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8752APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY BUILDING PROJECT 1 DENTI FICA7 i W,APPLICATION PERID BUILDING -ELECTRICAL -PLUMBING -MECHANICAL PERMIT NUMBER 8752 aLDIrvG VI ADOREss !_O0 C/r ffOO OW ER's NAi r PHONE O ELECTRIC PERMIT FEE PLAN CHECK VALIDATION DATE OF APPLICATION CONTRACTOR'S pa NAME �/7 "/4�� OUTLETS -SWITCHES -RECEP 10.00/1.00 LIGHTING FIXTURES 10.00/1.00 r,ONTR CT Rs ADDRESS /J LfJ %L% ;r)? Q /1 PPLIANCES- RESIDENTIAL 4.00 PANELS 10.00 ARCHITECT 1 OR O PANELS (OVER 200 AMP) 20.00 PLAN CHECK FEE P.C. NO. ENGINEER TIC, ry SIGNS TRANS. 3.00 AARCH OR DDRESS ENG. SPECIAL CIRCUIT 5,00 PERMIT VALIDATION EMP. METER OR POLE INS. 20.00 ZIP 6 �y APPLICAND TS S'I%N i,I CJ/➢/'//- 710 N -T (,u 6 / S MOTORS SEE FEE SCH. ,rO SERVICE CHANGE 20.00 LICENSED CONTRACTORS DECLARATION TEMP. POLE 30.00 I hereby affirm that 1 am licensed under provisions of Chapter 9 (commencing with Section 7000) of Division 3 of the Business and Professions Code, nd I license is in full for d cl. 'License Class Lie. Number Uatc_ V " Cont mdor OWNER -BUILDER DECLARATION I hereby affirm that 1 so exempt from the Contractor's License reason (Sec. 703 L5, BuI , to and Professions CLaw ode: Any city Code: Any city or county which Structure permit to mnsuance, Beq poor to its issuance, also Improv0. demolish, or repair any nnmlo file for such permit to file n rimed statement License vires the dp pursuant he is licensed pursuant en the provisions of the Contractor's Licensc he of Division 3 0l the Law (Chapter 9 (commencing with Section is exempt Business and Professions Code) or that he is exempt therefrom and g 7 ISSUANCE DATE BLDG. ELECT. ❑ PLG. MECH. ❑ O C1 Y of wed"',❑ t BUILDING PERMIT INFORMATION MISC.- REFER TO ORD VALUATION $/FT. PERMIT ISSUANCE ELEC. CONTR. LIC. N0. ELEC /_ TOTAL Kr PERMIT TO QTY. PLUMBING PERMIT FEE STORIES TYPE CONSTR. Anyviolation ofSection thebasisafoe the allegedexit malty cube too civil penalty by otloco, the )fire permit dollars the ($500),) of not more than five hundred dollars (8500).)'. - ALTER-DRAIN-WATER(EA.) 5.00 ❑ I, as owner .1 the property, or my employees with wages ur their sole compensation, will do the work. and the structure is not BACK FLOW PROTECT. DEVICE 4.00 OCC. GROUP RES. UNITS DRAINS -FLOOR, ROOF, AREA, COND. 5.00 intended or offered for sale (Sec. 7044, Business and Professions Code The Contractor's License Law docs not apply to an owner of property who builds or improves thereon, and who does such work himself ur through his own employees provided that such improve mems are not intended or offered for sale. If, however. the building FIXTURES - PER TRAP 5.00 SO. FT. FLOOR AREA TOTAL ACREAGE 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 am. prove for purpose of sale.). O I, as owner of the property, am exclusively contracting with GAS - EA. SYSTEM -OVER 4 (EA.) 2.00 BUILDING USE RES IND CON Pe Core, ❑ ❑ ❑ ❑ ❑ INDUSTRIAL WASTE INTER. 30.00 LAWN SPRINKLERS- 1 INC 5 V.B. 6.00 ASSESSORS PARCEL NO. licensed contractors to construct the project (Sec. 7044, Business and Professions Code: The Contractor's License Law dues 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 conlraclorts) licensed pursuant to the Contractor's License Law, SEWER -SANITARY -STORM EA. 200ft/10.00 TRACT NO. PARCEL NO. ❑ lam exempt under Sec. .B.&P.C. for this reason WATER HEATER W/VENT 6.00 Owner [)ale WATER SYSTEM 5.00 ACC. GATE ACC. FILE N0. WATER TREATING EQUIP, 5.00 WORK ERS'COMPENSA'I ION DECLARATION 1 hereby affirm that I have a certificate of consent to self -insure. or a certificate of Workers' Compensation Insurance, or a cenirmd ZONING ENG. SITE NO. copy thereof (See. 3800, Lab .C.). r� Policy No.-COI11pallyL iAmmpr)r- FIRE SPRINK v Cl❑ ❑ ENERGY T-24 v N ❑ ❑ &Cetlified' copy is hereby fu n,ished. Certif/L copy is file with me city inspci,iy`div-slsion. /1ppBcanl �2� g(,� MISC.- REFER TO ORD, PERMIT ISSUANCE 10.00 FLOOD ZONE A_L.U.C. CERTIIFFIICA'rE Of: EXEMPTION FROM WORKERS' PLG. CONTR. LIC. NO. PLG. TOTAL COMPENSATION INSURANCE i0 (This section need not he completed if the Permit is for one Y C:] ❑ Y ❑ N ❑ DTV. MECHANICAL PERMIT FEE FEE SUMMARY hundred dollars IS 100) or less.) I certify that in the performance of the work for which (his per- Mit is issued. I shall not employ any person in any manner so as to BUILDING become subject to the Workers Compensation Laws of California. Date Applieavl NOTICE 'r0 APPLICAN'r', If, after making this Certificate of Ex- ALTER OR ADD TO MECH. 5.00 APPLIANCE 5.00 PLAN CHECK emption, you should become subject to the Workera' Compensation provisions of the Labor Code, you must forthwith comply with such provisions or this permit shall be deemed revoked. FEE AIR HANDLING UNIT (TO 10=r-F.M.) 4.00 AIR HANDLING UNIT (OVER 10,000CF.M.) 6.00 SEISMIC FEE CONS' I'RUCrION LENDING AGI7NCY I 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. 3097, Civ.C.). MICROFILM HEATING UNIT (TO 100,000 B.T.U.) 8.00 HEATING UNIT (OVER 100,000 B.T.U.) 9.50 ELECTRIC !(P Lender's Name Lenders Addr. ess I certify that I have read this application andstate that the above inl'or,n tion is correct. I agree to comply with ail city and county ordinances and state laws relating to building construction, and VENTILATION FAN (SINGLE) 4.00 PLUMBING BOILER-COMP13 H.P. or 100,000 B.T.U.) 6.00 BOILER -COMP (Over 100,000 BTU.) SEE FEE SCH, MECHANICAL hereby mthorize representatives of this city to corer upon the above-mentioned property for inspection purposes. MISC. - REFER TO ORD. (We) agree to save, indemnify and keep harmless the City of Cupertino against )cubo' ins, judgments, costs and expenses wllidl May in any way a e against 'id City mnscyuen999e of the gran' gof this t / / CONST. TAX PERMIT ISSUANCE 10.00 MECH.CONT. LIC. NO. MECH. TOTAL TOTAL Signature of Applicant/Contractor Dale OFFICE COPY APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY BUILDING PROJECT 1 DENTI FICA7 i W,APPLICATION PERID BUILDING -ELECTRICAL -PLUMBING -MECHANICAL PERMIT NUMBER 8752 aLDIrvG VI ADOREss !_O0 C/r ffOO OW ER's NAi r PHONE O ELECTRIC PERMIT FEE PLAN CHECK VALIDATION DATE OF APPLICATION CONTRACTOR'S pa NAME �/7 "/4�� OUTLETS -SWITCHES -RECEP 10.00/1.00 LIGHTING FIXTURES 10.00/1.00 r,ONTR CT Rs ADDRESS /J LfJ %L% ;r)? Q /1 PPLIANCES- RESIDENTIAL 4.00 PANELS 10.00 ARCHITECT 1 OR O PANELS (OVER 200 AMP) 20.00 PLAN CHECK FEE P.C. NO. ENGINEER TIC, ry SIGNS TRANS. 3.00 AARCH OR DDRESS ENG. SPECIAL CIRCUIT 5,00 PERMIT VALIDATION EMP. METER OR POLE INS. 20.00 ZIP 6 �y APPLICAND TS S'I%N i,I CJ/➢/'//- 710 N -T (,u 6 / S MOTORS SEE FEE SCH. ,rO SERVICE CHANGE 20.00 LICENSED CONTRACTORS DECLARATION TEMP. POLE 30.00 I hereby affirm that 1 am licensed under provisions of Chapter 9 (commencing with Section 7000) of Division 3 of the Business and Professions Code, nd I license is in full for d cl. 'License Class Lie. Number Uatc_ V " Cont mdor OWNER -BUILDER DECLARATION I hereby affirm that 1 so exempt from the Contractor's License reason (Sec. 703 L5, BuI , to and Professions CLaw ode: Any city Code: Any city or county which Structure permit to mnsuance, Beq poor to its issuance, also Improv0. demolish, or repair any nnmlo file for such permit to file n rimed statement License vires the dp pursuant he is licensed pursuant en the provisions of the Contractor's Licensc he of Division 3 0l the Law (Chapter 9 (commencing with Section is exempt Business and Professions Code) or that he is exempt therefrom and g 7 ISSUANCE DATE BLDG. ELECT. ❑ PLG. MECH. ❑ O C1 Y of wed"',❑ t BUILDING PERMIT INFORMATION MISC.- REFER TO ORD VALUATION $/FT. PERMIT ISSUANCE ELEC. CONTR. LIC. N0. ELEC /_ TOTAL Kr PERMIT TO QTY. PLUMBING PERMIT FEE STORIES TYPE CONSTR. Anyviolation ofSection thebasisafoe the allegedexit malty cube too civil penalty by otloco, the )fire permit dollars the ($500),) of not more than five hundred dollars (8500).)'. - ALTER-DRAIN-WATER(EA.) 5.00 ❑ I, as owner .1 the property, or my employees with wages ur their sole compensation, will do the work. and the structure is not BACK FLOW PROTECT. DEVICE 4.00 OCC. GROUP RES. UNITS DRAINS -FLOOR, ROOF, AREA, COND. 5.00 intended or offered for sale (Sec. 7044, Business and Professions Code The Contractor's License Law docs not apply to an owner of property who builds or improves thereon, and who does such work himself ur through his own employees provided that such improve mems are not intended or offered for sale. If, however. the building FIXTURES - PER TRAP 5.00 SO. FT. FLOOR AREA TOTAL ACREAGE 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 am. prove for purpose of sale.). O I, as owner of the property, am exclusively contracting with GAS - EA. SYSTEM -OVER 4 (EA.) 2.00 BUILDING USE RES IND CON Pe Core, ❑ ❑ ❑ ❑ ❑ INDUSTRIAL WASTE INTER. 30.00 LAWN SPRINKLERS- 1 INC 5 V.B. 6.00 ASSESSORS PARCEL NO. licensed contractors to construct the project (Sec. 7044, Business and Professions Code: The Contractor's License Law dues 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 conlraclorts) licensed pursuant to the Contractor's License Law, SEWER -SANITARY -STORM EA. 200ft/10.00 TRACT NO. PARCEL NO. ❑ lam exempt under Sec. .B.&P.C. for this reason WATER HEATER W/VENT 6.00 Owner [)ale WATER SYSTEM 5.00 ACC. GATE ACC. FILE N0. WATER TREATING EQUIP, 5.00 WORK ERS'COMPENSA'I ION DECLARATION 1 hereby affirm that I have a certificate of consent to self -insure. or a certificate of Workers' Compensation Insurance, or a cenirmd ZONING ENG. SITE NO. copy thereof (See. 3800, Lab .C.). r� Policy No.-COI11pallyL iAmmpr)r- FIRE SPRINK v Cl❑ ❑ ENERGY T-24 v N ❑ ❑ &Cetlified' copy is hereby fu n,ished. Certif/L copy is file with me city inspci,iy`div-slsion. /1ppBcanl �2� g(,� MISC.- REFER TO ORD, PERMIT ISSUANCE 10.00 FLOOD ZONE A_L.U.C. CERTIIFFIICA'rE Of: EXEMPTION FROM WORKERS' PLG. CONTR. LIC. NO. PLG. TOTAL COMPENSATION INSURANCE i0 (This section need not he completed if the Permit is for one Y C:] ❑ Y ❑ N ❑ DTV. MECHANICAL PERMIT FEE FEE SUMMARY hundred dollars IS 100) or less.) I certify that in the performance of the work for which (his per- Mit is issued. I shall not employ any person in any manner so as to BUILDING become subject to the Workers Compensation Laws of California. Date Applieavl NOTICE 'r0 APPLICAN'r', If, after making this Certificate of Ex- ALTER OR ADD TO MECH. 5.00 APPLIANCE 5.00 PLAN CHECK emption, you should become subject to the Workera' Compensation provisions of the Labor Code, you must forthwith comply with such provisions or this permit shall be deemed revoked. FEE AIR HANDLING UNIT (TO 10=r-F.M.) 4.00 AIR HANDLING UNIT (OVER 10,000CF.M.) 6.00 SEISMIC FEE CONS' I'RUCrION LENDING AGI7NCY I 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. 3097, Civ.C.). MICROFILM HEATING UNIT (TO 100,000 B.T.U.) 8.00 HEATING UNIT (OVER 100,000 B.T.U.) 9.50 ELECTRIC !(P Lender's Name Lenders Addr. ess I certify that I have read this application andstate that the above inl'or,n tion is correct. I agree to comply with ail city and county ordinances and state laws relating to building construction, and VENTILATION FAN (SINGLE) 4.00 PLUMBING BOILER-COMP13 H.P. or 100,000 B.T.U.) 6.00 BOILER -COMP (Over 100,000 BTU.) SEE FEE SCH, MECHANICAL hereby mthorize representatives of this city to corer upon the above-mentioned property for inspection purposes. MISC. - REFER TO ORD. (We) agree to save, indemnify and keep harmless the City of Cupertino against )cubo' ins, judgments, costs and expenses wllidl May in any way a e against 'id City mnscyuen999e of the gran' gof this t / / CONST. TAX PERMIT ISSUANCE 10.00 MECH.CONT. LIC. NO. MECH. TOTAL TOTAL Signature of Applicant/Contractor Dale OFFICE COPY