The URL can be used to link to this page

7169D ¢ z Foo Q V U N3z w G0z �z z D � ON D F ~ Q y J d a a U aa 3 n lA H u O a aa aarE i Yp0 0 AWm sio 0 O Z z 0 LU ao 7 z UO LL U Ow 0 APPLICARIT-TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY BUILDING PROJECT I DENTIFICATI ON APPLICATION & PERMIT BUILDING - ELECTRICAL- PLUMBING -MECHANICAL PERMIT NUMBER 7169 BUILDING �1 W TASaco Fa OWNER'S PLAN CHECK VALIDATION " DTV. ELECTRIC PERMIT FEE PHONE ' coNr FACTORS N E UTLETS- SWITCHES -RECEP 5.00/1.00 / LIGHTING FIXTURES 5.00/1.00 yJ Llc. No 0 DATE OF APPLICATION raN TRACT 's DRESS 5' PHONE PPLIANCES-RESIDENTIAL 4.00 PANELS 5.00 AR'HITECT +H ENGINEER LIC. No. SIGNS 6.00 PLAN CHECK FEE SIGNS TRANS. 3.00 moo ESS ENO, SPECIALCIRCUIT 5.00 PERMIT VALIDATION EMP. METER OR POLE IN 15.00 zlv 01 APPLICANTS ADDRESS MOTOR EE FEE SCH. (A SERVICE CHANGE 10.00 k, LICENSI'1) CONT([ACTORS DECLARATION I hereby affvn (hut I un, licensed under provisions of Chapter 9 ISSUANCE DATE (commencing with Section 7000) of Division 3 of Ora Business and Professions CoJlkpa)A my license iz N full (urce c _f�iV Lic. Numhcr / BLDG. E ECT I ❑ PLG. MECH. ❑ ❑ Datee,(11asz Date -BUILDING PERMIT OWNER -BUILDER DECLARAT N 1 hereby collo (hal I um exempt Iron) the Contractor's License (Sea 7one,a Business and Professions Law lar the following myr.V.,Lwhich Coda Any city or county which Structure Permit Iuuaconstruct,, also improve, demolish, or repair any Structure. prim also its iateme INFORMATION MISC.- REFER TO ORD LUATION $/FT. PERMIT ISSUANCE 6.00 ELEC. CONTR. LIC. NO. ELEC. / signed t Tie is llic uhf dp Jal lar She rovisi l0 GIC a Ct act rInCN that he is licensed pursuant the provisions of the License TDTA�, gMIT TO QTY. PLUMBING PERMIT FEE eIlin ) of Dreision Law (Chapter 9lco sion. C d with Section is of Division 3 of the c 9(commencing Code) or that s dation exempt therefrom and Bas iness and he alleged the basis for the al4gcd exemption. Any violation af$eclion 7031.5 STORIES TYPE CONSTR. ALTER -DRAIN -WATER IEA.14.00 by any applicant for a permit%objects the applicant to a civil penalty of not more than live hundred dollars (S500).): - ❑ I, as owner o1'tire property, or my employees with wages as licit sol, compensation, will do the work, and the "rectum is nn[ BACK FLOW PROTECT. DEVICE 2.00 OCC. GROUP RES. UNITS DRAINS -FLOOR, ROOF, AR EA, COND. 4.00 intended or offered lox sale (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 docs such work FIXTURES - PER TRAP 4.00 SO, FT. FLOOR AREA TOTAL ACREAGE himself or through his own employees, provided [hal such in.prove- .ments are not intended or offered for sale. If, however, the building GAS-EA.SYSTEM-I INC-40UTLETS 4.00 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- prove for purpose of sale.). ❑ I, as owner of the property, am exclusively contracting with tile ... ed contractors to construct the project (Sec. 7044, Business GAS - EA. SYSTEM - OVER 4 (EA.) 1.00 BUIL IN G USE RES IND PB Omer . ❑ ❑ ❑ ❑ INDUSTRIAL WASTE INTER. 20.00 LAWN SPR IN KLERS - 1 INC 5 V.B. 5.00 ASSESSD 5 CEL NO. and Professions Code: 'I'he Contractor, 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%act% projects with a nmlydetons) licensed pursuant to tire Contractor's Llcensc Law. SEWER -SANITARY -STORM EA. 200ft/8.00 TRACT NO. PARCEL NO. WATER HEATER W/VENT 4.00 ❑ lam exempt under Scc. ,I).&P.C. I'or this reusan Owner Dale WATER SYSTEM 4.00 ACC. DATE ACC. FILE NO. WORKERS'CONIPENSATION DECLARATION WATER TREATING EQUIP. 4.00 I hereby allirn that I have a certificate of consent to self -insure. rues, or a cettifi,d rke' Compensation pesation 11 n or . certificate of Wors copy thcr• 00, Lab.C.l 1'nli,y No'eJ(T�JfrT: nnpany ❑ Ccrtilicd copy is l¢rehy l'umishW. ZONING ENG. SITE NO. - FIRESPRINK ENERGY T 24 TT��!!Cerli ,• y ix }IAcd: pi�B��Byy��atY Insnectiou division. AFV cant y N ❑ ❑ y N ❑ ❑ MISC.- REFER TO ORD. PERMIT ISSUANCE 6.00 FLOOD ZONE A.L.U.C. CIiR'1'IFICAT OI' EXEMPTION FROM WORKERS' PLG. CONTR. LIC. NO. PLG. TOTAL CONIPENSATION INSURANC17 11'his Section need not be completed if the permit is for one V❑ N❑ Y❑ N❑ QTY. MECHANICAL PERMIT FEE FEE SUMMARY llmldred dollars IS 100) or less.) I artily that in it,, performance of the work for which this per- Hit Is issued, I shall not employ any pets m in any nmeners+a, la hecane subject to IEC Workers' Conlpensalion Laws of California. Date Applicant BUILDING ALTER OR ADD TO. MECH. 4.00 1401 ICI' TO API'LICAN'1': If, after making this Certificate of I:x- emption, you should haeme subject ra the Workers' Compensation provisions of the Labm Code, you must I-or[hwit h comply with such provisions or [his permit Shall be deemed revoked. APPLIANCE 4.00 PLAN CHECK FEE AIR HANDLING UNIT (TO 10A00C.F.M.) 3.00 AIR HANDLING UNIT (OVER 10=C.F.M.) 5.00 SEISMIC FEE CONS'1'RUCI'ION LENDING AGENCY EXHAUST HOOD (WITH DUCT) 2.00 MICROFILM I hereby affirm [hill there is a construction ''Icnhim, agency for the Fell ... m n,c of the work for which the, permit is issued (Sea 3097, Ci V,C. ). HEATING UNIT (TO 100,000 B.T.U.) 4.00 HEATING UN IT (OVER 100,000 B.T.U.)7.50 ELECTRIC Lender's Name Lender's Address 1 certify that I have read this application and state that the above information is correct. I agree to comply will, all city and county ordinances and state laws relating to building construction, and VENTILATION FAN (SINGLE) 3.00 PLUMBING BOILER-COMP(3 H.P. Dr 100,000 B.T.U.) 4.00 BOILER -COMP (Over 100,WOBTU) SEE FEESCH. MECHANICAL Hereby authorize representatives of this city to enter upon the above-mentioned property for inspection purposes. MISC. - REFER TO ORD. CONST. TAX (We) agree to Save, indemnify and keep harmless the City of Cupertino gains[ liabilities udgments, costs and expenses which may in ny way accrue ainsl City in consequence of the PERMIT ISSUANCE 3.00 MECH. CONT. LIC. NO. MECH. TOTAL TOTAL _ ^ , /_1l/ grn g a( tl is pcnniL ' z Ig Lure of APPli' ICD star Date OFFICE COPY D ¢ z Foo Q V U N3z w G0z �z z D � ON D F ~ Q y J d a a U aa 3 n lA H u O a aa aarE i Yp0 0 AWm sio 0 O Z z 0 LU ao 7 z UO LL U Ow 0 APPLICARIT-TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY BUILDING PROJECT I DENTIFICATI ON APPLICATION & PERMIT BUILDING - ELECTRICAL- PLUMBING -MECHANICAL PERMIT NUMBER 7169 BUILDING �1 W TASaco Fa OWNER'S PLAN CHECK VALIDATION " DTV. ELECTRIC PERMIT FEE PHONE ' coNr FACTORS N E UTLETS- SWITCHES -RECEP 5.00/1.00 / LIGHTING FIXTURES 5.00/1.00 yJ Llc. No 0 DATE OF APPLICATION raN TRACT 's DRESS 5' PHONE PPLIANCES-RESIDENTIAL 4.00 PANELS 5.00 AR'HITECT +H ENGINEER LIC. No. SIGNS 6.00 PLAN CHECK FEE SIGNS TRANS. 3.00 moo ESS ENO, SPECIALCIRCUIT 5.00 PERMIT VALIDATION EMP. METER OR POLE IN 15.00 zlv 01 APPLICANTS ADDRESS MOTOR EE FEE SCH. (A SERVICE CHANGE 10.00 k, LICENSI'1) CONT([ACTORS DECLARATION I hereby affvn (hut I un, licensed under provisions of Chapter 9 ISSUANCE DATE (commencing with Section 7000) of Division 3 of Ora Business and Professions CoJlkpa)A my license iz N full (urce c _f�iV Lic. Numhcr / BLDG. E ECT I ❑ PLG. MECH. ❑ ❑ Datee,(11asz Date -BUILDING PERMIT OWNER -BUILDER DECLARAT N 1 hereby collo (hal I um exempt Iron) the Contractor's License (Sea 7one,a Business and Professions Law lar the following myr.V.,Lwhich Coda Any city or county which Structure Permit Iuuaconstruct,, also improve, demolish, or repair any Structure. prim also its iateme INFORMATION MISC.- REFER TO ORD LUATION $/FT. PERMIT ISSUANCE 6.00 ELEC. CONTR. LIC. NO. ELEC. / signed t Tie is llic uhf dp Jal lar She rovisi l0 GIC a Ct act rInCN that he is licensed pursuant the provisions of the License TDTA�, gMIT TO QTY. PLUMBING PERMIT FEE eIlin ) of Dreision Law (Chapter 9lco sion. C d with Section is of Division 3 of the c 9(commencing Code) or that s dation exempt therefrom and Bas iness and he alleged the basis for the al4gcd exemption. Any violation af$eclion 7031.5 STORIES TYPE CONSTR. ALTER -DRAIN -WATER IEA.14.00 by any applicant for a permit%objects the applicant to a civil penalty of not more than live hundred dollars (S500).): - ❑ I, as owner o1'tire property, or my employees with wages as licit sol, compensation, will do the work, and the "rectum is nn[ BACK FLOW PROTECT. DEVICE 2.00 OCC. GROUP RES. UNITS DRAINS -FLOOR, ROOF, AR EA, COND. 4.00 intended or offered lox sale (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 docs such work FIXTURES - PER TRAP 4.00 SO, FT. FLOOR AREA TOTAL ACREAGE himself or through his own employees, provided [hal such in.prove- .ments are not intended or offered for sale. If, however, the building GAS-EA.SYSTEM-I INC-40UTLETS 4.00 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- prove for purpose of sale.). ❑ I, as owner of the property, am exclusively contracting with tile ... ed contractors to construct the project (Sec. 7044, Business GAS - EA. SYSTEM - OVER 4 (EA.) 1.00 BUIL IN G USE RES IND PB Omer . ❑ ❑ ❑ ❑ INDUSTRIAL WASTE INTER. 20.00 LAWN SPR IN KLERS - 1 INC 5 V.B. 5.00 ASSESSD 5 CEL NO. and Professions Code: 'I'he Contractor, 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%act% projects with a nmlydetons) licensed pursuant to tire Contractor's Llcensc Law. SEWER -SANITARY -STORM EA. 200ft/8.00 TRACT NO. PARCEL NO. WATER HEATER W/VENT 4.00 ❑ lam exempt under Scc. ,I).&P.C. I'or this reusan Owner Dale WATER SYSTEM 4.00 ACC. DATE ACC. FILE NO. WORKERS'CONIPENSATION DECLARATION WATER TREATING EQUIP. 4.00 I hereby allirn that I have a certificate of consent to self -insure. rues, or a cettifi,d rke' Compensation pesation 11 n or . certificate of Wors copy thcr• 00, Lab.C.l 1'nli,y No'eJ(T�JfrT: nnpany ❑ Ccrtilicd copy is l¢rehy l'umishW. ZONING ENG. SITE NO. - FIRESPRINK ENERGY T 24 TT��!!Cerli ,• y ix }IAcd: pi�B��Byy��atY Insnectiou division. AFV cant y N ❑ ❑ y N ❑ ❑ MISC.- REFER TO ORD. PERMIT ISSUANCE 6.00 FLOOD ZONE A.L.U.C. CIiR'1'IFICAT OI' EXEMPTION FROM WORKERS' PLG. CONTR. LIC. NO. PLG. TOTAL CONIPENSATION INSURANC17 11'his Section need not be completed if the permit is for one V❑ N❑ Y❑ N❑ QTY. MECHANICAL PERMIT FEE FEE SUMMARY llmldred dollars IS 100) or less.) I artily that in it,, performance of the work for which this per- Hit Is issued, I shall not employ any pets m in any nmeners+a, la hecane subject to IEC Workers' Conlpensalion Laws of California. Date Applicant BUILDING ALTER OR ADD TO. MECH. 4.00 1401 ICI' TO API'LICAN'1': If, after making this Certificate of I:x- emption, you should haeme subject ra the Workers' Compensation provisions of the Labm Code, you must I-or[hwit h comply with such provisions or [his permit Shall be deemed revoked. APPLIANCE 4.00 PLAN CHECK FEE AIR HANDLING UNIT (TO 10A00C.F.M.) 3.00 AIR HANDLING UNIT (OVER 10=C.F.M.) 5.00 SEISMIC FEE CONS'1'RUCI'ION LENDING AGENCY EXHAUST HOOD (WITH DUCT) 2.00 MICROFILM I hereby affirm [hill there is a construction ''Icnhim, agency for the Fell ... m n,c of the work for which the, permit is issued (Sea 3097, Ci V,C. ). HEATING UNIT (TO 100,000 B.T.U.) 4.00 HEATING UN IT (OVER 100,000 B.T.U.)7.50 ELECTRIC Lender's Name Lender's Address 1 certify that I have read this application and state that the above information is correct. I agree to comply will, all city and county ordinances and state laws relating to building construction, and VENTILATION FAN (SINGLE) 3.00 PLUMBING BOILER-COMP(3 H.P. Dr 100,000 B.T.U.) 4.00 BOILER -COMP (Over 100,WOBTU) SEE FEESCH. MECHANICAL Hereby authorize representatives of this city to enter upon the above-mentioned property for inspection purposes. MISC. - REFER TO ORD. CONST. TAX (We) agree to Save, indemnify and keep harmless the City of Cupertino gains[ liabilities udgments, costs and expenses which may in ny way accrue ainsl City in consequence of the PERMIT ISSUANCE 3.00 MECH. CONT. LIC. NO. MECH. TOTAL TOTAL _ ^ , /_1l/ grn g a( tl is pcnniL ' z Ig Lure of APPli' ICD star Date OFFICE COPY