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11571 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY a� r BUI LDI NG PROJECT I DENTI FICATION PERMIT NUMBER RUILOINc APPLICATION & PERMIT 11571 ADDRESS 106!10 I-I-t LL R- ' T P- r BUILDING -ELECTRICAL-PLUMBING-MECHANICAL / OWNER'S PLAN CHECK VALIDATION T "AME C LL CITY. ELECTRIC PERMIT FEE P„ONE Z66�62oZ CONTRACTORS NAMEUTLETS-SWITCHES-RECEP 10.00/1.00 Llc.No. -1�0LIGHTING FIXTURES 10.00/1.00 ADDRESS R's PPLIANCES-RESIDENTIAL 4.00 ADDRESS JJ PRONE }30 PANELS 10.00 DATE OF APPLICATION ARCHITECT PANELS (OVER 200 AMP) 20.00 PLAN CHECK FEE P.C.NO. OR ENGINEER LIC.No. SIGNS TRANS. 3.00 AARCH.OR DDRESS ENG. SPECIAL CIRCUIT 5.00 PERMIT VALIDATION ZIP TEMP.METER OR POLE INS. 20.00 APPLICANTS MOTORS SEE FEE SCH. l 1R4lII alyl� ADDRESS � SERVICE CHANGE 20.00 'A+ G/_ w O o LICENSED CONTRACTORS DECLARATION V _ IP <L,u I hereby affirm that I am licensed under provisions of Chapter 9 �f IS ANCE DATE w a a (commencing with Section 7000)of Division 3 of the Business and BL LECT. PLG. MECH. F y- Professions Cod d my license is in full forE 1 f C ozm W. 'Licenw Cass Lic.Number )`�f �ggtm ❑ F w H J Dete 1O` Contractor 5 " a a OWNER-BUILDER DECLARATION BUILDING PERMIT _ a w INFORMATION D MISC.- REFER TO ORD X n w 1 hereby affum that I am exempt from the Contractor's License VALUATION $/FT. uo¢ Law for the following reason.(Sec.7031.5,Businessand Professions PERMIT ISSUANCE 10.00 514 X4 -1 Cade:Any city orcounly which requires a permit to construct,alter, ¢ to¢O improve,demolish,or repair any structure,prior to its issuance,also ELEC.CONTR. LIC.NO. ELEC. to DLL requires the applicant for such permit to file a signed statement that TOTAL PERMIT TO w$ he is licensed pursuant to the provisions of the Contractor's License Law(Chapter 'in with Section 7000)of Division 3 ofthe i o Business and Professions Code)or that he is exempt therefrom and CITY. PLUMBING PERMIT +/ III ¢ H$ the basis for the alleged exempt ion.Any viola t ion of Sect in It 7031.$ 111 SWORIES TYPE CONSTR. by any applicant for a permit subjects the applicant loacivil penalty ALTER-DRAIN&VENT- WATER IEA.) 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 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 docs 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 ACREAGE himself or through his own employees,provided that such improve- mentsare not intended oroffered for sale.IE however,the building GAS-EA.SYSTEM-I INC.4 OUTLETS 6.00 or improvement is sold within one year of completion,the owner- GAS-EA.SYSTEM-OVER 4 IEA.) 2.00 BU LDING USE builder will have the burden of proving that he did not build or im- IND CON PB Omar at prove for purpose of sale.). INDUSTRIAL WASTE INTER. 3000 ❑ I,as owner of the property,am exclusively contracting with . El 0 0 El licensed contractors to construct the project(Sec. 7044,Business LAWN SPRINKLERS-1 INC 5 V.B. 6.00 ASSESSORS PARCEL NO. and Professions Code: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.) 1,00 302 N/_�t0 � 06 contracts for such projects with a contructons)licensed pursuant to the Contractors License Law, SEWER-SANITARY-STORM EA.200ft/10.00 TRACT NO, PARCEL NO. ❑ Ions exempt under Sec. ,B.&P.C.lix this WATER HEATER W/VENT 6.00 / reason r Owner Uu[e WATER SYSTEM 5.00 ACC.DATE ACC.FILE NO, WO F.RS'COMPENSATION DECLARATION WATER TREATING EQUIP. 5,00 1 hereby affirm that I have a certificate of consent to self-insure, ZONING ENG.SITE NO. or a certificate of Workers'Compensation Insurance or a certified copy tlsercof(Sec..3800,Lab.G. . Policy No. Company Q ❑ Certified copy isherehy furnish FIRESPRINK ENERGY T 24 Z ❑ Cer'yy--led copy Is Illed�-whit on division. O ApplicanIt �llq�el' ^�+ MISC.- REFER TO ORD. YE] No YE] NE] I--' in PERMIT ISSUANCE 10.00 FLOOD ZONE A.L.U.C. � CERTIFICATE OF EATION I N P-R h1 ORKIiRS' Sl-I 1 COMPIot be completed INSURANCE the PLG.CONTR. LIC.NO. PLG. Y❑ NE] Y❑ N❑ CL Cl IT his seclirin need not he completed if the permit is for one TOTAL Z) Z hundred dollars IS 100)or less.) U O 1 certify that in the performance of the work for which this per, CITY. MECHANICAL PERMIT FEE FEE SUMMARY LL F mil is issued.I shall not employ any person in any manner so as to q U become subject to the Workers'Compensation Laws of California. /3 00U OL Date-Applicant ALTER OR ADD TO MECH. 5.00 BUILDING } to NOTICE TO APPLICANT: If, it,,making this Certificate of Ex- I- ? emption,you should become subject to the Workers'Compensation JAPPLIANCE 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 10,000C.F.M.) 4.00 CONSTRUCTION LENDING AGENCY AIR HANDLING UNIT(OVER 10=C.FM.) 6.00 SEISMIC FEE s 60 I hereby affirn 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.) 8.00 Lender's Name HEATI NG UN IT(OV ER 100,000 B.T.U.)9.50 ELECTRIC Lender's Address information that correct. read a ree application and state lcity d caboveounty VENTILATION FAN (SINGLE) 4.00 information n correct.I agree to comply with all city and county PLUMBING ordinances and state laws relating to building construction, and BOILER-COMP(3 H.P.or 100,000 B.T.U.) 6.00 hereby authorize representatives of this city to enter upon the BOILER-COMP (Over 100,000 BTU)SEE FEE SCH. MECHANICAL 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 CONST.TAX may in any way accrue against said City in consequence of the granting of this pe, MECH.CONT. UC.NO. MECH. ' 730 8'6 TOT TOTAL Signal of Applicant/Contractor I Dat OFFICE COPY POST THIS CARD NEAR FRONT OF BUILDING PFRA,IT NUMBERCITY OF CUPERTINO INSPECTION DIVISION JOB INSPECTION RECORD 1 PERMIT EXPIRATION JOB ADDRESS I co'l O TI I1 I hewec t t2 NIT•# LOT# PERMIT EXPIRES IF WORK OWNER CONTRACTOR IS NOT STARTED WITHIN INSPECTION DATE INSPECTOR INSPECTION RECORD 180 DAYS OF PERMIT ISSU- FOUNDATION IZ6�6 ANCE OR 180 DAYS FROM UFER LASTCALLED INSPECTION. PREGUNITE r PERMIT VALIDATION -23�( POUR NO CONC TIL A OVE HAS BEE IGNED - -� UNDERGROUND /SLAB PLUMBING ELECTRICAL - _ ISSUACE DATE MECHANICAL, a I ELECT. -'PLG. MECH, DO NOT POUR FLOOR UNTIL ABOVE HAS BEEN SIGNED BUILDING PERMIT WOOD FLOOR INFORMATION VALUATION $/FT. - PLUMBING _ MECHANICAL' PERMIT TO ELECTRICAL - /- FRAMING ( I/ t/1 .1,�• t A _ 1(. STORIES TYPE CONST.. INSULATION OCC.GROUP RES.UNITS PLACE NO SUBFLOOR UNTIL ABOVE HAS BEEN SIGNED ROOF SO.FT,FLOOR AREA TOTAL ACREAGE DIAPHRAGM BUILDING USE IND • CON PB 00", APPLY NO ROOFING UNTIL ABOVE HAS BEEN SIGNED ❑ ❑ Cl ❑ ROUGH ASSESSORS PARCEL NO. PLUMBING TRACT NO. PARCEL NO. GAS TEST MECHANICAL ACC.DATE - ACC.FILE N0. ELECTRICAL FINALS DATE INSP. FRAMING SAN # ZONING ENG,SITE NO. INSULATION PLUMBING GAS MECHANICAL FIRE SPRINK ENERGY T.ZA COVER NO WORK UNTIL ABOVE HAS BEEN SIGNED HEATING r ❑ " C] NEI v LATH-INTERIOR - ELECTRICAL, FLOODZONE A.L.U.C. LATH-EXTERIOR FIRE DEPT. Y❑ N❑ Y ❑ N❑ SHEETROCK - GRADE FEE SUMMARY SHEAR INTERIOR BUILDING J . SHEAR EXTERIOR - TEMPORARY APPROVALS BUILDING FIREWALLS ELECTRIC PLAN CHECK GAS I FEE NO TAPE OR PLASTER UNTIL ABOVE HAS BEEN SIGNED IOCCUPANCY ISEISMIC FEE 5 '? OCCUPANCY OF BUILDING IS NOT PERMITTED UNTIL BUILDING FINALISSIGNED BY BUILDING INSPECTOR. MICROFILM LU ARRANGE FOR INSPECTION BY PHONING 252.4505, 'ELECTRIC ONE WORKING DAY BEFORE REQUIRED INSPECTION. PLUMBING • 0� PLEASE GIVE JOB ADDRESS WHEN PHONING. ZMECHANICAL • — SEE PERMIT FOR EXPIRATION DATE — IMPORTANT!' CONST.TAX xy PLEASE READ REVERSE SIDE BEFORE CALLING FOR FINAL INSPECTION. TOTAL o by OFFICE COPY ' POST THIS CARD.NEAR FRONT OF BUILDING " CITY OF CUPERTINO PERMIT NUMBER INSPECTION-DIVISION `��� JOB INSPECTION RECORD '�' PERMIT EXPIRATION JOB ADDRESS Ic/1�i��fJ'( UNIT# _LOT# PERMIT EXPIRES IF.WORK OWNER L CONTRACTOR IS. NOT STARTED WITHIN INSPECTION DATE INSPECTOR INSPECTION RECORD 1810 DAYS OF PERMIT ISSU FOUNDATION - - - ANCE OR 180 DAYS FROM LIFER LASTCALLED INSPECTION.' PREGUNITE PERMIT VALIDATION - POUR NO CONCRETE UNTIL ABOVE HAS BEEN SIGNED —� UNDERGROUND /SLAB h J�fj191v PLUMBING ' ELECTRICAL - ISSUANCE DATE MECHANICAL , .BLDG. ELECT. PLG. MECH. , DO NOT POUR FLOOR UNTIL ABOVE HAS BEEN SIGNED I BUILDING PERMIT- WOOD FLOOR (d INFORMATION PLUMBING VALUATION SIFT. - - - . MECHANICAL _ ELECTRICAL PERMIT TD+:_ FRAMING INSULATION - •STORIES TYPE CONSTR. _ OCC.GROUPFEES UNITS PLACE NO SUBFLOOR UNTIL ABOVE HAS BEEN SIGNED ROOF "SO.FT.FLOOR AREA TOTAL ACREAGE DIAPHRAGM BUILDING USE RINO CON PB OMer APPLY NO ROOFING UNTIL ABOVE HAS BEEN SIGNED ES ❑ ' ❑ ❑ ❑ ROUGH ASSESSORS PARCEL NO. PLUMBING - GAS TEST- - TRACT NO. PARCEL NO. - MECHANICAL ACC.DATE , ACC.FILE NO. ELECTRICAL. FINALS DATE INSP. FRAMINGSAN # ZOrvING INSULATION PLUMBING � � ENG.- SITE NO. GAS MECHANICAL FIRE SPRINK ENERGY T.24 COVER NO WORK UNTIL ABOVE HAS BEEN SIGNED HEATING Y ❑ N❑ Y ❑ N❑ , LATH-INTERIOR ELECTRICAL YFLOOD ZONE A.L.U.C. LATH-EXTERIOR - FIRE DEPT. - Y❑ N❑ v I] -Nd SHEETROCK - GRADE FEE SUMMARY SHEAR INTERIOR BUILDING , BUILDING SHEAR EXTERIOR TEMPORARY APPROVALS . .FIREWALLS ELECTRIC . PLAN CHECK GAS FEE .. NO TAPE OR PLASTER UNTIL ABOVE HAS BEEN SIGNED JOCCUPANCY SEISMIC FEE OCCUPANCY OF BUILDING ISNOTPERMITTED UNTILBUILDING FINALISSIGNED BY BUILDING INSPECTOR. MICROFILM ARRANGE FOR INSPECTION BY PHONING 252-4505, ELECTRIC F ONE WORKING DAY BEFORE REQUIRED INSPECTION. PLUMBING ' f 'I0 PLEASE GIVE JOB•ADDRESS WHEN PHONING. .- SEE PERMIT,FOR EXPIRATION DATE - MECHANICAL IMPORTANT! CONST.TAX PLEASE READ REVERSE SIDE'BEFORE TOTAL -/-,_ CALLING FOR FINAL INSPECTION. • , • OFFICE COPY APPLICANT TO FILL IN INFORMATION WITHIN REO LINES - USE BALL POINT PEN ONLY .. BJI LDI NG PROJECT IDENTIFICATION ICATION & PERMIT J PERMIT NUMBER ADDRESG APPL10219 1� SUI LDI5 OWNER'S 2 _ T D BUILDING - ELECTRICAL-PLUMBING-MECHANICAL NAME PLAN CHECK VALIDATION J OTY. ELECTRIC PERMIT' ` FEE t �� PHONE ^(y a NAME ACTORS UTLETS-SWITCHES•RECEP 10.00/1.00 �. D LIC.NO.3(, LIGHTING FIXTURES 10.00/1.00 CONTRACTOR'S CONTRAS _0�+ tl!t[✓ / b4/*, APPLIANCES-RESIDENTIAL 4.00 0 r. HONE -G PANELS 10.00 DATE OF APPLICATION OORRCHITEC PANELS (OVER 200 AMP) 20,00 PLAN CHECK FEE .C.NO. ENGINEER LIC.No. ISIGNS TRANS. 3.00 ARCH. OR END SPECIALCIRCUIT S.QQ PERMIT VALIDATION ADDRZIP TEMP.METER OR POLE INS. 20.00 `• noo ESSTs MOTORS SEE FEE SCH. ,n �'f/l^-" - id C O SERVICE CHANGE 20.00 PAID woo LICENSED CONTRACTORS DECLARATION TEMP.POLE 30.00 a i w 1 hereby affirm that I am licensed under provisions of Cbapter 9 t 8 Al C UaTFIMCC y a (commencing with Section 7000)of Division 3 of the Business and BLDG. G. ECH. H D i Professions Code,and my license is Nm full fort,and If II. C ❑ z o= License Class___1�=Lie. ractmr�Fyr�!«� C J .1 ` O0r-D Dares_j-(f�Commctor L DE L+ x BUIL ING PERMIT ¢ ¢ a OWNER-BUILDER DECLARATION 3 a Li p MISC.- la€ plpp INFORMATION X y I herebyaffirm that I am exempt from the Contractor's License VALUATION S/FT. Fu00 J Law for the following reason.(Sec.7031.5,Business and Professions PERMIT ISSUANCE 10.00 Q Code:Anycitycounty whiny structurep riot to its issuance, ter,also ¢ ¢ improve,demolish,or repair any structure,prior to its issuance,also ELEC.CONTR. LIC.N0. ELEC. wO u requires the applicant for such permit to file a signed statement that TOTAL PERMIT TO "'S) $ he is licensed pursuant to the provisions of the Contractor's License /7Y� F z a Law(Chapter9(commencingwith Section 7000)of Division 3 ofthe f 4 er Business and Professions Code)or that he is exempt therefrom and QTY. PLUMBING PERMIT FEE ¢ 1- $ the basis for the alleged exemption.Any violation of Section 7031.5 STORIES TYPE CONSTR. i; _ by any applicant for a permit subjects the applicant loa civil penally ALTER-DRAIN -WATER (EA.) 5.00 of not more than five hundred dollars(5500).): ❑ 1,as owner of the property,or my employees with wages as BACK F LOW 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. 704,L 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/ SD FT.FLOOR PREP TOTALACREAGE • meets are throughhisown employees, ered forsle If,edthat,tsuch improve. GAS-EA.SYSTEM-11NC.4OUTLETS 6.00 meals are not intended or offered for sale.If,however,the building or improvement is sold within one year of completion,the owner- GAS EASYSTEM OVER 4 (EA) 200 builder will have the harden of proving That he did not build or im- - . - . . BUILDING USE prove fors owner ofsale.). INDUSTRIAL WASTE INTER. 30.00 RES IND 0 PB oma. ❑ d as owner of the property,ieI'projeciv Sc 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 Code:The Contractor's License Law does not apply to antr owner of properly who builds tr improves Thereon.and who LAWN SPRINKLERS-OVER 5(EA.) 0.1.00 contracts for such projects with a contrecmt(s)licensed pursuant to SEWER-SANITARY-STOR ft/10.00 the Contractor's License Law. TRACT NO. PARCEL NO. ❑ Iain exempt under Sec.-.R&P.C.for this WATER HEATER W/VENT 6.00 reason Owner Date WATER SYSTEM 1sP4ALC.DATE ACC.FILE NO, WORK ERS'COMPENSATION DECLARATION WATER TREATING EQUIP. .500 I hereby affirm that I have a certificate ofconsent to self-insure, CRY or a certificate of Workers'Compensation Insurance,or a certified ZONING ENG.SITE NO. copy thereof(Sec.3800,Lab.C.L Policy No. Compan Z 2 y z' 1 ❑ Certified copy is hereby furnished. FIRE SPRINK ENERGY T-24 O Certified copy is filed with the city inspection division. O Applicant MISC.- REFER TO ORD. Y❑ N❑ Y ❑ No ~ va PERMIT ISSUANCE 10.00 FLOOD ZONE A.L.U.C. LU CERTIFICATE COMPE COMPENSATION INS FROM WORKERS' W COMPENSATION INSURANCE PLC.CONTR. LIC.NO. PLG, Y El N❑ Y E] N E]Z (This section need not he complemd if the permit is for one TOTAL S hundred dollars(E 100)or IessJ U O 1 certify that in the performance of the work for which this per. QTY. MECHANICAL PERMIT FEE FEE SUMMARY LL F aril is issued,I shall not employ any person in any manner so as to O become subject to th Worke ' o passylon�,�yye of Culi10-7 ro DO Doh •! APPLICANT: p T: I i�` Lek ALTER OR ADD TO MECH. 5.00 BUILDING 119 7- } rn DateNOTICE TO APPLICANT:4f, filer making this Certificate of Iix- � ? coalition,you should become subject to the Workers'Compensation APPLIANCE 5.00 PLAN CHECK provisions of the Labor Code, you must forthwith comply with FEE f.) such provisions or this permit shall he deemed revoked AIR HANDLING UNIT(TO lo=t-F.M.) 4,00 CONSTRUCTION LENDING AGENCY AIR HANDLING UNIT(OVER 10MC.F.M.) 6.00 SEISMIC FEE 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,CW.C.). HEATING UNIT (TO 100,000 B.T.U.) 8.00 Lender's Name M Lender's Address HEATI NG UN IT(OVER 100,000 B.T.U.)9.50 ELECTRIC I Certify that l have rend 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 sate laws relating to building construction, and BOILER-COMP(3 H.P.Or 100,000 B.T.U.) 6.00 hereby authorize representatives of this city to enter upon the BOILER-COMP (Over 100,000 BTULSEE FEE SCH. MECHANICAL above-mentioned property for inspection purposes. (We) agree to save, indemnify and keep harmless the Cil,of MISC.- REFER TO ORD. Cupertino against liabilities,judgments, costs and expenses which PERMIT ISSUANCE 10.00 CONST.TAX may in any way accrue against said City in consequence of the grant Ingo this permit MECH.CONT. LIC.NO. MECH. TOTAL TOTAL gnalur of App icnI Contractor Date OFFICE COPY ' APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY BUILDING_ PROJECT IDENTIFICATION PERMITNDMBER ADDRESS APPLICATION & PERMIT 11456 h BUILDING-ELECTRICAL-PLUMBING-MECHANICAL .OE 'S PLAN CHECK VALIDATION "AME DTV. ELECTRIC PERMIT FEE Q PHONE NAMEnncroR' P OUTLETS-SWITCHES-RECEP 10.00/1.00 i/"$ON y( LIc.N pE, LIGHTING FIXTURES 10.00/1.00 CONTRACTOR'S APPLIANCES-RESIDENTIAL 4.00 ADDRESS /O, / aPHONE PANELS 10.00 DATE OF APPLICATION ARCHITECTPLAN CHECK FEE P.C.NO. on - PANELS (OVER 200 AMP) 20.00 ENGINEER LIC.No. SIGNS TRANS. 3.00 ADDRESS C. Oii ENG. SPECIAL CIRCUIT 5.00 PERMIT VALIDATION ZIP EMP.METER OR POLE INS. 20.00 ADDREr•s ADDRESS MOTORS SEE FEE SCH. ADDRESS SERVICE CHANGE 20.00 wre o LICENSED CONTRACTORS DECLARATION �/ G a i w 1 hereby affirm that 1 am licensed under provisions of Chapter 9 Cube I SUANCE DATE i (commencing with Section 7000)of Division 3 of the Business and BLDG. ELECT. 'PLG. MECH. 0 Professions Codey jnd my license is in full for of ❑ z o=- Licens g _,p_ c.N Liumber ❑ ❑ ❑ 0 r w Date ClClasorr- D Contracmr a Y f A3 BUILDING PERMIT ¢ a ¢ OWNER-BUILDER DECLARATION INFORMATION wOy0 MISC.- REFER TO ORD y I hereby affirm that I am exempt from the Contractor's License VALUATION $/FT. u0 ¢ Law for the following reason.(Sec.7031.5,Business and Professions PERMIT ISSUANCE 10.00 f i40J Code:Any city or county which requires a permit toconstruch alter, ¢ R ¢ 2 improve,demolish•or repair any structure,prior ro its issuance,also ELEC.CONTR. LIC.NO. ELEC. ta 0 u requires the applicant for such permit to file a signed statement that TOTAL PERMIT TO w$m he is licensed pursuant to the provisions of the Contractor's License Fzr Law(Chapter 9(commencing with Section 7000)of Division 3 ofthe iL(pL/Js x+/IQ.(J(�7g ¢ Business and Professions Code)or that Ise is exempt therefrom and OTY. PLUMBING PERMIT FEE It F the basis for the alleged exemption.Any violation of Section 7031.5 STORIES TYPE CONSTR. a. by any applicant for permit subjects the applicant loacivil penalty ALTER-DRAIN&VENT-WATER (EA.) 5.00 of not more than five hundred dollars(5500).): ❑ 1,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 F IXTUR ES-PER TRAP 5.00 50.FT.FLOOR AREA TOTAL ACREAGE 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 I NC.4 OUTLETS 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 ice- RES IND CON PB Other prove for purpose of sale.). INDUSTRIAL WASTE INTER. 30.00 ❑ 1,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 Code:The Contractor's License Law does not apply to an owner of properly who builds or improves thereon,and who LAWN SPRINKLERS-OVER 5(EA.). 1.00 contracts for such projects with a contractous)licensed pursuant to the Con tractor's License Law. SEWER-SANITARY-STORM EA.200ft/10.00 TRACT NO. PARCEL NO. 0 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. WORKERS'COMPENSATION DECLARATION WATER TREATING EQUIP. 5.00 1 hereby affirm that I have a Certificate of Consent to self-insure, ZONING ENG.SITE NO. or a certificate of Workers'Compensation Insurance,or a Certified copy there1(� LabC .) PolicMom7r1 O 0 Certified co is hereby furnls d. FIRE SPRINK ENERGY T 24 Z Z ❑ Certifie I f with t e city in comm division. MISC.- REFER TO ORD. y❑ N❑ y ❑ N❑ O Applicant OC -y - PERMIT ISSUANCE 10.00 FLOOD ZONE A.L.U.C. OC - C IF'CATE OF EXEMPTION 1• OM WORKERS' O. O COMPENSATION INSURANCE PLG.CONTH. LIC,NO. PLG, y❑ N❑ v ❑ N❑ (This section need not be completed if the permit is for one _ TOTAL Z) Z hundred dollars(S 100)or less.) U O 1 certify that in the performance of the work for which this per QTY. MECHANICAL PERMIT FEE FEE SUMMARY LL H mit is issued,I shall not employ any person in any manner so as to O L) become subject to the Workers'Compensation Laws of California. BUILDING _ Date Applicant ALTER OR ADD TO MECH. 5.00 } N NOTICE TO APPLICANT: If,after making this Certificate of Ex- F'- ? 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 U such provisions or this permit shall be deemed revoked. AIR HANDLING UNIT(TO 10MC.F.M.) 4.00 CONSTRUCTION LENDING AGENCY AIR HANDLING UNIT(OVER IOPMC.F.M.) 6.00 SEISMIC FEE 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. HEATING UNIT(TO 100,000 B.T.U.) 8.00 MICROFILM 3097,Civ.CJ. Lender's Name HEATING UNIT(OVER 100,000 B.T.U.0.50 ELECTRIC Lender's Address ' I certify that I have read This application and slate that BetaboveVENTILATION FAN (SINGLE) 4,00 ith information is correct.I agree to comply wall City and county PLUMBING ordinances and state laws relating to building construction, and BOILER-COMP(3 H.P.or 100,000 B.T.U.) 6.00 hereby authorize representatives of this city to enter upon the BOILER-COMP Oxr 100,000 BTU)SEE FEE SCH. MECHANICAL above-mentioned property 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 CONST.TAX may in any way accrue agat said City in consequence of the PERMIT ISSUANCE 10.00 gran' gofthis rm t. MECH.CONT. LIC.NO. MECH. �w ` _ TOTAL TOTAL .� IM re of App Icanl Co frac r ate OFFICE COPY APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY BUILDING PROJECT IDENTIFICATION PERMIT NUMBER BUILDING - -APPLICATION & PERMIT Ao°REaa BUILDING NaLC, PbICAL 11841 wNBR's PLAN CHECK VALIDATION AME e.LL 2GG-HZOZ DTV- ELECTRIC PERMIT FEE v orvE sAME ACTORS UTLETS-SWITCHES-RECEP 10.0011.00 uc.No. LIGHTING FIXTURES 10.00/1.00 CONTRACTOR S APPLIANCES-RESIDENTIAL 4.00 PHONE PANELS 10.00 DATE OF APPLICATION OARCHITECTPANELS (OVER 200 AMP) 20.00 - PLAN CHECK FEE P.C.NO. NGINEER uc.Na. SIGNS TRANS. 3.00ARCH ADDRESS OR ENG. SPECIAL CIRCUIT S.00 PERMIT VALIDATION ZIP rrEMP.METER OR POLE INS. 20.00 SEP I ( 1000 AMOTORS SEE FEE SCH. ADDRESS SERVICE CHANGE 20.00 ,City Of CuDertino w 0 O LICENSED CONTRACTORS DECLARATION Q,o I hereby affirm that I am licensed under provisions of Chapter 9 w (Commencing with Section 7000)of Division 3 of the Business and ISSUANCE DATE < SLOG. EL C G. MECH. H ve iProfessions Code,and my license is in full force and effect. - ID ❑ ❑ 2 O m- License Class Lie Number 4 H r w Dale Contmaor � � ' a m BU DING PERMIT or m w OWNER-BUILDER DECLARATION _ B% FORMATION as ;n y I hereby affirm that 1 am exempt from the Contractor's License Nftc.- REFER TO ORD u. o sr Law for the following reason.(Sea 7031.5,Bueinessand Professions VALUATION $/FT. i - PERMIT ISSUANCE 10.0 Code:Any city or county which requirese permit prior construct,Baer, 2 rt ¢ improve,demolish,or repair any structure,prior to its issuance,also ELEC.CONTR. LIC.N0. ELEC. e- G u requires the applicant for such permit to file a signed statement that TOTAL PERMIT TO E se he is licensed pursuant to the provisions of the Contractor's License r z rt Law(Chapter 9(commencing with Section 7000)of Division 3 of the E i p Business and Professions Code)or that he is exempt therefrom and QTY. PLUMBING PERMIT FEE F$ the basis for the alleged exemption.Any violation of Section 7031.5 STORIES TYPE CONS a;� by any applicant for a pefmitsobjects the applicantto a civil penalty ALTER-DRAIN (EA.) 5.00 of not more than five hundred dollars($500).): ❑ 1,as owner of the properly,or my employees with wages as BACK FLOW PROTECT. DEVICE 4.00 OCC.GROUP RES.UNITS their sole compensation,will do the work,and lire 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 SQ FT.FLOOR AREA TOTAL ACREAGE himself or through his own employees,provided that such improve- mentsarenotintendedorofferedforsale.If,however,the building GAS-EA.SYSTEM-1 INC.4 OUTLETS 6.00 or improvement is sold within one year of completion,the owner- GAS-EA.SYSTEM-OVER 4(EA.) 2.00 builder will have the burden of proving that he did not build or air- BUILDING USE RES IND CON PB Omer prove for purpose of sale.). INDUSTRIAL WASTE INTER. 30.00 0 1,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 Code: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 Cor such projects with a contractors)licensed pursuant to SEWER-SANITARY-STORM EA.200ft/10.00 the Contractor's License Law. TRACT NO. PARCEL NO. 0 I am exempt under Sec,.,BAP.C.for this WATER HEATER W/VENT 6.00 corer ✓ Dale WATER SYSTEM 5.00 ACC.DATE ACC.FILE O. WORKERS'COMPENSATION DECLARATION WATER TREATING EQUIP. 5.00 1 hereby affirm that I have a certificate of consent to self-insure, or a certificate of Workers'Compensation Insurance,or a certified ZONING ENG.SITE NO. copy thereof(Sec.3800,Lab.CJ. Policy No. Company C 0 Certified copy is hereby furnished. FIRE SPRINK ENERGY T-24 Z Z 0 Certified copy is filed with the city inspection division. F O Applicant MISC.- REFER TO ORD. y❑ N❑_ v ❑ N❑ � y CERTIFICATE OFd?XEMPTION FROM WORKERS' PERMIT ISSUANCE 10.00 FLOOD ZONE A.L.U.C. LU COMPENSATION INSURANCE PLG.CONTR. LIC.NO. PLG. C v❑ N❑ V ❑ NE] (This section need not be completed if the permit is for one TOTAL 0 Z hundred dollms($100)odes$.) U O 1 certify that in the performance of the work for which this per, CITY MECHANICAL PERMIT FEE FEE SUMMARY LL I- mit is issued,I shall not employ any person in any manner so as to O W become subject to the Workers'Compensation Laws of California. o. Date Applicant ALTER OR ADD TO MECH. 5.00 BUILDING } N NOTICE TO APPLICANT: If,after making this Certificate of Ex- ♦- Z emptier,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=CF.M.) 4.00 CONSTRUCTION LENDING AGENCY AIR HANDLING UNIT(OVER 10=C.F.M.) 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,CN.C.). HEATING UNIT(TO 100,000 B.T.U.) 8.00 Lender's Name HEATING UNIT(OVER 100,000 B.T.U.)9.50 Lender's Address ELECTRIC I certify that I 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-COMP(3H.P.or100,000B.T.U.) 6.00 hereby authorize representatives of this city to enter upen the BAILER-COMP (Over 100,000 BTU)SEE FEE$CH. MECHANICAL above-mentioned property 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 10.001CONST.TAX may in any way accrue against said City in consequence of the rant oftl permit MECH.CONT. - LIC.NO. MECH. 3Dy TOTAL TOTAL Signature of Applicant/Contractor 11tc OFFICE COPY