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3896 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALI_ POINT PEN ONLY • BUI LDI NO PROJECT 1 DENTI FIC/&N PERMIT NUMBER • j B�oIN ��7i� �N Dye �� APPLICA ON & P IT 3896 . ` ADDRESS u 2 I '^ n� - .0r 9 BUIL G- E C RICAL-PLUMBING-MECHANICAL OWNER'S Ar C> C-�G , < I PLAN CHECK VALIDATION �/ rvAME L0� Y F. Q V./ ELECTRIC PERMIT FEECON4+SaH �loa sS�Z� Jac, NAAMERACTDRs OUTLETS-SWITCHES-PIECED .5.00/1.00 4i/c,CeW Lf NOi__9 9/"-y ALLIGHTING FIXTURES 5.00/1.00 coNTRACTD Ls� T APPLIANCES AL 4.00 p- ADDRESS 9 �vi O !-'Mfv PHONE 'aN - PANELS. - 5.00 GATE OF APPLICATION ARCHITECT 11' / a SIGNS 6.00 PLAN CHECK FEE P,C.NO. ENGINEER < N /� �x uc,NO o SIGNS TRANS. 3.00 AARCH OR DDRESS ENG./��- V A �/ p � SPECIAL CIRCUIT PERMIT VALIDATION ,4" G/d42 iI{�r� EMP.METER OR POLE INS. APPILI EQ MOTORS S E M. J ADDRESS - / ' SERVICE CHANGE 10.00 '02 LICENSED CONTRACTORS DECLARATION City of ClIn cc u w I hereby affrin Unit 1 am licensed uuWer Pnrvisionsot Chap Wr9 I$SU TE (commencing with Section 7000)of Division 3 of the llusiness and IS G. ELEC LG. MECH. r 7 z Professions Cou and my license is in(all for •� d.ef ecL License lass Lic.Nmnhe Y .O m - o Date Con1, BUILDING PERMIT ¢ ¢o u o OW'NERIIUILDIiR DGCLARA'I']ON INFORMATION E ; u r I hereby affirm that I am exempt from the Contractor's License MISC._ REFER TO ORD S, VALUATION - $/FT. :. o¢ Law for the following reason.(Sec.]031.5,Easiness and Professions _ H _ PERMIT ISSUANCE 6.00 Cnocm Any city county which Structur a Permit m construct alter, ¢ ¢ 0 impprove,demolish, ,or repair nny structure,prior to it,issuance,also ELEC.CONTR. LIC.N0. ELEC. o u requites the applicant for such permit to file a signed statement that TOTAL IP PERMIT TO K Se he is licensed pursuant to the provisions of the Contractor's License F z r Law(Chapter 9(commencing with Section 7000)of Division 3 of the - SL/V [3 Yb/L a Business and Professions Code)or that he is exempt therefrom and Y. PLUMBING PERMIT FEE s i O ¢ r$ Rse basis for the alleged exemption.Any violation ofoa oval enc LS STORIES TYPE CONSTR. a � by any applicant lora permit dollar, $500),lic:mttoxcivil pen:dly ALTER-DRAIN -WATER (EA.) 4.00 ?� of not more than five hundred dollars(8500).1: ❑ 1,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 O property who builds or improves thereon,and who does such work FIXTURES-PER TRAP 4.00 O.FT.F OOR AREA TOTAL ACREAGE • himself or through lits own employees,provided that such improve- merits are not intended or offered for sale.If,however,the building GAS-EA.SYSTEM-11NC.40UTLETS 4.00 67 or improvement is sold.within one year of completion,the owner- o GAS-EA.SYSTEM-OVER 4(EA.) 1.00 BUILDING USE builder will have the burden of proving that he did not build or ire- - RES IND CON PB arbor Prove 1,as owner of sale.). O INDUSTRIAL WASTE INTER. 20.00 ❑ ❑ ❑ ❑ t as owner of the property,he exclusively contracting with 0 El licensed contractors :I construct the project(See. 7044,Business LAWN SPRINKLERS-.1 INC 5 V.B. 5.00 ASSESSORS PARCEL NO. to Professions Code:The Contractor's License Law does not apply o totrowner of property who builds trimprovesthereon,and who O LAWN SPRINKLERS-OVER 5(EA.) 9.00 ,�66 contracisfor such License Lwithucontracmr(sl licensed pursuantm SEWER-SANITARY-STORM EA. 00 the Conlmclor's License Law, � TRACT NO, PARCEL NO. ❑ I am exempt imdm Sec. B.SP.C.for Utz WATER HEATER W/VENT q,p0 Ori � 0 Date Owner WATER SYSTEM SEP A. ACC.OATE ACC.FILE NO. WORK F.RS'COMPF-NSATION DECLARATION' 0 WATER TREATING EQUIP, 4. I hereby affirm that I have a cerldic:Ite of consent to self-insure, /s• ora certificate of Workers'Comp sation Insurance,ora certified till ZONING ENG.SITE NO. copy thereof 1Sce.3800,Lab.0 !_ �)QN no Policy No Coulpa. dT/ �rLfjy�+-fes, O ❑ Certifiedcopy is hereby furnished. FIRE SPRINK ENERGY T 24 z - ❑ of opY is Iled w'th the city inspection division. ❑ ❑ ❑ ❑ O Ap MISC.- REFER TO ORD. Y N Y N T v / ./ PERMIT ISSUANCE I_ -6.00 CC CERTIFICATE.OI'EXEMPTION FROM WORKERS' FLOOD ZONE A.L.u.c. LL > COMPENSATION INSURANCE PLG.CONTR. LIC.NO. PLG. OV EL O This section need not be completed if the permit is fur one TOTAL Y❑ N❑ Y ❑ N❑ 7) Z hundred dollars($100)or less. U O . I certify that in the performance of the work for which this per n�. MECHANICAL PERMIT FEE FEE SUMMARY UT F put is Issued,I shall not employ any Person many nwnner so ar to -/ Y. O W become subject to the Workers'Compensation Laws of California. ?f p a Date Applicant ALTER OR ADD TO MECH. 4.00 BUILDING >_ W NOTICE TO APPLICANT: If,after making this Certificate'I Ex- F Z emption,you should become subject to the Workers'Compensation APPLIANCE 4.00 PLAN CHECK provisions of the Labor Cade, you must forthwith comply with FEE U such provisions or this permit shall he deemed revoked: AIR HANDLING UNIT(TO POACC.F.M.) 3.00 CONSTRUCTION LENDING AGENCY AIR HANDLING UNIT(OVER 10=C.F.M.) 5.00 SEISMIC FEE /9 ((7 I hereby affirm that there is a construction lending agency for ( EXHAUST HOOD (WITH DUCT) 2.00 the performance of the work ]or which this permit is issued(See. Q-- MICROFILM 3097,Civ.C.). I HEATING UNIT(TO 100,000 B.T.U.) 4.00 Lender's Name HEATINGUNIT(OVER 100,000 B.T.U.)7.50 Lender's Address _ ELECTRIC I cenify that I have read this application and state that the above VENTILATION FAN (569, p 0 information is correct I agree to comply with all city and cmmty BOILER-COMPO H.P.or 100 000 B.T.U.) 4.00 PLUMBING x,7 a -- ordinances and slate laws relating to building construction, and ' 4hereby awhorue representatives of this city to enter upon the 00 above-mentioned property for inspection PUIPOks. BOILEfl-COMP 1 ,00 BTU E SCH. MECHANICAL (We) agree to save, indemnify and keep harmless the City'of MISC.- REFER TO ORD. Cupertino against liabilities,judgments, costs and expenses which PERMIT ISSUAN o 00 CONST.TAX may in any way accrue•against said City in consequence of the Y Upertino 3.00 3 gonumg oftl' permit. MECH.CONT. LIC.NO. MECH. , TOTAL Sao TOTAL /] ��� Signa arc pplvial Crntrue nr Date. OFFICE COPY APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALI_ POINT PEN ONLY • BUI LDI NO PROJECT 1 DENTI FIC/&N PERMIT NUMBER • j B�oIN ��7i� �N Dye �� APPLICA ON & P IT 3896 . ` ADDRESS u 2 I '^ n� - .0r 9 BUIL G- E C RICAL-PLUMBING-MECHANICAL OWNER'S Ar C> C-�G , < I PLAN CHECK VALIDATION �/ rvAME L0� Y F. Q V./ ELECTRIC PERMIT FEECON4+SaH �loa sS�Z� Jac, NAAMERACTDRs OUTLETS-SWITCHES-PIECED .5.00/1.00 4i/c,CeW Lf NOi__9 9/"-y ALLIGHTING FIXTURES 5.00/1.00 coNTRACTD Ls� T APPLIANCES AL 4.00 p- ADDRESS 9 �vi O !-'Mfv PHONE 'aN - PANELS. - 5.00 GATE OF APPLICATION ARCHITECT 11' / a SIGNS 6.00 PLAN CHECK FEE P,C.NO. ENGINEER < N /� �x uc,NO o SIGNS TRANS. 3.00 AARCH OR DDRESS ENG./��- V A �/ p � SPECIAL CIRCUIT PERMIT VALIDATION ,4" G/d42 iI{�r� EMP.METER OR POLE INS. APPILI EQ MOTORS S E M. J ADDRESS - / ' SERVICE CHANGE 10.00 '02 LICENSED CONTRACTORS DECLARATION City of ClIn cc u w I hereby affrin Unit 1 am licensed uuWer Pnrvisionsot Chap Wr9 I$SU TE (commencing with Section 7000)of Division 3 of the llusiness and IS G. ELEC LG. MECH. r 7 z Professions Cou and my license is in(all for •� d.ef ecL License lass Lic.Nmnhe Y .O m - o Date Con1, BUILDING PERMIT ¢ ¢o u o OW'NERIIUILDIiR DGCLARA'I']ON INFORMATION E ; u r I hereby affirm that I am exempt from the Contractor's License MISC._ REFER TO ORD S, VALUATION - $/FT. :. o¢ Law for the following reason.(Sec.]031.5,Easiness and Professions _ H _ PERMIT ISSUANCE 6.00 Cnocm Any city county which Structur a Permit m construct alter, ¢ ¢ 0 impprove,demolish, ,or repair nny structure,prior to it,issuance,also ELEC.CONTR. LIC.N0. ELEC. o u requites the applicant for such permit to file a signed statement that TOTAL IP PERMIT TO K Se he is licensed pursuant to the provisions of the Contractor's License F z r Law(Chapter 9(commencing with Section 7000)of Division 3 of the - SL/V [3 Yb/L a Business and Professions Code)or that he is exempt therefrom and Y. PLUMBING PERMIT FEE s i O ¢ r$ Rse basis for the alleged exemption.Any violation ofoa oval enc LS STORIES TYPE CONSTR. a � by any applicant lora permit dollar, $500),lic:mttoxcivil pen:dly ALTER-DRAIN -WATER (EA.) 4.00 ?� of not more than five hundred dollars(8500).1: ❑ 1,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 O property who builds or improves thereon,and who does such work FIXTURES-PER TRAP 4.00 O.FT.F OOR AREA TOTAL ACREAGE • himself or through lits own employees,provided that such improve- merits are not intended or offered for sale.If,however,the building GAS-EA.SYSTEM-11NC.40UTLETS 4.00 67 or improvement is sold.within one year of completion,the owner- o GAS-EA.SYSTEM-OVER 4(EA.) 1.00 BUILDING USE builder will have the burden of proving that he did not build or ire- - RES IND CON PB arbor Prove 1,as owner of sale.). O INDUSTRIAL WASTE INTER. 20.00 ❑ ❑ ❑ ❑ t as owner of the property,he exclusively contracting with 0 El licensed contractors :I construct the project(See. 7044,Business LAWN SPRINKLERS-.1 INC 5 V.B. 5.00 ASSESSORS PARCEL NO. to Professions Code:The Contractor's License Law does not apply o totrowner of property who builds trimprovesthereon,and who O LAWN SPRINKLERS-OVER 5(EA.) 9.00 ,�66 contracisfor such License Lwithucontracmr(sl licensed pursuantm SEWER-SANITARY-STORM EA. 00 the Conlmclor's License Law, � TRACT NO, PARCEL NO. ❑ I am exempt imdm Sec. B.SP.C.for Utz WATER HEATER W/VENT q,p0 Ori � 0 Date Owner WATER SYSTEM SEP A. ACC.OATE ACC.FILE NO. WORK F.RS'COMPF-NSATION DECLARATION' 0 WATER TREATING EQUIP, 4. I hereby affirm that I have a cerldic:Ite of consent to self-insure, /s• ora certificate of Workers'Comp sation Insurance,ora certified till ZONING ENG.SITE NO. copy thereof 1Sce.3800,Lab.0 !_ �)QN no Policy No Coulpa. dT/ �rLfjy�+-fes, O ❑ Certifiedcopy is hereby furnished. FIRE SPRINK ENERGY T 24 z - ❑ of opY is Iled w'th the city inspection division. ❑ ❑ ❑ ❑ O Ap MISC.- REFER TO ORD. Y N Y N T v / ./ PERMIT ISSUANCE I_ -6.00 CC CERTIFICATE.OI'EXEMPTION FROM WORKERS' FLOOD ZONE A.L.u.c. LL > COMPENSATION INSURANCE PLG.CONTR. LIC.NO. PLG. OV EL O This section need not be completed if the permit is fur one TOTAL Y❑ N❑ Y ❑ N❑ 7) Z hundred dollars($100)or less. U O . I certify that in the performance of the work for which this per n�. MECHANICAL PERMIT FEE FEE SUMMARY UT F put is Issued,I shall not employ any Person many nwnner so ar to -/ Y. O W become subject to the Workers'Compensation Laws of California. ?f p a Date Applicant ALTER OR ADD TO MECH. 4.00 BUILDING >_ W NOTICE TO APPLICANT: If,after making this Certificate'I Ex- F Z emption,you should become subject to the Workers'Compensation APPLIANCE 4.00 PLAN CHECK provisions of the Labor Cade, you must forthwith comply with FEE U such provisions or this permit shall he deemed revoked: AIR HANDLING UNIT(TO POACC.F.M.) 3.00 CONSTRUCTION LENDING AGENCY AIR HANDLING UNIT(OVER 10=C.F.M.) 5.00 SEISMIC FEE /9 ((7 I hereby affirm that there is a construction lending agency for ( EXHAUST HOOD (WITH DUCT) 2.00 the performance of the work ]or which this permit is issued(See. Q-- MICROFILM 3097,Civ.C.). I HEATING UNIT(TO 100,000 B.T.U.) 4.00 Lender's Name HEATINGUNIT(OVER 100,000 B.T.U.)7.50 Lender's Address _ ELECTRIC I cenify that I have read this application and state that the above VENTILATION FAN (569, p 0 information is correct I agree to comply with all city and cmmty BOILER-COMPO H.P.or 100 000 B.T.U.) 4.00 PLUMBING x,7 a -- ordinances and slate laws relating to building construction, and ' 4hereby awhorue representatives of this city to enter upon the 00 above-mentioned property for inspection PUIPOks. BOILEfl-COMP 1 ,00 BTU E SCH. MECHANICAL (We) agree to save, indemnify and keep harmless the City'of MISC.- REFER TO ORD. Cupertino against liabilities,judgments, costs and expenses which PERMIT ISSUAN o 00 CONST.TAX may in any way accrue•against said City in consequence of the Y Upertino 3.00 3 gonumg oftl' permit. MECH.CONT. LIC.NO. MECH. , TOTAL Sao TOTAL /] ��� Signa arc pplvial Crntrue nr Date. OFFICE COPY