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1619CITY OF CUPERTINO 4TION FOR COMMERCIAL BUILDING AND ®'� cIi't OF CUpSdTINO PERMITIN OV •\ CERTIFICATE pF OCCUPANCY / UILDINQ INBPECTIQN OIV1910N Plans Received By .................... ____ ...... ................ Date .... REO.: Plans.... Survey.... Calcs: Struc._.. Energy.... Elect.._ Mach..... Plans Checked By .... ._................ ............ .... Date ... ....... Application Approved BY -4, Date ValidatedBY ..._....._........_............_ ..................... Date ............. Compensation Certificate Verified By ..W7....... Date ..j��.Wo , IIIIFANEo ••e $ Permit Fee (plus penalty if applicable) ....... $....................... Plan Check Fee (less deposit of $.......... Rct. #..........) $......._.............. Energy Plan Check Fee (Dep, of $........ Rct. #........) $....................... Strong Motion Fee ......... ........... $................. _..-. Plumbing Permit Fee ................................................$.. . Electrical Permit Fee ........................................... Mach. Htg./Coolg. Permit $ .............................: $..... ......... .._._.. Construction Tax ............................................. $__....__........_. Sewer Conn. Fee ......... Water Conn, Fee .._..... .... $..... Landscape Fee .................... Street Tree Fee ............ $....................... Misc. Fee ......... _.......... ..._...................................._._._ $........._. _......... Type Const......... Group........ Div...-..... Occ. Load........ No. Exits........ Floor Loads: 1st._ 2nd.... Other.... Sprinklered._. Area Sep. Walls.... Environmental Status: Exempt............ Other......... _......_..........__..._.. Design Review Approval: Bldg ............. Site ............ Sign ............ UseZone ............ P.D. Conditions ... ... ......'............................................... Cond. Use Permit #...... Variance #...... Parking Spaces.... Load. Sp..... ApprovedBy ..__ ......... ..............._.............._._........ Date ...._._.............. .... ncroachment Permit ........................ Grant of Easement.....-.... ....... ....... Curb, Gutter, Sidewalk,Driveway: Replace Repair Sewer.._........ Conn. Fee $.. _._... _.... Water. ............... Meter $... ............ Agreement for Completion of Public Works Improvements .................. Plans Checked By--.... Date........ Approved By...._.. Date .................... N0. EACH FEE PERMIT INSTALLATION Light Outlets _... __... Switches...... ...... Fixtures............ Receptacles ... '?r..... TOTAL NUMBER (less than 1000 watts),....._._.._..._$ .50 Range........ Cooking Unit........ Oven _._........__..__. _.. 2.00 ..__._._... Dryer.... Garb. Disp... Dishwasher .... ...__. __._.......... 2.00 ............... SERVICE OR TEMPORARY POWER to ... 2.00 . . 100 amp/$5.00, 200/$7.00, 500/$9.00 800/$20.00, 1200/$40.00 ........ .... ..... _ .........__..................... MOTORS, Generators, Welders, Heaters, per HP—KW—KVA to 1/$2.00, 5/$3.50, 20/$8.50, 50/$10.00, 100/$12.00, 500/$15.00 ...... ...._...__._........................._........ _. .........._._. _......_..... Signs with I XFMR._... _....................._............._..... ._ 2.00 _ .............. Each additional XFMR/Time Clock _.._........... ... .50 .. .............. Annual Electrical Maintenance .......... _..... 25.00 ..........__.. Other (see Ordinance Current) (/-d ..... ...: ..._ ..._ PermitFee........................................................................ $ 6.00 TOTAL ELECTRICAL PERMIT FEE (plus penalty if app. []) $ fl•D-D .. Forms / Foundation .._.._._........._..._.... By: ............... ... Date:................ Plumbing Ground Work ..._...._...... _..................._......... _.....__.... ....._..... ughElectrical ..................................................................... 1m _ .. a - Plumbing and Heating ................................... ........................... sulatlon / Energy.......... ........... ....:.... ................................... GasTest ........................ ......................... ........................ ........................... Temporary Power Gas / Elect............................................................... Final- Electrical .................. ................... ............... ......... ........................... Final - Building / Mechanical ........................................... ..... Final - Design Review / Landscaping.................................................... Final — Public Works........................................................... 980 PERMIT NUMBER �(o ,. ... , "r,17C IN STREET ADDRESS OF PROJECT: /..46 7 S.__.C...A...N.L�4.................................... Legal Description: Tract :. .................... Block. ..... Lot. Description of Work: ._ 0.ra..crA�(.._._................................................ 1st Struct. Improvement on Parcel: Yes.ke. No.... Area of Bldg ............... Separate Structure ............ or Addition/Alter tion to Exist. Bldg..(...... No. of Stories ..... ./_..... Use of Buildbrbg.....1.+^...L.._........................... Valuation I Project: $.... __y.51.a........... ......................... .................. Owner: 04.ofN.... ZtLl)............. ............ ...... _............. Phone:.................... Contractor: ................ City Bus. Lic. #.., 1_111!x.3........ y.... Address:-./P?/s..... R.drfa„r�.... .,)9v_Q._. ....... Phoned... ......... ' Contractor - Electrical: .W.:..m. &.5 ...... E1.2..cT.r ,:c ._................... City Business License #../ Yl!. 3.... Phone:kK.1.93.C.5 Plumbing: ......_..... ................ .................._.............................. City Business License #.._................ Phone:.................... Heating and Cooling ............ ........ ...... ...__... ..._....................... City Business License #.................... Phone:.................... Architect/ Designer: .._.._..._.... .................. ... .-........ Phone:.................... Engineer: .... ....... ........ ........ _ .............. Phone:......_.. Unknown Lender:........._._._._._. .......... _._._..._........................... _........ ..... ...... "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 workma�lJ('' co/mppensa�tionnllaws California." / SIGNATURE OF A PL CANT/OWNER ✓"_�(Kk! ....... . DATE V.Y:-... .. . _.._.. .... % .....x,. I certify that as the applicant I am licensed under the pr visions of the ContrContractors License law and further that my License No. , .�..(._�J.0.1..... actors Classification .... G .. !... .... ___ is is In full force and effect: or ............ I certify that i am exempt from the "Licensed Req. ''ed" provisions of the Contractors License Law. (State basis of exemption., I hereby acknowledge that I have read this application and state that the above Is correct and agree to comply with all City Ordinances and State Laws regulating building. I (We) agree to save, indemnify and keep harmless the City of Cupertino against liabilities, judgments, costs and expanses which may in any way acture against said City in gonsequen ofath granting of this perm)iit. SIGNATURE OF e 1 y{� � %6-b. APPLICANT/CONTRACTOR V �//l'Vvh:'v... DATE ...... _./.............. NOTE: When properly validated this form constitutes a Building Permit. This permit expires and becomes null and void should work not be commenced within 120 days from validation date, or should authorized construction be suppended of abandoned for a period of 120 days after work Is commenced. PERMIT INSTALLATION NO. EACH I FEE Gas Sytem with up to 5 outlets .......................... ......... $ 4.00 ---..... Each additional outlet .................................. .......... 1.00 ............. Water System (Installation, Alt. or Repair) ...... .......... 4.00. ___....._.. Water Closet.... Water Heater.... Ld. Tray.......... ......... . 4.00.............. Lavatory.... Shower Pan.... Bathtub.... Sink.. .... - __ .... 3.00.............. Wash. Mach..... Dishwasher.... Garb. Disp................... 3.00.............. Sewer._........_......................_......................_................. 8.00, ............. Lawn Sprinkler Sys. $6.00 Ea. add Sys.$2.00. ........ .............. ............. Vacuum Breakers .............................................4.50 ................. .. Slop Sink....... Floor Sink........ Floor Drain .... 400 ........ Urinal...Interceptor.... Water Softener..........4............. PlumbingPiping without fixtures ...... a.00 ........ Msc ...._.._. ......._............................... _..�......... .............. ............. PermitFee .. .... ........................ ..................... ....................... $ 6.00 TOTAL PLUMBING PERMIT FEE (plus penalty if app. p) $ PERMIT INSTALLATION NO. EACH FEE Forced Air Unit......... ...... to 100M ................................. $ 6.00 ..........----- over 100M .................... ........ 10.00 ............... Comfort Cooling Unit_ ... to 3 ton/HP .......... .... _. ........... 6.00 ............... to 15 ton/HP ........................... 9.50 ............... to 30 ton/HP .......................... 12.00 ............... to 50 ton/HP .......................... 17.00 ............... Space Heater........ Wall Heater ....... ____ ..... _.......... . .., 6.00 ............. Flues - other than above .................................... ......... ... 3.00 ............... Vent Fan: Kitchen........ Bath ............................... ......... ... 3.00 .............. Commercial Range Hood .............. .. 6.00 ..... Misc............................................................................................................ PermitFee........................................................................ $ 6.00 TOTAL Htg./ Coolg. Permit Fee (plus penalty If app. p) $ Other (see Ordinance Current) (/-d ..... ...: ..._ ..._ PermitFee........................................................................ $ 6.00 TOTAL ELECTRICAL PERMIT FEE (plus penalty if app. []) $ fl•D-D .. Forms / Foundation .._.._._........._..._.... By: ............... ... Date:................ Plumbing Ground Work ..._...._...... _..................._......... _.....__.... ....._..... ughElectrical ..................................................................... 1m _ .. a - Plumbing and Heating ................................... ........................... sulatlon / Energy.......... ........... ....:.... ................................... GasTest ........................ ......................... ........................ ........................... Temporary Power Gas / Elect............................................................... Final- Electrical .................. ................... ............... ......... ........................... Final - Building / Mechanical ........................................... ..... Final - Design Review / Landscaping.................................................... Final — Public Works........................................................... 980 PERMIT NUMBER �(o ,. ... , "r,17C IN STREET ADDRESS OF PROJECT: /..46 7 S.__.C...A...N.L�4.................................... Legal Description: Tract :. .................... Block. ..... Lot. Description of Work: ._ 0.ra..crA�(.._._................................................ 1st Struct. Improvement on Parcel: Yes.ke. No.... Area of Bldg ............... Separate Structure ............ or Addition/Alter tion to Exist. Bldg..(...... No. of Stories ..... ./_..... Use of Buildbrbg.....1.+^...L.._........................... Valuation I Project: $.... __y.51.a........... ......................... .................. Owner: 04.ofN.... ZtLl)............. ............ ...... _............. Phone:.................... Contractor: ................ City Bus. Lic. #.., 1_111!x.3........ y.... Address:-./P?/s..... R.drfa„r�.... .,)9v_Q._. ....... Phoned... ......... ' Contractor - Electrical: .W.:..m. &.5 ...... E1.2..cT.r ,:c ._................... City Business License #../ Yl!. 3.... Phone:kK.1.93.C.5 Plumbing: ......_..... ................ .................._.............................. City Business License #.._................ Phone:.................... Heating and Cooling ............ ........ ...... ...__... ..._....................... City Business License #.................... Phone:.................... Architect/ Designer: .._.._..._.... .................. ... .-........ Phone:.................... Engineer: .... ....... ........ ........ _ .............. Phone:......_.. Unknown Lender:........._._._._._. .......... _._._..._........................... _........ ..... ...... "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 workma�lJ('' co/mppensa�tionnllaws California." / SIGNATURE OF A PL CANT/OWNER ✓"_�(Kk! ....... . DATE V.Y:-... .. . _.._.. .... % .....x,. I certify that as the applicant I am licensed under the pr visions of the ContrContractors License law and further that my License No. , .�..(._�J.0.1..... actors Classification .... G .. !... .... ___ is is In full force and effect: or ............ I certify that i am exempt from the "Licensed Req. ''ed" provisions of the Contractors License Law. (State basis of exemption., I hereby acknowledge that I have read this application and state that the above Is correct and agree to comply with all City Ordinances and State Laws regulating building. I (We) agree to save, indemnify and keep harmless the City of Cupertino against liabilities, judgments, costs and expanses which may in any way acture against said City in gonsequen ofath granting of this perm)iit. SIGNATURE OF e 1 y{� � %6-b. APPLICANT/CONTRACTOR V �//l'Vvh:'v... DATE ...... _./.............. NOTE: When properly validated this form constitutes a Building Permit. This permit expires and becomes null and void should work not be commenced within 120 days from validation date, or should authorized construction be suppended of abandoned for a period of 120 days after work Is commenced. PERMIT INSTALLATION NO. EACH I FEE Gas Sytem with up to 5 outlets .......................... ......... $ 4.00 ---..... Each additional outlet .................................. .......... 1.00 ............. Water System (Installation, Alt. or Repair) ...... .......... 4.00. ___....._.. Water Closet.... Water Heater.... Ld. Tray.......... ......... . 4.00.............. Lavatory.... Shower Pan.... Bathtub.... Sink.. .... - __ .... 3.00.............. Wash. Mach..... Dishwasher.... Garb. Disp................... 3.00.............. Sewer._........_......................_......................_................. 8.00, ............. Lawn Sprinkler Sys. $6.00 Ea. add Sys.$2.00. ........ .............. ............. Vacuum Breakers .............................................4.50 ................. .. Slop Sink....... Floor Sink........ Floor Drain .... 400 ........ Urinal...Interceptor.... Water Softener..........4............. PlumbingPiping without fixtures ...... a.00 ........ Msc ...._.._. ......._............................... _..�......... .............. ............. PermitFee .. .... ........................ ..................... ....................... $ 6.00 TOTAL PLUMBING PERMIT FEE (plus penalty if app. p) $ PERMIT INSTALLATION NO. EACH FEE Forced Air Unit......... ...... to 100M ................................. $ 6.00 ..........----- over 100M .................... ........ 10.00 ............... Comfort Cooling Unit_ ... to 3 ton/HP .......... .... _. ........... 6.00 ............... to 15 ton/HP ........................... 9.50 ............... to 30 ton/HP .......................... 12.00 ............... to 50 ton/HP .......................... 17.00 ............... Space Heater........ Wall Heater ....... ____ ..... _.......... . .., 6.00 ............. Flues - other than above .................................... ......... ... 3.00 ............... Vent Fan: Kitchen........ Bath ............................... ......... ... 3.00 .............. Commercial Range Hood .............. .. 6.00 ..... Misc............................................................................................................ PermitFee........................................................................ $ 6.00 TOTAL Htg./ Coolg. Permit Fee (plus penalty If app. p) $ Sheet 2 CITY OF CUPERTINO BUILDING PERMIT Permit Pilo: Address: /d 6 75 1>. ANZA a)oa Date: //�/1Ifr0 BUILDING PROJECT IDENTIFICATION Applicant's Mailing Address jo.2/o A.rrf,,, AJ.Q C(AT:wa Address of Building / d G % pe A fo zo (w c, Owner's name Telephone No. Contractors Name Contractor's ?Tailing Address Architect or Engineer Architect's or Engineer's Address o Zcu 1I-11 • if r"tY5 yjeer /e 1/o AAv: .,i Cis a .-7-i voo Lic. No. 3 "yTTyI Lic. No. LICENSED CONTRACTORS DECLARATION I hereby affirm that I am licensed under provisions of Chapter 9 (commencing with Section 7,000) of Division 3 of the Business and Professions Code,and m� license is in full force and effect. '.Js 7 (q o r License Class C Lic. Number Date yf /j V5e'ti Contractor (,I'.{{, (,,s OWNER -BUILDER DECLARATION 1 hereby affirm that 1 am exempt from the Contractor's License •Law for the following reason (Sec. 7031.5, Business and Professions Code: Anycityorcounty which requiresapermit toconstruct,alter, 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 Contractor's License Law (Chapter 9 (commencing with Section 7000) of Division 3 of the 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 the applicant to a civil penalty of not more than five hundred dollars (5300).): ❑ I. as owner of the property, or my employees with wages as their sole compensation, will do the work, and the structure is not intended or offered for sale (Sec. 7044, Business and Professions Code: The Contractors 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, provided that such improvements are not ini ended or offered for sale. If, however, the building or improvement is sold within one year of completion, the owner -builder will have the burden of proving that he did not build or improve for the purpose of sale.). ❑ I, as owner of the property, am exclusively contracting with 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 contracts for such projects with a contractor(s) licensed pursuant to the Contractors License Law.). ❑ 1 am exempt under Sec. , B.&P.C. for this reason —_ Date, Owner WORKERS' COMPENSATION DECLARATION I herelav affirm that i have a certificate of consent to self -insure, or a certificate of Workers' Compensation Ins c�rtifiey copy thereof (Ser 600, 'ab.C.�. 5e:.t.O4 nee, or a NO,C Policy No. Cumpany 9�'-1c Certified copy is hereby furnished. C % i 76 93 Certified copy is filed with the county building inspection depart en or county dd�a��artmer(� (1 , ,I Date/ Applicant ,.Liar....• u �hi7Yi� CERTIFICATE OF EXEMPTION FROM WORKERS' COMPENSATION INSURANCE (This section need net be completed if the permit is for one hundred dollars ($I00) or less.) I certify that in the performance of the work for which this permit is issued, l shall not employ any person in any manner so as to become subject to the Yorkers' Compensation Laws of California. Date Applicant NOTICE TO APPLICANT: If, after making this Certificate of Exemption, 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. 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, Civ.C.). Lender's Name Lender's Address ' I certify that I 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' hereby authorize representatives of this county to enter upon the above-mentioned property for inspection purposes. Signature of AppBeent or Agent Date "OWNER -BUILDER VERIFICATION "Attention Property Owner: '.'An 'owner -builder' building permit has been applied for in your name and bearing your signature. "Please complete and return this information in the envelope provided at your earliest opportunity to avoid unnecessary delay In processing and issuing your building permit. No building permit will be issued until this verification is received. I. 1 personally plan to provide the major labor and materials for construction of the proposed properly improvement (yes or no) 2 I (have/have not) signed an application for a building permit for the proposed work. A 1 have contracted with the following person (firm) to provide the proposed construction: Name Address City Phone Contractors License No. 4. I plan to provide portions of the work, but 1 have hired the following person to coordinate, supervise, and provide the major work- Name Address City Phone Contractors License No. 5. 1 will provide some of the work but 1 have contracted (hired) the following persons to provide the work indicated: Name Address Phone Type of Work Signed: Property owner Social Security number _ Date: