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9253 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY / BUILDING PROJECT IDENTIFICATION PERMITNUMBER I ADDRESS APPLICATION & PERMIT 9253 ADDRESS x/6g/ 4/00 LiINE BUILDING -ELECTRICAL-PLUMBING -MECHANICAL NAME a PLAN CHECK VALIDATION NAME CITY, ELECTRIC PERMIT FEE WfLLipI" AvEfz y PHONE NAMERAcrDRs UTLETS-SWITCHES-RECEP 10.00/1.00 _ bL .e LIC.NO. LIGHTING FIXTURES 10.00/1.00 CONTRACTOR S ADDRESS ,StlN.vy✓Itc tp.p2rj" APPLIANCES-RESIDENTIAL 4,00' _ 0.50 /r/Q a PHONE � (- Z PANELS 10.00 - DATE OF APPLICATION AKcmTECi PLAN CHECK FEE + D.C.NO. OR PANELS (OVER 200 AMP) 20.00 ENGINEER - -UC.No,• SIGNS.TRANS. 3.00 ARCH.OR ENG. PERMIT VALIDATION ADDRESS SPECIALCIRCUIT 5.00 ' ZIP EMP.METER OR POLE INS. 20.00 APPLICANT A MOTORS SEE FEE SCH. SERVICE CHANGE 20.00 WOZO LICENSED CONTRACTORS DECLARATION TEMP.POLE 30.00 a . U 1 hereby affirm that I am licensed under provisions Of Chapter 9 ISSUANCE DATE E­ <a (Commencing with Suction 7000)of Division 3 of the Business and BLDG. ELECT. PLG. MECH. r• m i Professions Code,and my license is in full force and effect. - ❑ ❑ ❑ ze 0•n o License Class Lia Number ,Z H Date Contractor ,�p-•9 �� Q y E � y/{. �11A1�, Ic IS w a OWNER-BUILDER DECLARATION ✓ '" BUILDING PERMIT o A U INFORMATION w g H I hereby affirm that 1 am exempt from the Contractor's License MISC.- R RTO ORD L_ O ¢ Law for the following reason.(Sec.703 L5,Business and Professions VALUATION $/FT. � - I Code:Any City orcounty which requires a permit to construct,alter, PERMIT ISSU E _Wke. - rc ¢ 0 improve,demolish,or repair any structure,prior to its issuance,also ELEC.CONTR', LIC.NO. ELEC. O Q requires the applicant for such permit to file a signed statement that - TOTAL �0 he is licensed pursuant to the provisions of the Contractor's License PERMIT TO m z rt Law(Chapter 9(commencing with Section 7000)of Division 3 of the e4HE-�_r 4 O Business and Professions Code)or that he is exempt therefrom and Y. PLUMBING PERMIT FEE a I- the basis for the alleged exemption.Any violation of Section 7031.5 11 STORIES TYPE CONSTR. a3 ^ by any applicant for a permit subjects the applicant to a civil penalty - ALTER-DRAIN -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 their Sole compensation,will do the work,and the structure is not OCC.GROUP RES.UNITS intended Or offered for sale (Sec. 7044, Business and Professions DRAINS-FLOOR,ROOF,AR EA,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 SO.FT.FLOOR AREA TOTAL ACREAGE, himself or through his own employees,provided that such improve- mentsarenot 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 the burden of proving that he did not build or im- IGAS-EA.SYSTEM-OVER 4(EA.) 2.00 BUILDING USE prove for purpose of sale.). INDUSTRIAL WASTE INTER3000 RES IND CON Pe Omar 13 . . I,as owner of the property,am exclusively contracting with '� licensed contractors to construct the project(Sec.7044,Business LAWN SPRINKLERS-i INC 5 00 - ASSESSORS PARCEL NO. and Professions Code:The Contractor's License Law does not apply V.B.. . to ancontracts owner of property who builds tr improves thereon,and who LAWN SPRINKLERS-OVER 5(EA.) 1.00 the Contract suchLicenects Lwitha contracmr(s)licensed pursuant to SEWER-SANITARY-STORM EA.200ft/10.00 the Contractor's License Law. TRACT N0, PARCEL NO. ❑ lam exempt under Sec. ,B.&P.C.for this reason WATER HEATER W/VENT 6.00 Owner ' Date WATER SYSTEM 5.00 ACC.DATE ACC.FILE NO. WORK ERS'COMPENSATION DECLARATION WATER TREATING EQUIP. 5.00 I 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. -7[ copy thereof(Sec.3800,Lab.CA Policy No. Company 0 ❑ Certified copy is hereby furnished. FIRE BPO INK ENERGY T-]< Z Z ❑ Certified copy is filed with the city inspection division. 'I FO J Applicant I MISC.- REFER TO ORD. Y[3 N❑ Y [3 NE] = T CERTIFICATEOF EXEMPTION FROM WORKERS' PERMIT ISSUANCE 10.00 FLOOD ZONE A.L.u.C. LU > COMPENSATION INSURANCE PLG.CONTE. LIC.NO. PLG. 0. 0 (This section need not be completed if the,permit is for one TOTAL Y IN Y ❑ NC:] :) Z hundred dollars($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 U mit is issued,I shall not employ any person in any manner so as to become su je tc the Workers'tytQpens ion !,5,(lL liforni' O i Date - Applicant BUILDING Do NOTICE TO APPLICANT: If,after makin this CeALTER OR ADD TO MECH. 5.00 } g Deal, Ex- 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 10,000 C.F.M.) 4.00 CONSTRUCTION LENDING AGENCY AIR HANDLING UNIT(OVER 10PMC.RM.) 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,Civ.C.). HEATING UNIT(TO 100,000 B.T.U.) 8.00 Lender's Name Lender's Address HEATING UNIT(OV ER 100,000 B.T.U.)9.50 ELECTRIC 0 � I certify[hat l have read this application and stale that the above VENTILATION FAN ISINGLE) 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(3 H.P.Or100,000B.T.U.) 6.00 hereby authorize representatives of this city to enter upon the BOILER (Over 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 whichiPERMIT ISSUANCE 10.00 - CONST.TAX may in any way accrue against said City in of the granting o.)this per t. MECH.CONT. LIC.NO. MECH. TOTAL TOTAL ' Ignatureof Apphcxnl/C!o`nU�actorU Date OFFICE COPY r APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY / BUILDING PROJECT IDENTIFICATION PERMITNUMBER I ADDRESS APPLICATION & PERMIT 9253 ADDRESS x/6g/ 4/00 LiINE BUILDING -ELECTRICAL-PLUMBING -MECHANICAL NAME a PLAN CHECK VALIDATION NAME CITY, ELECTRIC PERMIT FEE WfLLipI" AvEfz y PHONE NAMERAcrDRs UTLETS-SWITCHES-RECEP 10.00/1.00 _ bL .e LIC.NO. LIGHTING FIXTURES 10.00/1.00 CONTRACTOR S ADDRESS ,StlN.vy✓Itc tp.p2rj" APPLIANCES-RESIDENTIAL 4,00' _ 0.50 /r/Q a PHONE � (- Z PANELS 10.00 - DATE OF APPLICATION AKcmTECi PLAN CHECK FEE + D.C.NO. OR PANELS (OVER 200 AMP) 20.00 ENGINEER - -UC.No,• SIGNS.TRANS. 3.00 ARCH.OR ENG. PERMIT VALIDATION ADDRESS SPECIALCIRCUIT 5.00 ' ZIP EMP.METER OR POLE INS. 20.00 APPLICANT A MOTORS SEE FEE SCH. SERVICE CHANGE 20.00 WOZO LICENSED CONTRACTORS DECLARATION TEMP.POLE 30.00 a . U 1 hereby affirm that I am licensed under provisions Of Chapter 9 ISSUANCE DATE E­ <a (Commencing with Suction 7000)of Division 3 of the Business and BLDG. ELECT. PLG. MECH. r• m i Professions Code,and my license is in full force and effect. - ❑ ❑ ❑ ze 0•n o License Class Lia Number ,Z H Date Contractor ,�p-•9 �� Q y E � y/{. �11A1�, Ic IS w a OWNER-BUILDER DECLARATION ✓ '" BUILDING PERMIT o A U INFORMATION w g H I hereby affirm that 1 am exempt from the Contractor's License MISC.- R RTO ORD L_ O ¢ Law for the following reason.(Sec.703 L5,Business and Professions VALUATION $/FT. � - I Code:Any City orcounty which requires a permit to construct,alter, PERMIT ISSU E _Wke. - rc ¢ 0 improve,demolish,or repair any structure,prior to its issuance,also ELEC.CONTR', LIC.NO. ELEC. O Q requires the applicant for such permit to file a signed statement that - TOTAL �0 he is licensed pursuant to the provisions of the Contractor's License PERMIT TO m z rt Law(Chapter 9(commencing with Section 7000)of Division 3 of the e4HE-�_r 4 O Business and Professions Code)or that he is exempt therefrom and Y. PLUMBING PERMIT FEE a I- the basis for the alleged exemption.Any violation of Section 7031.5 11 STORIES TYPE CONSTR. a3 ^ by any applicant for a permit subjects the applicant to a civil penalty - ALTER-DRAIN -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 their Sole compensation,will do the work,and the structure is not OCC.GROUP RES.UNITS intended Or offered for sale (Sec. 7044, Business and Professions DRAINS-FLOOR,ROOF,AR EA,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 SO.FT.FLOOR AREA TOTAL ACREAGE, himself or through his own employees,provided that such improve- mentsarenot 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 the burden of proving that he did not build or im- IGAS-EA.SYSTEM-OVER 4(EA.) 2.00 BUILDING USE prove for purpose of sale.). INDUSTRIAL WASTE INTER3000 RES IND CON Pe Omar 13 . . I,as owner of the property,am exclusively contracting with '� licensed contractors to construct the project(Sec.7044,Business LAWN SPRINKLERS-i INC 5 00 - ASSESSORS PARCEL NO. and Professions Code:The Contractor's License Law does not apply V.B.. . to ancontracts owner of property who builds tr improves thereon,and who LAWN SPRINKLERS-OVER 5(EA.) 1.00 the Contract suchLicenects Lwitha contracmr(s)licensed pursuant to SEWER-SANITARY-STORM EA.200ft/10.00 the Contractor's License Law. TRACT N0, PARCEL NO. ❑ lam exempt under Sec. ,B.&P.C.for this reason WATER HEATER W/VENT 6.00 Owner ' Date WATER SYSTEM 5.00 ACC.DATE ACC.FILE NO. WORK ERS'COMPENSATION DECLARATION WATER TREATING EQUIP. 5.00 I 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. -7[ copy thereof(Sec.3800,Lab.CA Policy No. Company 0 ❑ Certified copy is hereby furnished. FIRE BPO INK ENERGY T-]< Z Z ❑ Certified copy is filed with the city inspection division. 'I FO J Applicant I MISC.- REFER TO ORD. Y[3 N❑ Y [3 NE] = T CERTIFICATEOF EXEMPTION FROM WORKERS' PERMIT ISSUANCE 10.00 FLOOD ZONE A.L.u.C. LU > COMPENSATION INSURANCE PLG.CONTE. LIC.NO. PLG. 0. 0 (This section need not be completed if the,permit is for one TOTAL Y IN Y ❑ NC:] :) Z hundred dollars($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 U mit is issued,I shall not employ any person in any manner so as to become su je tc the Workers'tytQpens ion !,5,(lL liforni' O i Date - Applicant BUILDING Do NOTICE TO APPLICANT: If,after makin this CeALTER OR ADD TO MECH. 5.00 } g Deal, Ex- 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 10,000 C.F.M.) 4.00 CONSTRUCTION LENDING AGENCY AIR HANDLING UNIT(OVER 10PMC.RM.) 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,Civ.C.). HEATING UNIT(TO 100,000 B.T.U.) 8.00 Lender's Name Lender's Address HEATING UNIT(OV ER 100,000 B.T.U.)9.50 ELECTRIC 0 � I certify[hat l have read this application and stale that the above VENTILATION FAN ISINGLE) 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(3 H.P.Or100,000B.T.U.) 6.00 hereby authorize representatives of this city to enter upon the BOILER (Over 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 whichiPERMIT ISSUANCE 10.00 - CONST.TAX may in any way accrue against said City in of the granting o.)this per t. MECH.CONT. LIC.NO. MECH. TOTAL TOTAL ' Ignatureof Apphcxnl/C!o`nU�actorU Date OFFICE COPY r APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY BUILDING PROJECT I DENTI FICATI ON PERMIT NUMBER auAPPLICATION & PERMIT .�( ILDING — l` ADDRESS BUILDING — ELECTRICAL—PLUMBING—MECHANICAL OWNER'$ 9253 PLAN CHECK VALIDATION X NAME QTY. ELECTRIC PERMIT FEE PHONE NAMERAcroRs OUTLETS-SWITCHES-RECEP 10.00/1.00 _ - LIC.No. LIGHTING FIXTURES 10.00/1.00 CONTRADTO PPLIANCES-RESIDENTIAL 4.00 J� ADDRESS SJNA/rlMCL rLrGU$ PHONE 246!2PANELS 10.00 DATE OF APPLICATION APCHIr ECT PANELS (OVER 200 AMP) 20.00 PLAN CHECK FEE N.C.NO. D ENGINEER uc.no. SIGNS TRANS. 3.00 ARCH ENG. SPECIAL CIRCUIT S.00 PERMIT VALIDATION ZIP EMP.METER OR POLE INS. 20.00 ASr$ ADDRESS MOTORS SEE FEE SCH. S SERVICE CHANGE 0.00 0 0 2 LICENSED CON'TRAC'TORS DECLARATION T MP.POLE 30.00 r a o U I hereby uffrin that I am licensed under provisions of Chapter 9 >� ISSUANCE DATE y a a_ (commencingwith Section 7000)of Division 3 of the Business and BLDG. ELECT. PLG. MECH. H y z Professions Code,and my license is in full force and effect. ❑ EJ 13J O 0 so I] License ClassLie.Number — p mz. F Dale Contractor :[¢ ¢ _ OWNFR-BUILDER DECLARATION BUILDING PERMIT S 0 a u INFORMATION st ; LL I 1 hereby affirm that I um exempt from the Contractor's License MISC.— REFER TO ORD u O j Law for the following reason.(Sec.7031.5.Businessand Pronasions VALUATION $/FT. — PERMIT ISSUANCE 10 v,i Code:Any mulish county it any structure. aperitif riot o construct,.also ¢ Q Q inlpfove,demolish.Or repair any stmclura,prior to its iS5ua0Cf,8150 ELEC.CONTR. LIC.NO. ELEC. is, K m u rNuires the applicant for such permit to file a signed statement that TOTAL /0 PERMIT TO w he is licensed pursuant to the provisions of the Contractor's License r z i Law(Chapter 9(commeneingwitli Section 7000)of Divis,on3ofthe Q Business and Professions Code)or that he is exempt therefrom and QTY. PLUMBING PERMIT FEE Fz�e L7_ E i o the basis for the allege)exemption.Any violation permit ocion 7031.5 STORIES TYPE CONSTR. dam by any applicant fire peit subjects the totoa civil penalty ALTER-DRAIN -WATER (EA.) 5.00 of not more than five hundred dollars 185001.1'. ❑ 1,as owner of the Property,or my employees with wages us BACK FLOW PROTECT. DEVICE 4.00 OCC.GROUP RES.UNITS licit one compensation,will do the work,and the structure is not intended or offered for sale(Sea 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 docs such work FIXTURES-PER TRAP 5.00 S0.FT FLOOR AREA TOTAL ACREAGE • himself or through his own employees.provided that such improve- mens are not intended or offered for sale.If.however,the building GAS-EA.SYSTEM-1 1 NC.4 OUTLETS 6.00 or improvement is sold within one year of completion, the owner- builder will have the burden of proving that he did not build or int iGAS-EA.SYSTEM-OVER 4 (EA.) 2.00 BUILDING USE prove for purpose of sale.). .ar-•-"" - INDUSTRIAL WASTE INTER3000 RES IND CON PB Omer ❑ 1,as owner of the property,am exclusively contracting with . . 11 ❑ Q El 11 licensed contractors to construct Ole 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 IEA.) 1.00 contracts for such projects with a colorations)licensed pursuant to the Contractor's License Luw. SEWER-SANITARY-STORM EA.200ft/10.00 TRACT NO, PARCEL NO. ❑ lam exempt under Sec. ,tl.&BC.for this WATER HEATER W/VENT 6.00 reason Owner Date WATER SYSTEM 5.00 ACC.DATE ACC.FILE NO. WORK Ii RS'COMPENSATION DIICI.ARATION WATER TREATING EQUIP. 5.00 1 itereby 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 O ❑ Certified copy is hereby furnished FIRE SPRINK ENERGY T44 z Z ❑ Certified copy is filed with the city inspection division. O� Applicant MISC.- REFER TO ORD. Y N❑ Y F1 N� <r yl CERTIFICA'IIi OF BXCMPTION FROM WORKERS' PERMIT ISSUANCE 10.00 FLOOD ZONE A.L.D.C. LLQ COMPENSATION INSURANCE PLG.CONTR. LIC.NO. PLG. V� N� Y � N� CLZ (This section need not be completed if The permit is for one TOTAL U O hunired dollars(S100) O less.) I certify that in the performance of the work for which this per- QTY. MECHANICAL PERMIT FEE FEE SUMMARY LL H mit is issued,1 shall not employ any person in any manner so as to Q w become subject to the Workers'Co ens inn Laws of Californio Date77,___¢¢._��..,,..�— Applicant .r�C� +-+r�A .. ALTER OR ADD TO MECH. 5.00 BUILDING } N NOTICI%15 AYPLICAN'r I ,alt r Ing t us er autc u I:x- Z cmplion,you should become subject to Ole 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 CONSTRUCTION LENDING AGENCY AIR HANDLING UNIT(OVER 10=C.F.M.) 6.00 SEISMIC FEE I hereby affirm that there is a construction]ending 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 HEATING UNIT(OV ER 100,000 B.T.U.)9.50 Lenders Naeres� ELECTRIC Q 11V I certify that l 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 comity PLUMBING ordinances and state laws relating to building construction, and BOILER-COMP13 H.P.or 100,000 B.T.U.) 6.00 hereby authorize representatives of this city t0 enter upon the BOILER-COMP Over 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 PERMIT ISSUANCE 10.00 CONST.TAX may in any way accrue against said City in consequence of the granting of this pen l' MECH.CONT. - LIC.NO: MECH. ` _ TOTAL TOTAL ig J�(\ aT eofAlip' ontracmr ale INSPECTOR COPY I