL MECH.CONT. LIC-NO. MECH. t �.�8 %,TOTALA IgnaIure Contractor ale .I P w OFFICECOPV -