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9283IjPPLICANT TO FILL IN INFORMATION WITH 1"OED LINES -USE BALL POINT PEN ONLY BUI LDI NG PROJECT I DENTI FICATI ON APPLICATION & PERMIT BUIL G-ELECTRICAL-PLUMBING-MECHANICAL PEHMIT NUMBER 9283 BUILDING ADORE ss ' OWrvER$,� NAME C.V rQSN No %Ow Y1 cz&-r`R1L CITY. ELECTRIC PERMIT FEE PLAN ECK.1,1LIDATION r(J PHONE 3 4�/ co TRacro s NAME ' OUTLETS-SWITCHES-RECEP 10.00/1.00 LIGHTING FIXTURES 10,00/1.00 LIG NO, 0NTRA DDEEScroRs A APPLIANCES - RESIDENTIAL 4.00 PANELS 10.00 PHONE DATE OF APPLICATION ARCHITECT OR 9 ENGINEER it i L1 C O LIC No. / Z (� Od PANELS (OVER 200 AMP) 20.00 PLAN CHECK FEE P.O. NO. SIGNS TRANS. 3.00 ADD ESS Erv0' ZIP SPECIAL CIRCUIT 5.00 PERMIT VALIDATION PAID JUL TEMP. METER OR POLE INS. 20.00 aDDRES5S A DRE MOTORS SEE FEE SCH. SERVICE CHANGE 20.00 15 1986 no LICENSED CONTRACTORS DECLARATION TEMP. POLE30.00 1 hereby affirm that 1 an, licensed under pro islons of Chapter 9 .CiNE9JSVgq (commencing with Section 7000) of Division 3 of the Business and Professions Code, and my license is in full force and effect License Class Lic, Number B�DG. E EC L�JI FILE. MECH. ❑ Date Contractor ' B PERMIT OWNER -BUILDER DECLARATION 1 hereby affirm that 1 am exempt from the Contractor's License Law forProfessions nthe ycitfollowing reason, (Sec. quires a permit to Code: Any city or county which requirese permit to construct, , also to R] issuance, that priorsigned improve, demolish. Or repair h p rmit I. for each permit to ❑Ic a signed statement that requires the dp pursuant he is licensed pursuant to the provisions of the Contractor's License of t therefrom 3 of and Luca (Chapter 9 (commencing with Section is exempt Business and ProfessionsCode)xempt or that he is exempt therefrom and NFORMATION MISC.- REFER TO ORD V LUATION $/FT. PERMIT ISSUANCE 10.00 ELEC. CONTR. L G NO. ELEC. TOT PERMIT TO ,� l-�� OTV. PLUMBING PERMIT FEE STORIES TYPE CONSTR. [he 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 one than five hundred dollars ($500).): ALTER-DflAIN&VENT-WATER IEA.15.00 ❑ I, as owner of the property, or my employees With wages as their sole compenmtion, will do the work, and the structure Is not BACK FLOW PROTECT. DEVICE 4.00 c Ol)p � RES. uNIT 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 F IXTUR ES - PER TRAP 5.00 SO. FT. FLOOR AREA TOTAL ACREAdE 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 INC.4 OUTLETS 6.00 or improvement is sold within one year of completion, the owner- builder will have lire 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: '1'lie 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.) 2.00 BUILDING USE R IND CON PIP, Omer ❑ ❑ ❑ INDUSTRIAL WASTE INTER. 30.00 LAWN SPRINKLERS- 1 INC 5 V.B. 6.00 LAWN SPRINKLERS - OVER 5 (EA.) 1.00 ,❑ 1 ASSESSOHS PARCEL NO. contracts for Such projects with a contraetm(s) licensed pursuant to the Contractor's License Law. SEWER-SAN ITARV-STORM EA, 20011/10.06 TRACT NO. PARCEL NO. WATER HEATER W/VENT 6.00 ❑ I am exempt under See,-, B,&P,C, for this Cason Owner Date WATER SYSTEM 5.00 ACC. DATE ACC. FILE NO. WORKERS'COMPENSATION DECLARATION WATER TREATING EQUIP. 5.00 I hereby affirm dial I have a certificate of consent to self-m"ov. or a certificate of Workers' Compensation Insurance, or a certified ZONING ENG. SITE NO. copy thereof(Sec. 3800, Lab.C.). 1119 No. Company FIRE SPRINK ENERGY T-24 Certified copy is hereby ur 'B ed ❑ Cer' etJ co y Is r nspeclion division. A lira V ❑ N ❑ V N ❑ ❑ MISC. - REFER TO ORD. ATEOF 1 'ROM WORKERS' PERMIT ISSUANCE 10.00 FLOODZONE A.L.U.C. PLG. CONTE. LOC. NO. PLG. TOTAL COMPI'N$ATION INSURANCE (This section need l be completed if the pemit is for one acomr Y ElN ❑ Y ❑ IN❑ OTY. MECHANICAL PERMIT FEE FEE SUMMARY hundred dollas ($100) or less.) 1 certify that in tic performance of the work for which this pc'- mil 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 MECH. 5.00 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 will such provisions or this permit shall be deemed revoked. FEE AIR HANDLING UNIT (TO 10=CF.M.) 4.00 AIR HANDLING UNIT(OVER 10MC.F.M.) 6.00 SEISMIC FEE CONSTRUCTION LENDING AGENCY I hereby affirm that there is a construction )ending agency for C once of the work for which this permit is issued (Sec. the performance 3097, EXHAUST HOOD (WITH DUCT) 5.00 MICROFILM HEATING UNIT (TO 100,000 B.T.U.) 8.00 HEATI NG UNIT (OVER 100,000 B.T.U.)9.50 ELECTRIC Lender's Name Lender's Address I certify that l have read this application andstate that the above information is correct. I agree to comply with all city and county ordinances and state laws relating to building construction, and VENTILATION FAN (SINGLE) 4.00 PLUMBING BOILER-COMP(3 H.P. or100,0008.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-mentioncd property for inspection purposes. MISC. - REFER TO ORD. (We) agree to Save, indemnify and keep hmmle,)ys the City of Cupertino against liabilities, ]r gmenls sts d Atpenses which may 'n any wa accrue a sl r' c equence of the CONST. TAX PERMIT ISSUANCE 10.00 MECH. CONT. L1C. NO. I MECH. TOTAL TOTAL v g O x arrgit. a- I a u of ppheanl Con actor Dal OFFICE COPY CERTIFICATE OF COMPLETION �o7—z BUILDING INSPECTOR'S OFFICE •�, CITY OF CUPERTINO - DATE 19-FS:f BLDG. PERMIT NO. �-6 S- THE BLDG. LOCATED AT (� 2 D �/1 ��Lp /1-- OWNED BY-.--716 (A C Tl- /I�(-A/n• I HAS BEEN OM PLRETED) FOR USE AS n to cI O 0Z CERTIFICATE OF COMPLETION BUILDING INSPECTOR'S OFFICE CITY OF CUPERTINO DATE y -� 19� BLDG. PERMIT NO. �6 S� THE BLDG. LOCATED AT 10 2 /) A P d In „in-Q h f- OWNED BY ,J Jl (COMPLETED / HAS BEEN ALT� ER�OR USE AS CERTIFICATE OF COMPLETION �v77z BUILDING INSPECTOR'S OFFICE CITY OF CUPERTINO DATE 41.— 1— , 192= BLDG. PERMIT NO. ��_6 -73 IHE BLDG. LOCATED AT I/ () 2 ()IV VCA IA u b .P /) r- OWNED BY ITT N/A_�T(-//,,��,, HAS BEE�C�O_MPPLETDED FOR USE AS C oI D �FiLTEREDI ELECTRIC SERVICE NOTICE BUILDING INSPECTOR'S NOTICE CITY OF CUPERTINO To /J r You are hereby authorized to Connect electrical service for Owner or Tenant � � No. of Wires Motor Load Size of Wires OFFICE COPY 7 — 19 A d- � o ) J _Size of Switch Heating Load K.W. . V 11 110 New Service ` Reconnect ( Light -- No. 04 Meters 1 Meat )20 _.Three Wire Mare Service Na. 04 Add. Meters 11 Power. Three Phase Move Meler ELECTRICAL INSPECTOR CERTIFICATE OF COMPLETION��- BUILDING-INSPECTOR'S OFFICE CITY OF CUPERTINO DATE-( 19�L BLDG. PERMIT NO. THE BLDG. LOCATED AT /to Z /1 Z ��I/\ OWNED BYE 7�/ r l7 00. - HAS BEEN OMPLETED FOR USE AS r' ALE DI ELECTRIC SERVICE NOTICE BUILDING INSPECTOR'S NOTICE CITY OF CUPERTINO To ,/'� 5 '> . z You are hereby authorized to Connect electrical service for (a— OFFICE COPY 3 - z d e �? Owner or Tenons At ,I No. of Wires Size of Wires Slze of Switch Motor Load I Heating Load K W Voltage Ilp New Service Reconnecl ' ( -- 1\ Iyp�Three Wire More Service No. of Meters Lghr Heat NoThree Phase Move Meter . of Add. Meters Power � //C \J 11 QM EL ECTRICAL INSPECTOR V I �oT �— CERTIFICATE OF COMPLETION BUILDING INSPECTOR'S OFFICE f CITY OF CUPERTINO DATE-L!=�' 19g� BLDG. PERMIT NO. THE BLDG. LOCATED AT In2LSr 'o 4o ae OWNED By L - / 1 MPLETEDI OR USE AS HAS BEEN-tAtTERED) V" ILDING INSPECTOR CERTIFICATE OF COMPLETION p 1 Z— BUILDING�INSPECTOR'S OFFICE cI T I BUILDING INSPECTOR'S OFFICE CITY OF CUPERTINO- Bld g. Depi. 'Vice Copy I ❑ Backflow:Device Sanitary Permit No. r I 'ElSewer Connection Plumbing Permit No. �/ s3 j ,❑ Plumbing Final ' Lot. No. . n Owner or Tenant 6"- Z61 At Tract Date Connected ,l /- 191'V Dote. Final =_ S' 19 7" I 'I OO M PLUMBING INSPECTOR BUILDING INSPECTOR'S OFFICE Dep'. CITY OF CUPERTINO - Bldg. otnce Copy ❑ Backflow Device Sanitary Permit No.� I '� Sewer Connection " Plumbing 9 Permit No. rri �/�� ❑-- `q Plumbing Final Lot No. Owner or Tenant Tract Date Connected 19 &Date Finol �' 19'p`- i I 0„ PLUMBING INSPECTOR BUILDING INSPECTOR'S OFFICE Bld, Dep'. CITY OF CUPERTINO officecopy Sanitary Permit No. ' ❑ Backflow Device ' Plumbing Permit No. ' / 3 El Sewer Connection - Lot No. Plumbing Final n � Owner or Tenant At 16 ci 2 i Tract ✓ 19,E �� Date Final 19 �S— Dare Connected - / ©„ PLUMBING INSPECTOR BUILDING INSPECTOR'S OFFICE Bldg. D.W. -ice CITY OF CUPERTINO Off Copy Sanitary Permit No. ' ❑ Backflow Device , Plumbing Permit No. El Sewer Connection i ' Lot No. Z Plumbing Final ` n^ i ' "' 'wn �n lip - Owner or Tenant v At Date Connected195%�19 � Date Final 3 �t- OM PLUMBING INSPECTOR I BUILDING INSPECTOR'S OFFICE BldCg. pi. CITY OF CUPERTINO o9me opv ❑ Backflow Device Sanitary Permit No. )Cl Sewer Connection Plumbing Permit No. 57o J Plumbing Final Lot No. h'X�111 d Owner or Tenant At Tract ! % Date Connected �� — / _ 19,ftODote Final 3f i t/ 19f"< l OO M PLUMBING INSPECTOR BUILDING INSPECTOR'S OFFICE Bldg. Dep'. CITY OF CUPERTINO off,e Copy li ❑ Backflow Device I 0 Sewer Connection 0 Plumbing Final Owner or Tenant At ZG 1 Sanitary Permit No. Plumbing Permit No. nICZ Lot No. v Date Connected G 19Z,L/DateFinal 3 — /S—'19x� �'„, PLUMBING INSPECTOR ! I -- BUILDING INSPECTOR'S OFFICE CITY OF CUPERTINO 1 i ❑ Backflow Device D/'Sewer Connection I OO Plumbing Final Owner or Tenant i Traci Bldg. Dept. Offoce Copy Sanitary Permit No. Plumbing Permit No. S S 3 Lot No. 1 Date Connected %// '/— 19��Dote Fi i ELECTRIC SERVICE NOTICE BUILDING INSPECTOR'S NOTICE CITY OF CUPERTINO ---� /S '191P To � � 1 19 You are hereby authorized to Connect electrical service for Owner or Tenant irc.,r.� LV T!'/7�✓Ir-a-..!✓� No. of Wires Motor Land Heating Load Size of Wires K. W of Switch Voltage � / x OFFICE COPY No. 04 Meters / Ughr I10 New Service Reconnect Heat 120 Three Wire More Service No. of Add. Meters Power Three Phose Move Meter ©" ELECTRICAL INSPECTOR ^' ELECTRIC SERVICE NOTICE OFFICE COPY BUILDING INSPECTOR'S NOTICE CITY OF CUPERTINO �O 19� To You are hereby authorized to Connect electrical service for Owner or Tenant At No. of Wires _ Motor Load _ Heating Load _ Size of of Switch K. W. von uyz 110 New Service " Reconnect Light / ( No. of Meters Heat 120Three Wire More Service No. of Add. Meters l(/1 Power Three.Phose Move Meter �• ELECTRICAL INSPECTOR -- l/ ELECTRIC SERVICE NOTICE BUILDING INSPECTOR'S NOTICE CITY OF CUPERTINO _ 119 To You are hereby authorized to Connect electrical service for Owner or Tenant 2— At—/ No. of Wires Size of Wires Size of Switch Motor Load Voltage� Phase .. K. W, Voltage Hearing Load Light-1 10—Ni,w Service Rewr,nect No. of Meters Heat _—120Thiee Wire More Service No. of Add. Meters Power Three Phase Move Meter OM ELECTRICAI INSPECTOR v OFFICE COPY ELECTRIC SERVICE NOTICE OFFICE COPY BUILDING INSPECTOR'S NOTICE CITY OF CUPERTINO 19 To C �. / i� You are hereby authorized to Connect electrical service for Owner or Tenant " v No. of Wires Size of Wires Size of Switch Motor Load Voltage Phase Heating Load K. W. Voltage ! ( Light 110-New Service Ren conect No. of Meters Heat ]20_Three Wire More Service No. of Add. Meters Power Three Phase Move Meter ©w ELECTRICAL INSPECTOR ELECTRIC SERVICE NOTICE OFFICECOPY BUILDING INSPECTOR'S NOTICE CITY&CUPERTINO - 19 S� To A� You are hereby authorized to Connect electrical service for Owner or Tenant At - No. of Wires Size of Wires Slze of Switch Motor Load Voltage Phase Hearing Load K.W. Voltage No. of Meters / Light /l Heot 110_ 11ew Service I 120_Three Wire Reconnect More Service No. of Add. Meters t�. .b� Power _ `ELECTRICAL INSPECTOR Three Phase CA Move Meter ELECTRIC SERVICE NOTICE OFFICECOPY BUILDING INSPECTOR'S NOTICE CITY `)F CUPERTINO /� To �� .•_ r• You are hereby authorized to Connect electrical service for Owner or Tenant -fi.-^ • r At No. of Wires Size of Wires Size of Switch Motor Load Voltage Phase I Heating Load K. W. Voltage Light.]10__New / Service Reconnect No. of Meters Heat 120_Three Wire More Service No. of Add. Meters Power Three Phase Move Meter ©M ELECTRICAL INSPECTO="sue, BUILDING INSPECTOR'S OFFICE Bldg. Dept. CITY OF CUPERTINO Office Copv 0 ' Backflow Device Sanitary Permit No. • r Plumbing Permit No. El Sewer Connection / L a t No. !' It Plumbing Final Owner or Tenant I Dote Connected 19' rf Date Final C— "T9 ©M PLUMBING INSPECTOR I CERTIFICATE OF COMPLETION pTz BUILDING INSPECTOR'S OFFICE CITY OF CUPERTINO DATE _ 19-Rtj� BLDG, PERMIT NO. THE BLDG. LOCATED ATZ,g(2- OWNED BY �n t 0 c`T(S—.—��d-SIP I, / COMPLETEDD FOR USE AS HAS BEEN1_ACTE EDI CERTIFICATE OF COMPLETION y�OT Z BUILDING INSPECTOR'S OFFICE _ ,CITY OF CUPERTINO DATE U —. 19 , - BLDG. PERMIT NO. S� THE BLDG, LOCATED AT 1 h > �� I �� I o OWNED BY HAS BEEN L.OMPLET D FOR USE AS (A EREDI ELECTRIC SERVICE NOTICE OFFICE COPY i BUILDING INSPECTOR'S NOTICE CITY OF CUPERTINO To ,19 .F 1 4" You are hereby authorized to Connect electrical service for Owner or Tenant n, At 113, 2 n O a No. of Wires Size of Wires Size of Swilch Motor Load Voltage Phase i Hearing Load K. W. Voltage No. of Meters / ( Light I10-New Service Reconnect Heol 120_-Three Wire More Service No. of Add. Meters l{/) Power Three Phase Move Mere, v M � ELECTRICAL INSPECTOR _ r CITY OF. CUPERTINO IN-�-,PECIION RECORD <<-7FFFCE COPY) .10014); ..L PERMIT ISSUED DATE ui in ectrica Plumbing Mechanical emp as ec Solar Fire Sprinkler Sign Misc. FINAL NS • • ' ATE Gas MIMED • - BUILDING DATE Pad Certification INSP. oun ation _ re- unite Slab -Yleffbrme-{ eam Underfloor it ers Floor Steel ie owns -z S �ismec racin W walls-panels Frame Wf at , 0ia .. oar nt xt. Firewalls Other Net A rove „i.ca W % 'iva "r 7 L1 ELECTRICAL DATE L" Power Pole INSP.' ergroUnd Roughirin i Walls ei in _ / y ixtures nt xt Motors Grounding Power Uther NotApproved K Lo is 3 s F PLUMBING DATE Backflow INSP. r un oor Partial ou ug omp ete Solar u ater'4 Insulation Main Drain o ain as er Not Approved- . ELECTRICAL DATE Underfloor S.M. INSP. Ducts & Insulation Fire Dampers Fire lace cease ct & Hood e Hour Shaft ensate Drain Eui ent Anc ora e Air t ebTi-r—' Not Approved . BUILDING R.e�Ca �n.....✓r.li � �'s-If ��..C-� `T -z6�� �`V R e �u (emu L1z�- v - • ELECTRICAL PLUMBING MBCHANI CAL MCELLANEDUS APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY •-` BUILDING PROJECT IDENTIFICATION ,. APPLICATION & PERMIT BUILDING - ELECTRICAL- PLUMBING - MECHANICAL PERMIT NUMBER 5653 BUILDING n ADDRESS fyOd �74 OWNER'S Jr¢IZYsAtitO pi L3+��(L NAME Ce OSY-I�v STY. - ELECTRIC PERMIT '"FEE, PLAN CHECK VALIDATION NAMM oE ACTORS UTLETS-SWITCHES-RECEP 5.00/1.00 • LIC. No. LIGHTING FIXTURES 5.00/1.00 ADDSEBB Tons ADDRESS PPLIANCES- RESIDENTIAL 4.00 PANELS 5.00 PHONE DATE OF APPLICATION ARCHITECT Ofl ENGINEER C� LIC. No. SIGNS B - PLAN CHECK FEE P.C. NO. ' SIGNSTRANS. 3.00 ARCH. OR ENG. 72116 p,R,ayn - pyA.e ADDRESS L/'I C s1p,� - - L /?. SPECIALCIRCUIT 5.00 PERMIT VALIDATION ///---��� ( 1 ' / (t \�UQ{[w1-.1 ���/8-5� EMT. METER OR POLE INS. 15.00 APPLICANTS/3o7 . m• ADDRESS �11--`�/Z� S'c-+IL✓1 U¢, C' L rp MOTORS SEE FEE SCH. SERVICE CHANGE 10.00 LICENSEDCONTRACTORS DECLARATION I hereby affirm that I am licensed under provisions of Chapter 9 ISSUANCE DATE (commencing with Section 7000) of Division 3 of the Business and professions Code, and my license is in full force and effect. ClassLie. Number BLDG. ELECT. I PLG. nali ❑ ❑ MECH. 1-1License Dale Contractor OWNCR-BUILDER DECLARATION 1 hereby affirm that I am exempt from the Cons and P S License Law for the following reason.(Sew.703 uires a,ermit Business ocnd Professions Code: Any city or county which requirese permit toconstruct,, alter, onprove, or repair any tore, to Its issuance, also , BUILF PERMIT : .! )NF�ORMATION MISC. - REFER TO ORD VALUATION S/FT. PERMIT ISSUANCE 6.00 ELEQ CONTR. LIG NQ ELEC he applicant e a signed requires n e dp ursuat for such permit ns file a signed statement That permit he is licensed pursuant to the Provisions of the Contractor's License Law (Chapter 9(commencing with Section 7000)of Division 3 ofthc 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 (lie applicant to a civil penalty of not more than five hundred dollars (1500).): TOTAL TOTAL I PERMIT TO L 1 %q 77n C4nZol.lft8 units) OTY. "- PLUMBING PERMIT ,FEE'a STORIES 0 t�l Pe/tlne TYPE CONSTR. 5 N. Hr. ALTER -DRAIN & VENT -WATER (EA.)4.00 xo ❑ I, as owner of the property, or my employees with wages as their sale compensation, will do the work, and the structure Is not intended or offemd for sale (Sec. 7044, Business and Professions BACK FLOW PROTECT. DEVICE 2.00 OCC. GROUP R-1 RES. UNITS 8 DRAINS -FLOOR, ROOF, AREA, COND. 4.00 Code: The Contractor's License Law does not apply to an owner of property who builds or improves thereon, and who doessuch work FIXTURES - PER TRAP 4.00 sD. FT. FLOOR AREA TOTALACREAGE himself or through his own employees, provided that such improve- mentsarenotintendedoroircred]orsale.If,however,thebuilding 14,000 GAS-EA.SYSTEM-11NC.40UTLETS 4.00 r improvement is sold within one year of completion, the owner- builder will have the burden of proving that he did not build or im- prgvc-for purpose of sale.). yYPI, as owner of the property, ern exclusively contracting with li nsed contractors to construct Ole project (Sec. 7044, Business GAS - EA. SYSTEM - OVER 4 (EA.) 1.00 BUILDING USE REs wD CON PB Omer ❑ ❑ ❑ ❑ ❑ INDUSTRIAL WASTE INTER. 20.00 LAWN SPRINKLERS- 1 INC 5 V.B. 5.00 ASSESSORSPARCEL NO. and Professions Code: fhe Contractor's License Law does not apply tri owner of property who builds or improves thereon, and who LAWN SPRINKLERS - OVER 5 IEA.) 1.00 269-2-2 contracts tar such projects with a aontractoroO licensed pursuant to the Contractor's License Low. SEWER -SANITARY -STORM EA. 200ft/8.00 TRACT NO. PARCEL NO. WATER HEATER W/VENT 4.00 ❑ lam exempt under Scc. .B.&P.C. for this rcasmr 7575 Owner Dntn WATER SYSTEM 4.00 ACC. DATE ACC. FILE NO. WORK ERS'COMI'ENSA'I' ION DECLARATION WATER TREATING EQUIP. 4.00 I he'rehy affirm that I have a certificate of consent to Rlph6llre. or a certificate of Workers' o Compensation Insurance. r a certified copy thereof(See 3800, Lab.CJ. Policy No. Cmnpany ZONING ENG. SITE NO. ^ ❑ Certified copy is hereby furnished. ❑ Certified copy is filed with the city inspection division. Applicant FIRE SPRINK Y❑ IN ENERGY T 24 Y❑ N❑ MISC.- REFER TO ORD. CF-R'I'II'ICATI: OI' EXIifdI'TION FROM WORKERS' PERMIT ISSUANCE O.00 FLOOD ZONE A.L.U.C. PLG.CONTR. LIC. NO. PLG. TOTAL COAIPENBATION INSURANCE (This section need or be completed if the permit is for one y❑ N❑ V❑ N❑ QTY. MECHANICAL PERMIT FEE . -'t FEE SUMMARY hundred dollars(5100) or less.) I certify that in the performance of the work for which this per. Slit is issued, I shall not employ any person in any manner was to become )ubje t to the Workem'Com_ pensption Laws of California. Dale-7/17L16_jCSPL Applicam C+1❑P40.TYwf1 N(ITIC i A PLICAN'I': IC a cr making this Ccrt ificam of -x- emptiolL you should become subject in the Workeri Compensation provisions of the Labor Code, you must forthwith comply with such provisions or this permit shall be deemed rcv.kcd. CONSTRUCTION LENDING AGENCY BUILDING 1,260.50 ALTER OR ADD TO MECH. 4.00 APPLIANCE 4.00 PLAN CHECK FEE AIR HANDLING UNIT (TO 10=1C.F.M.) 3.60 AIR HANDLING UNIT (OVER 10=C.F.M.) 5.00 SEISMIC FEE 30.17 EXHAUST HOOD (WITH DUCT) 2.00 MICROFILM 1 hereby affirm that there is a construction lending agency for the performance of the work for which this per it is issued (Sec. 3097, Civ.C.). ,--� HEATING UNIT (TO 100,000 B.T.U.) 4.00 HEATING UNIT (OVER 100,000 B.T.U.)7.50 ELECTRIC Lerlder'x Name RA -t� Lender's Address I certify that I hove read this application and state that the above information is correct. I agree to comply with all city and county ordinances and star, laws relating to building construction, and VENTILATION FAN (SINGLE) 3.00 PLUMBING BOILER- COMP(3 H.P. or 100,000 B.T.U.) 4.00 BOILER -COMP (Over 100.000 BTU)SEE FEE SCH. MECHANICAL hereby :mlhoriee representatives of this city to enter upon the above -mentioned property for inspection purposes. MISC. - REFER TO ORD. CONST. TAX (We),agrcc to save, Indemnify and keep harmless the City of Cupertino against liabilities, judgments, costs and expenses which may in ally way accrue against said CI l in consequence of the PERMIT ISSUANCE 3.00 MECH.CONT. LI0.N0. TOTAL TOTAL 1,290.67 gr' ling lUspemf L/ /� �� �111Signature of Applicant Contractor DlItte OFFICE COPY