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7145 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY PERMIT NUMBER BU I LDING PROJECT IDENTIFICATION APPLICATION & PERMIT a°"DING c noun liII)10,3 WILDING ELECTRICAL PLUMBING MECHANICAL 7145 • owry u ,jl '�j'yaE'r '33��r1", ?k" ytt ^`.�•.I�C�n �!:f T3�i PLAN CHECK VALIDATION NAnsE _ '} aG.ty EL'ryECT�,yR}I,C,�PERMIT« I TjP /FEE � PHONE f+ ( �' co.TRE crD s TLETS-SWITCHES-RECEP 5.00/1.00 Nn - f i MI iC. 0., LIGHTING FIXTURES 5.00/1.00 r,ONT Ac7oR's PPLIANCES-RESIDENTIAL4.00 ADDRESS �-� PANELS 5.00 DATE OF APPLICATION ARCHITE T SIGNS 6.00 PLAN CHECK FEE P.C.NO, OR LIE. 'J-DD c.No. SIGNS TRANS. ARCH.OR ENG. SPECIAL CIRCO IT 5.00 PERMIT VALIDATION ADDRESS zip EMP.METER OR POLE INS. 15.00 APPLICANTS MOTORS SEE FEE SCH. ADDR ESS � SERVICE CHANGE 10.00 woo LICENSED CONTRACTORS DECLARATION Q p l~j I Imrchy affirm that I am licensed under provisions of Chapter 9 A nam (commencing with Section 7000)of Division 3 of the Business and MECH. H,m z Professions Code,and my license is in full for D m License Class Lie.Number w F w Dam /--� _ Contracto04 OE r T/--y� 1 2L IT' w¢ V NI: DER DECLARATI N INFORRIATIONIM Li MPERMIT REFER TO ORD I hereby affirm that I am exempt from the Contractors License VALUATION S/PT. ;_0 4 law for the following reason.(Sec.7031.5.Business and ProfessionsE 6.00 Code:Any cityor County whictirequlresa permit loconstruMallaq . . LIG NO. Q O improve,demolish,or repair any structure,prior to its issuance,also ELEC. Ort 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 Contractors License Law(Chapter (commencingith Secuon7000)of Divisions tire . J 'y; _LL '%'t vu`{ ris- c a Business and Professions Code)or that Ise is exempt therefrom and �Q,,�TY1Y_ (,�P� APLUMBING PERMIT p "nYT Q.h� FEE 1 i O p 'IVY«J'�''fn3t^cP%r�'t'ya0 fy(MT; ?f'�l,J�"'S=�' t t' w` r STORIES TYPE CONSTR. o the basis for the alleged exemption Any violation of Section 7031 5 ! _ w. !2 by any applicant fern permit subjects the applicant to a civil penalty ALTER-DRAIN&VENT-WATER (EA.) 4.00 of not more than five hundred dollars(S500)J: ❑ I,as owner of the property,or my employees with wages as BACK FLOW PROTECT.DEVICE 2.00 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. 4.00 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 4.UD 50.FT.FLOOR AREA TOTAL ACREAGE himself or through his own employees,provided that such improve- GAS-EA.SVSTEM-11NC.40UTLETS 4.00 meats are not intended or offered for sale.If,however,the building or improvement is sold within one year of completion,the owner-M20.00 STEM-OVER 4 IEA.) 1.00 BUILDING USE builder will have the burden of proving that he did not build or ire- RES IND CON PB Omer prove forpurpose of sale.). L WASTE INTER. 20.00❑ 1,as owner of the property,am exclusively'contracting withlicensed contractors to construct the project(Sec.7044,BusinessNKLERS-1 INEI El 1:1 C 5 V.B. 5.00 ASSESSORS PARCEL NO. andProfessionsCode:The Contractor's License Law does not applyto an ownof property who builds or improves thereon,and whoNKLERS-OVER 5 IEA.) 1.00contracts for such projects with a contractoos)licensed pursuant toOle Comrecuo's License Law. ITARY-STORM EA.200ft/8.00 TRACT NO. PARCEL NO. ❑ 1 am exempt under Sec. .B.&P.C.for thisATER W/VENT 4.00 reasonOwner Dale WATER STEM 4.00 PCC.DATE ACC.FILE NO. WORKERS'COMPENSATION DECLARATION WATER TREATING EQUIP. .00 I hereby affirm that I have a certificate of consent to self-insure. , ZONING ENG.SITE NO. or a c h I to of Woe ,S'a/gC000mpensat'pn usurance,or certified P. Q' Q cd s i rc urshp FIRE SPRINK ENERGY T-24 Z Z ❑ Certified is filed w'h cit' ins ion iv _ MISC.- REF E, OORD, y N y N� Applicant I--' PERMIT ISSUANCE 6.00 FLOOD ZONE A.L.u.c. � - CERT i ATF-OFEXEMPTION FROM WORKERS' LLI > COMPENSATION INSURANCE PLG.CONTR. LIC.NO. PLG. y N Y ry CL O (This sectio need not be completed if the permit is for one TOTAL Z hundred dollars(S 1001 or less.) T FEE SUMMAfiV U O 1 certify that in tire performance of the work for which this per- OTY ` ' AJ ""MECHANICAL'PERMITe, ytr�ry a� �y:FEEif a .. r✓..Y T. LL H mit Is Issued,I shall not employ any person in any manner so as to - 1 N- a,{, w nF. -L♦ {,•,v. "0• .f`may-n Si,+�- 0 w become subject to the Workers'Compensatmn Laws of California ' BUILDING 0. Date Applicant ALTER OR ADD TO MECH. 4.00 } Us NOTICE TO APPLICANT: If,after making this Certificate of Ex- Z emption.you should become subject to the Workers'Compensation APPLIANCE 4.00 PLAN CHECK provisions of the labor Code, you must forthwith comply with FEE CJ such provisions or this permit shall be deemed revoked. AIR HANDLING UNIT(TO 10=C.F.M.) 3.00 CONSTRUCTION LENDING AGENCY AIR HANDLING UNIT(OVER 10=C.F.M.) 5.00 SEISMIC FEE 1 hereby affirm that there is a construction lending agency for EXHAUST HOOD(WITH DUCT) 2.00 the performance of the work for which this permit is issued(Sec. MICROFILM 3097,Civ C.). H EATI NG UN IT(TO 100,000 B.T.U.) 4.00 Lender's Name HEATING UN IT(OVER 100,000 B,T.U.)7.50 ELECTRIC Lenders Address . 1 certify that I have read this application and State that the above VENTILATION FAN (SINGLE) 3.00 PLUMBING information is correct I agree to comply with all city and count, BOILER-COMP13 H.P.Or 100,000 B.T.U.) 4.00 ordinances and stale laws relating to building construction. and hereby collmiizc representatives of this city to enter upon the BOILER-COMP (Over 100,000 BTU(S EEFEE SCH. MECHANICAL above-mentioned property for inspection purposes. (WC) agree to save, indemnify end keep harmless the City of MISC.- REFER TO ORD. Cupertino against liabilities,judgments, costs and expenses which PERMIT ISSUANCE 3.00 CONST.TAX ly in any way hccrue against said Cit consequence of the ,ng of tl i5 eiL L ECH.CONT. LIC NO. MECH. h';��`$ ,"� `�1t��TorALTOTAL'��;a.' / / ./re of pliant/Contracto )ate OFFICE COPY APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY PERMIT NUMBER.' BUILDING PROJECTlDENTIFICATION APPLICATION & PERMIT BDILOING c ADOR WILDING-ELECTRICAL-PLUMBING-MECHANICAL 7145 OWN PLAN CHECK VALIDATION NAME _ T ELECTRIC PERMIT FEE ✓- enorvE f COZ'H CToS TLETS-SWITCHES-RECEP 5.00/1.00 NAME k, limb I 1 11C-q.. LIGHTING FIXTURES '5.00/1.00 CONT ACTORS I PPLIANCES-RESIDENTIAL 4.00 ADDRESS / PANELS 5.00 DATE OF APPLICATION 15 ARRCHITE T SIGNS 6.0D PLAN CHECK FEE P.C.N0. ENGINEER sec.No. SIGNS TRANS. 3.00 ADDRESS Ervc' SPECIAL CIRCUIT 5.00 PERMIT VALIDATION ZIP fTEMP.METER OR POLE INS. 15.00 APPLICANTS MOTORS SEE FEE SCH. e SERVICE CHANGE 10.00 '10-ac o LICENSED CONIKACTORS DECLARA'f ION t;Q U u I hereby affirm that 1 am licensed under provisions of Chapter 9 //IS UAN E DATE a a (commencing with Section 7000)of Division 3 of the Business and BLDG. ELECT. L MECH. r N i Professions Cod,,and my licrnsu is in full lure I . ❑ cense Class Lic.Number o � H Date_A Cnrtrunor y E i-i BUILDING PERMIT o i u O NI: .DF.R DfiCLARATI N INFORMATION E: I hereby atfirn that 1 am exempt from the Contractors License MISC.- REFER TO ORD 3 VALUATION $/FT. F .. ¢o J haw fur the lollowing reason.(Sec.7031.5.Businessand Professions PERMIT ISSUANCE 6.00 Code:Any city or county which requires a permit to construct,alter ac so ¢Q improve,demolish,or repair any structure,prior to its issuance,also ELEC.CONTR. LIG NO. ELEC. E o u requires the applicant for such permit to file a signed statement that TOTAL PERMIT TO to m he is licensed pursuant to the provisions of the Contractor's License t- za Law(Chapter 9(commencing with Section 7000)ofDivision 3 ofthe Business and Professions Code)or that Ile is exempt therefrom and CITY. PLUMBING PERMIT FEE ¢ r the basis for the alleged exemption.Any violation of Section 7031.5 STORIES TYPE CONSTR. a3 � by any applicant for a permit subjects the applicant to a civil penalty ALTER-DRAIN -WATER (EA.) 4.00 of not more than five hundred dollars($5000.): ❑ I,as owner of the property,or my employees with wages as BACK F LOW PROTECT. DEVICE 2.00 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. 4.00 Code:'rhe Contractor's License Law docs not apply to an owner of property who builds or improves thereon,and who does such work FIXTURES-PER TRAP 4.00 SD.FT.FLOOR AREA TOTAL ACREAGE himself or through his own employees.Provided that such....Prove- ments in not intended pr offered for sale.If,hnwcvcr,the budding GAS-EA.SYSTEM-1 INC.4 OUTLETS 4.00 or improvement is sold within one year of completion,the owner- builder will have lite burden of proving that he did not build or ice- iGAS-EA.SYSTEM-OVER 4 (EA.) 1.00 BUILDING USE prove for purpose ofsale'), INDUSTRIAL WASTE INTER. 20.00 RES IND CON PB Coheir ❑ I,as owner of the property,am exclusively contracting with ❑ ❑ ❑ ❑ ❑ licensed contractors to construct the project(Sea 7044,Business LAWN SPRINKLERS-1 INC 5 V.B. 5.00 ASSESSORS PARCEL NO. and Professions Code:1'he 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 for such projects with a contnctods)licensed pursuant to the Contractors License Law. SEWER-SANITARY-STORM EA, 200ft/8.00 TRACT NO. PARCELNO. - ❑ Ian,exenlpf under Sec. ,B.AI'.C.for thisWATER HEATER W/VENT 4.00 mason Owner Dwe WATER SYSTEM 4.00 ACC.DATE Ace.FILE No. WORK ERS'CONl PFNSA'I'ION DECLARATION WATER TREATING EQUIP. 4.00 1 herehy Coffin that I have n certificate of consent to self-insure. ZONING ENG.SITE NO. Or a ceNiO� te of Workers'Compensati n surancc,or «rificJ P a (] Ci t rely 'u dt FIRE SPRINK ENERGY T24 z Z ❑ Certified e p Iz fled wit t cit ins •c bn 'y" MISC.- REFER TO ORD. FIVA O Applicant_ V ❑ N❑ v ❑ N❑ CERT' I \TE0Fh\IiMP1'IONPRO\f W'ORKIIRS' PERMIT ISSUANCE 6.00 FLOODZONE A.L.UC, LLI � C(ISt I'IiNSA1'ION INSURANCE PLG.CONTR. LIC.NO. PLG. Y❑ N❑ Y ❑ N❑ Z ('Phis sectio need not he completed if the permit is for one TOTAL hundred dollars(5100)or less.) U O 1 certify that in the performmnce of the work for which this per, CITY. MECHANICAL PERMIT FEE FEE SUMMARY IL F mit is issued, I shall not employ any person in any manner so as to O bcconm subject to the Workers'Compensatimit Laws of California. Q a Date - Applicant ALTER OR ADD TO MECH. 4.00 BUILDING } m NOTICE 10 APPLICANT: If,after making this Certificate of Ex- �'F 2 enudion,you should become subject to the Workers'Compensation APPLIANCE 4.00 PLAN CHECK •- - provisions of the Labor Code, you must forthwith comply with FEE 1'p'U such provisions or this permit shall be deemed revoked. AIR HANDLING UNIT(TO 10=C.F.M.) 3.00 �- CONSTRUCTION LENDING AGENCY AIR HANDLING UNIT(OVER I0,000GEM.) 5.00 SEISMIC FEE I hereby affirm that there is a construction lending agency for EXHAUST HOOD(WITH DUCT) 2.00 the performance of the work for which this permit is issued(Sec. MICROFILM 3097.Civ.CJ HEATING UNIT(TO 100,000 B.T.U.) 4.00 Lenders Name HEATING UNIT(OVER 100,000 B.T.U.)7.50 Lender's Address ELECTRIC I certify that I have read this application and start that the above VENTILATION FAN (SINGLE) 3.00 • in lormation 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.or 100,000 B.T.U.) 4.00 hereby authorize representatives of this city to enter upon the BOILER-COMP(Over 100,DOOBTU)SEEFEESCH. 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 'y in any way came against Said Cityjq consequence of the PERMIT ISSUANCE 3.00 tying of ll's et nit. II/A(rf ECN.CONT. LIC.NO. MECH. TOTAL TOTAL S' reef p cant/Contracto ate V / . N, INSPECTOR COPY - t