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10824 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY BUILDING PROJECT IDENTIFICATION PERMIT NUMBER BUILDING APPLICATION & PERMIT ADORC55� r � , ��, „ �� 10824 /`� BUILDING -ELECTRICAL-PLUMBING-MECHANICAL 16L, 1. OWNER'S - PLAN CHECK VALIDATION NAM�. oeo,Sa.� ' 5''241 CITY. ELECTRIC PERMIT FEE 1a✓1Vi+16. PHONE HoxTanc.oRs _�c UTLETS-SWITCHES-REC LIC.NO. EP 70.00/1.00 O A}'D LIGHTING FIXTURES 10.00/1.00 N0. CONTRACTOR'S PPLIANCES-RESIDENTIAL 4.00 AOOR 55 NS' Fy�}y s (� 1 (W/ �TT{I\IoyNE} PANELS 16.00 DATE OF APPLICATION onnCHITFCT . PANELS (OVER 200 AMPI 20,66 PLAN CHECK FEE P.C.NO. ENGINEER uc.No. SIGNS TRANS. 3.00 pCRE55 ENG. SPECIAL CIRCUIT 5.66 "� PERMI VALIDATION ZIP' EMP.METER OR PO I 20.00 'AID ADDRESNrs T MOTORS E FEE SCH. N ADDRESS ��IVVV��'��000 SERVICE CHANG 'sn^ 20,00 woo LICENSED CONTRACTORS DECLARATION - C < U I hereby affrm that I am licensed under provisions of Chapter 9 ISSUANCE DATE w 4 N (commencing with Section 7000)of Division 3 of the Business and BLDG. ELECT. PLG. MECH. H vi z Professions Cod red my license is in full for polff 1. ❑ z 0 m - License Class hie.Number VL+ 9 z F Dale - (y_Contractor ,l ✓' c VV X m ¢a OWNFR-BUILDER DECLARATION Y � , ��J a BUILDING PERMIT w v INFORMATION K 3 LL uHi 1 hereby affirm that I am exempt from the Contractor's License ISC.- RE R T ORD u0a Law for the following reason.(Sec.703 L 5,B usiness an d Professions ERMIT ISSUANCE 10.00 VALUATION f � Code:Any cityorcounty which requiresa permit to construct,alter, Q Ie ¢ a 0 improve,demolish,or repair any structure,prior to its issuance,also LEC.C NTR. LIC.N ELEC. /` V v w0 LL requires the applicant for such permit to file a signed Statement that TOTAL S PERMIT TO $ he is licensed pursuant to the provisions of tire Contractor's Licens xr� rzr Law(Chapter 9(commencing with Section 7000)o'Division3oft Fmo Business and Professions Code)or taut he is exem t herefrom- d OTY. PLUMBINO:'PERMIT FEE /- Q r ro the basis for the alleged exemption.Any violation L •coon 70 1.5 STORIES TYPE CONSTR. La � ,- by any applicant for a permit subjects the appllcal l h acivilp airy ALTER-DRAIN&VENT-WATER IEA.) 5.00 of not more than five hundred dollars(8500).): ❑ I,as owner of the property,or my employ es with ages as BACK FLOW PROTECT. DEVICE 4.00 OCC.GROUP RES.UNITS yq their sole compensation,will do the work,and 11 c struct re is not - __ intended or offered for sale (Sec. 7044, Busines and ofessmas DRAINS-FLOOR,ROOF,AREA,COND. 5.00 Code:The Contractor's License Law does not app t n owner of property who builds or improves thereon,and who es such work FIXTURES-PER TRAP 5.06 S 50.FT.FLOOR AREA TOTALACREAGE 8 ) himself or through his own employees,provided that such improve- GAS-EA.SYSTEM-11NC.40UTLETS 6.00 mems are not intended or offered for sale.II',however,the building or improvement is sold within one year of completion,lire owner- GAS-EASYSTEM OVER 4 IEA) 200 BUILDING USE builder will have the burden of proving taut he did not build or 1m . - . . - RES IND CON PR OUM1ae 1,as o Prove owner of sale.). RES WASTE INTER. 30.00 El El C1❑ 1,as ownner of the property,am exclusively contracting with licensed contractors to construct the project(Sec.7044,Business LAWN SPRINKLERS-1 INC 5 V.B. 6.00 ASSESSORS PARCEL NO. and Professions Code:The 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 Contraclor(s)licensed pursuant to SEWER-SANITARYV-$TOR ft/10.00 the Contracmr's License Law. TRACT NO. PARCEL NO. ❑ I am exempt under Sec. ,BARC.for this WATER HEATER W/VENT 6.00 reason Owner _ Date WATER SYSTEM '�at '.'SDO IANACC.DATE ACC.FILE NO. WORK ERS'COMPENSATION DECLARATION WATER TREATING E I . 5.00 1 hereby affirm that I have a certificate of consent to self-insure, or a certificate of Workers'Compensation Insurance,or a certified Of CupertinoZONING ENG.SITE N0. copy t lmrcof(Scc.3800,Lab.C.). S_I I1 P iL �♦_M Policy No. Company 1r�//✓V 0 ❑ Certified copy is hereby furnished. FIRE SPRINK ENERGY T 24 Z 2 ❑ Cerlific .�c�opy i f I c city Inspection division. O Applicant�[I ' MISC,- REFER TO ORD. Y ❑ N❑ Y ❑ N❑ Cr T CERTIFICATE OF EXIiMPI'ION FROM WORKERS' PERMIT ISSUANCE 10.00 A ' FLOOD ZONE A.L.0 C.• LU > COMPENSATION INSURANCE PLG.CONTR. LIC.NO. - Z (This section need not be completed if the permit is for one TOTAL a Y❑ N❑ Y F] N❑ hundred dollars($100)or less.) 0 O I certify that in the performance of the work for which this per- CITY. MECHANICAL PERMIT FEE FEE SUMMARY LL H mit is issued.I shall not employ any person in any manner so as to U become subject to the Workers'Compensation Laws of California. Up Date Applicant ALTER OR ADD TO MECH. 5.00 - BUILDING .jd/.f-a } to NOTICE TO APPLICANT: If,after making this Cerliftcme o1'Ex- ? emption,you should become subject to the Workers'Compensation APPLIANCE 5.00 PLAN CHECK SD` provisions of the Labor Code, you must forthwith comply with FEE U such provisions or this permit shall be deemed revoked. AIR HANDLING UNIT(TO 10=C.F.M.) 4.00 CONSTRUCTION LENDING AGENCY AIR HANDLING UNIT(OVER 10,000C.F.M.) 6.00 SEISMIC FEE r. 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. MICROFILM 3097,Civ.C.), HEATING UNIT(TO 100,000 B.T.U.) 8.00 Lender's Name Lenders Address HEATI NG UN IT(OV E R 100ELECTRIC ,000 B.T.U.)9.50 a i - s 1 certify that I have read this application and slate that the above VENTILATION FAN (SINGLE) 4.00 information n correct I agree to comply with all city and county PLUMBING ordinances and state Ixws relating m building construction, and BOILER-COMPI3 H.P.Or 700,000 B.T.U.) 6.00 hereby authorize representatives of this city to enter upon lire g01 LER-COMP(Over 100,000 BTU)SEE FEE SCH. MECHANICAL above-mentioned property for inspection purposes. (We),agree to save, indemnify and keep harmless the City o1' MISC.- REFER TO ORD. Cupertino against liabilities,judgments, costs and expenses which PERMIT ISSUANCE 10.00 CONST.TAX may III any way accrue against said City in consequence of the granting of this permit MECH.CONT, LIC.NO. MECH. )�.J /A �� TOTAL TOTAL //0 61 ignature of Applicant/Contractor Date APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY BUILDING PROJECT IDENTIFICATION PERMIT NUMBER BUILDING APPLICATION & PERMIT ADDRESS S S7 � `+ 1~1' P-® 10824 �Z '(�•! !OW 6UILOING -ELECTRICAL-PLUMBING-MECHANICAL OwNER'S -• - PLAN CHECK VALIDATION """' SIR GTY. ELECTRIC PERMIT FEET= ,v P7 CONTRACTOR'S NAgk� /��_�F OUTLETS-SWITCHES-RECEP 10.00/1.00 /70 ffi Wr'�/ �' �6736 LIGHTING FIXTURES 10.00/1.00 LIC.NO. CONTRACTORS PPLIANCES-RESIDENTIAL 4.00 AODR ss Uj ' ocis PANELS 10.00 GATE OF APPLICATION ARCHITECT PANELS (OVER 200 AMP) 20.00 PLAN CHECK FEE P.C.NO. OR ENGINEER --- LIC.No. SIGNS TRANS. 3.00 ARC OR ENG. ..- PEI MI VALIDATION ADDRESS SPECIALCIRCUIT 5.00 'AID ZIP EMP.METER OR PO I LSCH. 00 APPLICANT MOTORS E FEE SCH. ADDRESS SERVICE CHANGMN •' 20.00 y/ o o LICENSED CONTRACTORS DECLARATION C�' /�r5•ertlno <v u I hereby affirm that 1 am licensed under provisions of Chapter 9 ISSUANCE DATE h Q T (commencing with Section 7000)Of Division 3 of the Business and BLDG. ELECT. PLG. MECH. H i Professions Cod nd my license is in full for ff Z 0 w - License Class Lic.Number ❑ -.2011,19441911!1-_y O z F Er, Dale - Contractor Q Y ¢ ¢ OWNER-BUILDER DECLARATION v^�� '� - BUILDING PERMIT - a w III INFORMATION E: ;w r I hereby affirm that I am exempt from the Contractor's License ISC.- RE T ORD a VALUATION F u o ¢ Law for the following reason.(Sec.7031.5,Business and Professions ERMIT ISSUANCE 10.00 0 - Code:Any city or county which requires a permit to construct.alter, x re ¢ ¢o improve,demolish,or repair any structure,prior to its issuance,also LEC.C NTH. LIC.N ELEC. ) �. 3/v r v wG LL requires the applicant for such permit to file a signed statement that ...�-�� TOTAL PERMIT TO $w he is licensed pursuant to the provisions of the Contractor's Livens vvaj�� pp r2 > Law(Chapter 9 Commencingwith Section 7000)ofDivtsion 3 oft - "• � ^EM�UC�� C,A.�^0 ¢ Business and Professions Code)or that he is exam herefrom d OTY. UMBING PERMIT.' - 'FEE•• /- re 1- the basis for the alleged exemption.Any violation f clion70 .5 - STORIES TYPE CONSTR. a ; by any applicant fora permit subjects the npplica t aciviI alty ALTER-DRAIN -WATER IEA.) 5.00 of not more than five hundred dollars(5500).): ❑ 1,as owner of the property,or my emplo es with ages as BACK FLOW PROTECT.DEVICE 4.00 OCC.GROUP RES.UNITS their sole compensation•will do the work,and t strut m isno[ intended or offered for sale (Sec. 7044, Busines and ofessions DRAINS-FLOOR,ROOF,AREA,COND. 5.00 Code:The Contractor's License Law does not app t n owner of • property who builds or improves thereon,and who es such work FIXTURES-PER TRAP 5.00 S-- SD.FT.FLOOR AREA TOTAL ACREAGE himself or through his own employees,provided thaI uch improve- GAS-EA.SVSTEM-11NC.40UTLETS 6.00 mems are not intended c r offered for sale.If,however,the building or improvement is sold within one year of completion,the owner- GAS-EASYSTEM OVER 4 (EA.) 200 builder will have the burden of proving[hal lie did not build or im- . - . . BUILDING USE prove for purpose ofsale.). INDUSTRIAL WASTE INTER. 30.00 RES IND CON PB Oma, ❑ 1,as owner of the property,am exclusively contracting with ❑ ❑ ❑ ❑ ❑ licensed contractors (a construct the project(Sec. 7044•Business LAWN SPRINKLERS- 1 INC 5 V.B. 6.00 ASSESSORS PARCEL NO. and Professions Code:The Contractor's License Law does not apply to an owner of property who builds or improves thereon.and who LAWN SPRINKLERS-OV ER 5 IEA.) 1.00 contracts for such projects with a contractoRs)licensed pursuant to SEWER-SANITARYV-STOR ft/10.00 the Contractor's License Law. TRACT NO. PARCEL NO. ❑ I on exempt under Sec.-,B&RC.for this WATER HEATER W/VENT 6.00 reason Owner Date WATER SYSTEM ),,i i0 ACC.DATE ACC,FILE NO. WORKERS'COMPENSATION DECLARATION WATER TREATING E I 5.00 1 hereby affirm that I have a certificate of consent to self-insure, or a certificate of Workers'Compensation Insurance,or a certified ofCupertino ZONING ENG.SITE NO. copy thereoflSec.3800,Lab.C.). Policy No. Company O ❑ Certified copy is hereby furnished. FIRE SPRINK ENERGY T-24 Z Z ❑ Certifie copyf yte city inspection division. O Applicant Ale MISC.- REFER TO ORD. Y ❑ N❑ Y ❑ N❑ CC T CERTIFICATE OF EXEMPTION FROM WORKERS' PERMIT ISSUANCE 10.00 0 � FLOOD ZONE A.L.U,C. W COMPENSATION INSURANCE PLG.CONTR. LIC.NO. PLG. 0.Z (This section need not be completed if the permit is for one TOTAL sal- Y❑ N❑ Y [:] N❑ hundred dollars IS 100)or less.) U O I certify that in the performance of the work for which This per, OTY MECHANICAL.PERMIT. FEE. FEE SUMMARY y I- mil is issued,I shall not employ any person in any manner So as to U become subject ID the Warken'Compensation Laws of California. JJ 7 y Dam Applicant BUILDING L�-D • N NOTICE TO APPLICANT: If.after making this Certificate of Ex ALTER Ofl ADD TO MECH. 5.00 emplion,you should become subject to the Workeri Compensation APPLIANCE 5.00 PLAN CHECK G'` provisions of the Labor Code, you must forthwith comply with FEE such provisions or this permit shall be deemed revoked. AIR HANDLING UNIT ITO 10=C.F.M.) 4.00 CONSTRUCTION LENDING AGENCY AIR HANDLING UNIT(OVER I0OOOC.FM.) 6.00 SEISMIC FEE t� 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. HEATING UNIT ITO 100,000 B.T.U.) 8.00 MICROFILM L �ender's Name00 Lenders Address HEATING UNIT(OVER 100,000 B.T.U.)9.50 ELECTRIC as 1 certify that I have read this application and state that the above information is correct. I agree to comply with all city and county VENTILATION FAN (SINGLE) 4.00 PLUMBING a dinances and state laws relating to building construction, and BOILER-=(3 H.P.or 100,000 B.T.U.) 6.00 / nby authorize representatives of this city to enter upon the BOI LER-COMP (Over 100,000 BTU)SEE FEE SCH. MECHANICAL ve-mentioned property for inspection purposes. Val agree to save, indemnify and keep harmless the City of MISC.- REFER TO ORD. -lino against liabilities,judgments, costs and expenses which PERMIT ISSUANCE 10.00 CONST.TAX n any way accrue against mid City in conuq dance of the It of this permit. MECH.CONT. LIC.NO. MECH. TOTAL v of Applicant/Contractor Date TGTAL