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7046APPLICANT TO FILL IN INFORMATION WITHIN RED LINES,— USE BALL.POINT,PEN ONLY BUI LDI NG PROJECT I DEN. TI FICATION - -' " APPLICATION•&PERMIT BUILDING — ELECTRICAL- PLUMBING — MECHANICAL PERMIT NUMBER - 7046 SoILDING. ,. RDDRES OWNER''. _ ,p ) a al;ONE LS? • -"-- - TY. ELECTRIC PERMIT FEE 1 PLAN CHECK VALIDATION - C NT.CTm NAME UTLETS-SWITCHES-RECEP 5.00/1.00 I LIC, NO' LIGHTING FIXTURES' -5.00/1.00 ^' - ' DATE OF APPLICATION ADDRESS TOR's PHONE J 'APPLIANCES- RESIDENTIAL 4.00 ; PANELS ` 5.06 OPRCHITECT� _ ,. ENGINEER '. uc. No. it SIGNS' , - 6.00 PLAN CHECK FEE P.C. N0. . ' SIGNS TRANS. 3.00 ARCH. OR ENG. - - ADDRESS SPECIALCIRCUIT - '5.00 PERMIT VALIDATION TEMP. METER OR POLE INS. 15.00 ° ZIP LI APPLICANT'S ADDRESS •. I MOTORS SEE FEE SCH. SERVICE CHANGE', 10.00 - - oK• " - r p - r'/U/ - LICENSED CONTRACTORS DECLARATION' - I hereby affirnrthat I am licensed under provisions of Chapter 9 (commencing with Section 7000) of Division 3 of the Business and Professions Code, and my license is in full force and effect License Class Liu. Number - - ISSUANCE DATE 'BLDG. ELECT. 'PLG. MECH. ❑ El El? El Uatc Coractorto, nt , OWNER -BUILDER DECLARATION '.. I hereby affirm that I am exempt from the Contractor's License Law for the following reason. (Sec. 7031.5, Businessand Professions Code: An cit or count which re u tune permit o construct, Any y y - BUILDINGPERMIT INFORMATION MISC-,— . ; "• REFER TO ORD pERM1T ISSUANCE 6.00 VALUATION , $/FT. ELEC. CONTR. - LIC. N0. ELEC. _ TOTAL DTV. PLUMBING PERMIT FEE _improve, demolish, or repair any structure, prior to its issuance, also r t also requires the applicant for such permit l0 file a signedContractor's Li that pursuant to the provisions of the Contractor's License he Is (Chapter Laww(Chand Professions erefrion om the' Business and Professions Cade) or that he is exempt therefrom and Codeng ) or Section is exempt ' PERMIT TO J7 6 ` L. Or the basis for the alleged exemption. Any violation of Section7031:5 by any applicant for a permit subjects the, applicant toe civil penalty of not more than five hundred dollars ($5000.): i STORIES TYPE CONSTR. ALTER -DRAIN & VENT -WATER (EA.) 4.00 " 11 - 1, as owner of the property, or my employees with wages as their sole compensation, will do the work, and the structure is not BACK FLOW PROTECT. DEVICE 2.00 OCC. GROUP R , ES. UNITS DRAINS -FLOOR, ROOF, AR EA, COND. 4.00 ' filnmdedmr offered for .to (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 hemildingprove. mems are oti mends own employees,le. If, however, the amts are not intended or offered for sale. If, however, the building FIXTURES- PER TRAP 4,66 GAS -EA. SYSTEM- 1 INC. 4 OUTLETS 4.00 . SO FT. FLOOR AREA .TOTAL ACREAGE or improvement is sold within one year of completion, the owner- .builder will have the burden of proving that he did not build or on, GAS - EA. SYSTEM - OVER 4 (EA.) LOO - BUILDING USE ' 'prove 11, s owner of sale p,', ❑ 1, as owner of [he property, a`m exclusively. contracting with RES IND CON ' PB Orb r ❑ ❑ ❑' ❑ ❑ INDUSTRIAL WASTE INTER. - 20.00 licensed contractors to construct the project (Sec. 7044, Business and Professions Code: The Contractor's License Law does not apply to an owner (if. property who builds or improves thereon, and who LAWN SPRINKLERS - 1 INC 5 V.B. 5.00 LAWN SPRINKLERS - OVER 5 (EA.) 1.00 ASSESSORS PARCEL NO. ' contracts for such projects with a contractor(s) licensed pursuant to the Contractor's License Law.. - TRACT NO. PARCEL NO. SEWER -SANITARY -STORM EA. 260ft/8.00 ❑ 1am exao Iunder Se ." - .,B.&P.C. for this reason WATER HEATER W/VENT' 4.00 Owner "Dote - WATERSYSTEM4.00 ACC. DATE ACC FILE NO. woKKERs'coMPEN TIO DECLARATION - WATER TREATING EQUIP.�JD 4.00 I hereby affirm that I have a certificate of consent to self -insure„ or a certificate of Workers' Compensation'Insurance, or a ccrtifi_ed ZONING ENG. SITE NO. copy thereof (Sec. 3800, Cab .C.).t Policy No. +'Company • ' Cit') RE.FrERTOu'OR D. FIRE SPRINK Y ❑ N❑ ENERGY T-24 LY`❑ N❑ ❑ Certified copy is hereby furnished. ❑ Certified copy is fled with the city inspection division: Applicant - CERTIFICATE OP EXEMPTION FROM WORKERS' PERMIT ISSUANCE 6.00 "F LOODZONE A.LU.C. PLG. CONTR. LIC. NO. PLG. ev TOTAL ,. COMPENSATION INSURANCE. "" (This section need+not, be -completed if the permit is for one Y ❑ N ❑ Y ❑ N ❑ hundred dollars (8100) or IessJ I certify that in the performance of the work for which'this per- mit is issued, I shall not employ any person in any, manner so as to OTV MECHANICAL PERMIT FEE FEE SUMMARY BUILDING , , become subject to the Workers' Compensation Laws of California. 'Date - Applicant - _ NOTICE TO APPLICANT: If; after making this Certificate of Ex- ALTER OR ADD TO MECH. ,4.00 _ _ APPLIANCE 4.00 AIR HANDLING UNIT (TO 10=11F.M.) - 3.00 PLAN.CHECK FEE ' emplion,'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. AIR HANDLING UNIT (OVER 10,000C.F.M.) 5.00 SEISMIC FEE CONSTRUCTION LENDING AGENCY .'I hereby. affirm that there is a construction lending agency for EXHAUST HOOD (WITH DUCT) 2.00 the performance of the work foGwhich this permit is issued (Sec. 3097, Cur C.), - Lender's Name MICROFILM ' HEATING UNIT (70.100,000 B.T.U.) 4.00 HEATING UNIT (OVER 100,000 B.T.U.)7.50 ELECTRIC - Lender's Address - I certify that I have read`lhis application and state that the above information is correct. I agree to comply with all city a "I'vounty ordinances and state laws relating to building construction, and VENTILATION FAN (SINGLE) - 3.00 PLUMBING ,p _ / BOILER-COMP(3 H.P. 01'100,000 B.T.U.) 4.00 BOILER -COMP (Over i00,000BTt1) SEE FEE SCH. ' MECHANICAL hereby authorize, representatives of this city to: enter upon the above-mentioned properly for inspection phrposes: _ MISC. =.- REFER TO'ORD'. CONST. TAXs . (We) agree to save, indemnify and keep harmless the -City of Cupertino against liabilities, judgments, costs and expenses which' may in any way accrue against void' Ct+ in -consequence of the PERMIT ISSUANCE ”' .3. To gmnti of Is per ,r 9// MECH. CONT. LIC. NO: ,. t.;,. MECH. - TOTAL TOTAL Sgnati pplicamt/Con for to OFFICE COPY i� i i BUILDING INSPECTOR'S OFFICE CITY OF CUPERTINO Bldg. C pf P �, ❑ Backflow Device Sanitary Permit No. l` Sewer Connection - Plumbing Permit No. R,- I� Plumbing Final Lot No. Tract -.. - Date Connected --- 19 Final/'/Ip �5�` igp5— PLUMBING INSPECTOR APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY BUILDING PROJECT IDENTIFICATION APPLICATION & PERMIT BUILDING - ELECTRICAL- PLUMBING - MECHANICAL PERMIT NUMBER 7046 BUILDING DDRESS OwNER'- " E _ 0 TY. ELECTRIC PERMIT FEE PLAN CHECK VALIDATION $Iff4Y.NIZSZ NAMON ERAcroRs OUTLETS - SWITCHES -RECEP 5.00/1.00 LIGHTING FIXTURES 5.00/1.00 I.C. ND. AS CONTRADDRESS APPLIANCES PPLIANCES- RESIDENTIAL 4.00 PANELS 5.00 PHONE DATE OF APPLICATION ARCHITECTSIGNS OR ENGINEER LIC. No. 6.00 PLAN CHECK FEE P.C. NO. SIGNS TRANS. 3.00 ARCH.E"G' ADD SPECIAL CIRCUIT 5.00 PERMIT VALIDATION TEMP. METER OR POLE INS. 15.00 ZIP ADDR ADP ESS Ess MOTORS SEE FEE SCH. SERVICE CHANGE 10.00 J LICENSED CONI'RACI'ORS DECLARATION 1 herehy aflirm that I am licensed under Provisions of Chapter 9 (commencing with Section 7000) of Division 3 of the Business and professions Code, and my license Is In full force and effect. umber License Class Lie. Number- ISSUANCE DATE ' BLDG. ELECT. 101 PLG. MECH. El Date Date Contractor BUILDING PERMIT OWNER -BUILDER DECLARATION I hereby affirm that I am exempt from the Contractor's License Law for the followingreason.(Sec. 7031.5, Business and Professions Cade: Any city.rcounly which requires a permit to construct. alter. impnrr, demolish, or repair any structure, prior to its issuance, also INFORMATION MISC.- REFER TO ORD VALUATION S/FT. PERMIT ISSUANCE 6.00 ELEC. CONTR. LIC. NO. ELEC. risluirea the applicant for such permit t0 file a signed Statement that he is licensed pursuant to the provisions of the Contractor's License TOTAL PERMIT TO A4 QTY. PLUMBING PERMIT FEE (Chapter 9 (commencing with Section 7000) of Division 3 of the Business and professions Code) or that he is exempt therefrom and -Law STORIES TYPE CONSTR. the basis ler the alleged exemption. Any violation of Section 7031.5 by any applicant lir a permit subjects the applicant to a civil penalty .f not more than five hundred dollars (8500).): ALTER -DRAIN & VENT -WATER (EA.) 4.00 ❑ I, ;is owner of the property, Or my employees with wages as Their sole Coln pcnswion, will do the work, and the structure is not BACK FLOW PROTECT. DEVICE 2.00 OCC. GROUP RES. UNITS DRAINS -FLOOR, ROOF, AREA, COND. 4.00 intended nr cloned for ,.IS (See 7044, Business and Professions Coda 'I'be Cunlracoir's License Law docs not apply to an owner of FIXTURES - PER TRAP 4.00 So. FT. FLOOR AREA , TOTALACREAGE property who builds or improves there.., and who docs such work himself or through his own employees, provided that such improve - ments arc not intended or offered for sale.11f, however, the building GAS -EA. SYSTEM q,00 or improvement is cold within one year .f completion, the owner- builder will IDS,, tiro burden of proving that he did not build or im prove for purpose owner of safe.). thp contracting74,u with ❑ L as owner Of the property, am GAS - EA. SYSTEM -OVER 4 (EA.) 1.00 BUILDING USE RES IND CON PB Omer ❑ ❑ ❑ ❑ . ❑ INDUSTRIAL WASTE INTER. 20.00 rojecty Se andpro <nions od or construct the project (Sec. 7044, of apply and professions Code: The Contractor's License Law does not apply to owner of property who builds improves thereon. and who LAWN SPRINKLERS- 1 INC S V.B. 5.00 LAWN SPRINKLERS -OVER 5 (EA.) 1.00 ASSESSORS PARCEL NO. contracts for such projects with a contractors) licensed pursuant to tr tr the Contractor', License. Law. . TRACT NO. PARCEL NO. / SEWER -SANITARY -STORM EA. 200ft/8.00 ❑ l ant exemt under SCS. ,B.&P.C. for this WATERATER W/VENT 4.00 Owonerne, Date WATER SYSTEM 4.00 ACC. DATE ACC. FILE NO. WATER TREATING EQUIP. 4.00 WORKERS'COMPEN I101 DECLARATION 1 hereby dfinn that 1 time A ceriGcme of concent m self -insure, or a ex,tificme of Workers' Compensation Insurance- or a certified ZONIrvG ENG. SITE NO. copy thereof (Sec. 3800, Lab.CJ. Policy No. Company ❑ Ccrtifiedcapyishcrchyfurnished. ❑ Certified copy La filed with the city inspection division. Applicant FIRESPRINK Y ❑ N❑ ENERGY T-24 Y ❑ N❑ MISC.- REFER TO ORD. Cls k'I'119Cn'I'IS OP IiXIiM 111 [ON PROM WORKERS. PERMIT ISSUANCE 6.00 '-- Pt.00D ZorvE A. L.u.c. PLG. CONTR. LIC. N0. PLG. TOTAL COhIPENSAI'ION INSURANCE Prhis Section need not be completed if the permit is for one YE] N❑ Y ❑ N❑ QTY. MECHANICAL PERMIT FEE FEE SUMMARY bonded dollars IS 100) .. less.) I certify that in the performance of the work for which this per. not is issued, I shall not employ any person in any mannerso as to BUILDING become subject t. the Workers' Compensation Laws .f California. Date Applicant - NOTICIi TO APPLICANT': If, after making this Certificate of Ex - ALTER OR ADD TO MECH. 4.00 APPLIANCE 4.00 PLAN CHECK Sorption, you should become subject I. the Workers'Compensation provisions of lire Labor Code, you must forthwith comply with such provisions or this permit shall be deemed revoked FEE 00 AIR HANDLING UNIT (TO 10,0C.F.M.) 3.00 AIR HANDLING UNIT (OVER 10=11F.M.) 5.00 SEISMIC FEE CONS'I'RBerION LENDING AGENCY I hereby affirm that there is a construction lending agency for EXHAUST HOOD (WITH DUCT) 2.00 the performance of the w ... k for which this permit is issued (Sea 3097, Civ.C.). MICROFILM HEATING UNIT (TO 100,000 B.T.U.) 4.00 HEATING UNIT (OVER 100,000 B.T.U.)7.50 ELECTRIC Lender's Name Name Lender's a I certify that I have read this application and state mat the above information is correct. I agree to comply with all city and county ..dlnvmes and state laws relining t0 building construction, and VENTILATION FAN (SINGLE) 3.00 PLUMBING q � /T BOILER -COMP (3 H.P. or 100,000 B.T.U.) 4.00 BOILER -COMP (Over 100,000 BTU) SEE FEE SCH. MECHANICAL hereby aultorim representatives of this city to enter upon tire ahove-mmnni.rwd property for inspection purposes_ (We) ago. t. Savo indemnify and keep harmless the City of MISC. - REFER TO ORD. Cupertino against liabilities, judgmmnts, costs and expenses which may in any way accrue against Said City in consequence of the igmntingpf lith, permit 'O 1 4 CONST. TAX PERMIT ISSUANCE 3.00 MECH. CONT. LIC NO. MECH. TOTAL Signatmerot Apptcanl/C.nt for D ti, INSPECTOR COPY