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18446 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY BUILDING PROJECT IDENTIFICATION .PERMIT NUMBER aDILDING � APPLICATION & PERMIT - 1 �446 A �+ ADOHE55 ^ I `F 4 O / � �. x)7JsLL/.V6i (� BUILDING -ELECTRICAL-PLUMBING-MECHANICAL 1,,, OWNER'5 PLAN CHECK VALIDATION NAME V. ELECTRIC PERMIT FEE S * 171 ( cDNrRAcrom'S Ly.C. .4qg 2_3/J OUTLETS.-SWITCHES-RECEP 10.00/1.00 'D , `',IV LIC.NO, LIGHTING FIXTURES 10.00/1.00 '� rj"Q ADDRRAcroR's tea( T. APPLIANCES-RESIDENTIAL 4.00 p � ,}L �''�• 96d ADDRESS �A)11 h �/PHONE �7� /' PANELS • 10.00 1L E't1FMP ICRTION A ARCHITECT P.C.PLAN CHECK FEE NO. OR PANELS (OVER 200 AMP) - 20.00 _ ENmNEER a L�._S��✓t7 uc.No.�'D�p Oso SIGNS TRANS. 3.00 ARCH.OR ENG, PERMIT VALIDATION ADDRESS /J�' ` SPECIAL CIRCUIT 5.00 EMP.METER OR POLE INS. 20.00 3 AwucANrs- - MOTORS SEE FEE SCH. ADDRESS (1 f ( J . .77�LLlje/ jl CECHANGE 20.00X-Puw o o LICENSED CONTRACTORS DECLARATION -til I o l a L,� I hereby atria, thatl am licensed under provisionsof Clmpter9 ISSUANCE DATE W Iu (commencing with Section 7000)of Division 3 of the Business andMAR ¢N BLDG. LECT. PLG. MECH. r m z Professions Code,and my license is in full force and effect - [ „ys z out - License Class Lie.Number - hF7CI� �A`••'I o � r Date Contractor a f City of Cupertino BUILDING PERMIT K O n o OWNER-BUILDER DECLARATION - INFORMATION K ; Thereby affirm that I ant exempt from the Contractor's License REFER TO ORD 1 VALUATION ea u w¢ Law for the following reason.(Sec.7031.5,Business and Professions PER 'ANCE 'L(�gggg $/FT. Code:Any city or county which requires a permit to construct, - rtwy E C.CO TR. LIC. v M ¢a improve,demolish,or repair any structure,Prior to its issuance,ui ELEC. r1 ^� p wG¢ requires the applicant for such permit to file a signed staleme t tha TOTAL I•� PERMIT TO $ - he is licensed pursuant Io the provisions of the Contracto[s Lic so - l H i�' Law(Chapter 9(commencing with Section 7000)of Division 3 of t F /LV/lN Business and Professions Code)or that he is exempt therefrom and TV. PLUMBING PERMIT FEE 'l ¢o K r$ the basis for the alleged exemption.Any violation of Section]031.5 STORIES TYPE CONSTR. by any applicant faro permit subjects theanttnacivil penalty A E RAIN&VENT-WATER (EA.) 5.00 Of no ore than flue hundred dollars($SO0q.)OIJ: t 1, is owner of the property,or my employees with wages as BACK FLOW PROTECT. DEVICE 4.00 j their sole compensation,will do the work,and the structure is not OCC.GROUP RES.UNITS intended or offered for sato (Sce. 7044, Business and Professions DRAINS-FLOOR,ROOF,AREA,COND. 5.00 Code:The Contmelor's License Law docs not apply to an owner of O property whobuildsor improves thereon,and who docs such work F IXTUR ES-.PER TRAP 5.00 O 511 FT.FLOOR AREA TOTAL ACREAGE -� himself re through his own employees,provided that such improve. mimprovnot ment intended or within onefor yearl o If,however,the building GAS-EA.SYSTEM-11NC.40UTLET$ 6.00 or improvement will have is sold within one year of completion,the owner GAS-EA.SYSTEM-OVER 4 (EA.) 2,00 builder will have the burden of proving that he did not build or im- BUILDING USE RES IND CON PB Otha, prove 11,aso mer off the INDUSTRIAL WASTE INTER. 30.00 0 ❑ � 11 ❑ I,as owner 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 Codu: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 contractors)licensed panuant It, lite Contractor's License Law, SEWER-SANITARY-STORM EA.200ftI10.00 TRACT NO. PARCEL NO. ❑ lam exempt under Sec ;B.AP.C.for this WATER HEATER W/VENT '6.00 reason Owner Date WATER SYSTEM 5.00 ACC.DATE ACC,FILE NO. WORK E RS'COMPFNSA'I'ION DECLARATION WATER TREATING EQUIP. 5.00 I hereby affirm that l have a certificate of consent to self-insure _ ZONING or a cerliflnate of Workers'Compensation Insurance,or a certified ENG.SITE NO. Copy thereof(Sec.3800,Lab.C.L Policy No. Company O Cl Certil led copy is herehy furnished. FIRE SPRINK ENERGY T 24 Z z ❑ Certified copy is fled with the city inspection division_. MISC.- REFER TO ORD: O Applicant Y [:3ry v No ~ �+ PERMIT ISSUANCE Z oo 10.00 `,L,GU 11 CC CERTIFICATE OF IiXEh11''I'ION PROM WORKERS' • FLOOD ZONE. . A.L.U.C. LU > CONIPENSWION INSURANCE PLG.CONTE. ❑C.NO. PLG. CL 0 This section need not be completed,it the permit is for one TOTALC(� Y❑ N Y N ::) Z hundred dollars IS 100)or less.) - U O I certify that in the perl'ornonce of the work for which this per- OTV. MECHANICAL PERMIT - FEE FEE SUMMARY LL F mit is issued,I shall not employ any person in any manner so as to O W become subject to the Workers'Compensation Laws of California. nn/ y Dam Applicant ALTER OR ADD TO MECH. 5.00 BUILDING Lam' } 0 NOTICE TO APPLICANT: If,after making this Certificate of fix- '{/ ? emption,you stmuld become subject to the Workers'Compensation APPLIANCE 5,00 PLAN CHECK 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 AIRHANDLING UNIT(OVER IQOWOF.M.) 6.00 .SEISMIC FEE 21b Ihereby 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(See. MICROFILM -� 3097,Civ.C.L HEATING UNIT(TO 100,000 B.T.U.) 8.0 Lender's Nome HEATING UNIT(OVER 100,000 B.T. 0 S7 Lender's Address ELECTRIC I certify Thal I have read this application and state that the above VENTILATION FAN (SINGLE) 4. 0 2 �y4 information n correct. I agree to comply with all city and county BOILER:COMPI3.H.P.or 100,000 B.T.U.) 6.00 PLUMBING '�3r� ordinances and state laws relating to building construction,uon, ands Hereby authorise representatives of this city to enter upon`tlm above-mentioned property BOI LER-COMP Over 100,006 BTU)SEE FEE SCH. MECHANICproperty for inspection purposes„ . (We) agree to save, indemnify and keep harmless the City of MISC.- REFER TO ORD. Cupertino against liabilities,judgments, costs aad expenses Which PERMIT ISSUANCE '� 4a QB •�(� ruCONST.TAX may In any way in against said City in consequ nee of the ranting of this pentdlp( e � MECH.CONT. LIC.NO. MECH. TOTAL O WTOTAL 3SS •l!� .- Signature o1'Applicant/Contractor Late U OFFICE COPY' APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY BU LDI NG PROJECT I DENTI FICATI ON .PERMIT NUMBER BUILDING APPLICATION & PERMIT 18446 •OOn%E55 Y� x�/7- J( /IrLL/N(ir (� MECHANICAL aD BUILDING-ELECTRICAL-PLUMBING1 p A n OWNER'S L•' PLAN CHECK VALIDATION NAME 1'••l Y. ELECTRIC PERMIT FEE syu ,�P,a-� �� a � 3 cONTRACTODS N� C�/�ts g�_3%j OUTLETS 10.00/1.00 -) r � . NAk. (�f/ 1JC.NO. LIGHTING FIXTURES 10.00/1.00 moa ese Tons k 7-- (-/i/�-� PPLIANCES-RESIDENTIAL 4.00 � ,y� r � g Lk41MCa �/aHONE e`Ty,..7(��T 1 ' PANELS 10.00 dh EVF P ICXTION ARCHITECT PANELS (OVER 200 AMP) 20.00 PLAN CHECK FEE P.C.NO. OR p ` L ENGINEER aL �i'a.✓/a LIC.No.(•aD/a 0�-(J SIGNS TRANS. 3.00 ARCH,OR ENG, SPECIAL CIRCUIT 5,00 PERMIT VALIDATION ADonEss / L /n J l\lL -F S zl �S EMP. METER OR POLE INS. 20.00 APPucANrs MOTORS SEE FEE SCH. AOORE55 (� C / ERVICE-CHANGE PAID 20.00 o o LICENSED CONTRACTORS DECLARATION SII V`- <U. I berchy affirm that 1 am licensed under provisions of Cha Pte 9 ISSUANCE DATE H a vAi (coneu'ncin,with Section 7000)Of Division 3 of the Business a d h, - - - BLDG. LECT. PLG. MECH. H w z Professions Code,and my license is In[till force and effect. z o w - License Class Lic.NBmber H Date Con(raclm a y c(ty rrIRP.({If10 BUILDING PERMIT c w a owNrl(-nuu.rnsR Drcl.narcnoN INFORMATION w ; LL H I hereby affirm that I am exennpl from the Contractor'.s Lice ` ITJe- R ER TO ORD VALUATION SIFT. � .. 0 4 Law for the following reason.(Sec 7031.5,Business and Professions PE ITJ ANCE 'L(�.iB,BB �� i Code_Any city or county which raluiresa permit loconsiru9l,alter, 30, re M < improve,denmiish,or repair any stn¢turC,Prior to its issuan c,a1.0 E C. O TB. LIC. ELEC. D u requires the aPPBcnnt for such permit to file.signed sWtcme t the TOTAL 15 PERMIT TO w $m he is licensed Pursuanl to the provisions of the Contractor's L k Tse Hi > Law(Chapter9(cummeneing with Seel ion 7000)of Division 3of1 a Ilusiness and Professions Code)or that In,is c.cmpt therefrom a d TY. UMBING PERM T FEE Ixo ¢ the basis for the alleged exemption.Any violation.(Seel ion 7031. L� STORIES TYPE CONSTR. T ; by xny apPlicaN finr x permit mbjeds the applict toe civil Penalty TE - RAIN& VENT-WATER (EA.) 5.00 _jj L_ of no(.h�orc th.n Hirth romttd dollas[55001.1: ty/I,ax owner of the property,or try enl plOyces with wages as ACK F LOW P OTECT.DEVICE 4.00 OCC.GROUP RES.UNITS their sole conlpensalion,will do lire work,and the structure is not intended or offered for sale (Sec. 7044, Inkiness and Professions DR 'INS R,ROOF,AR EA,COND. 5.00 Code 'IIIc Contractors 1-1cense I-aw dues not apply to an owner of property who hudds or improves hereon,and who docs such work FIXTURES-PER TRAP 5.00 �� SO./FT.FLOOR AREA TOTALACREAGE • Ihimscl for rtthroughhis ownemployees,Provideddietsuch i mprove- C1�O Bents are not intended or offered lin sale.If,howevcq the building GAS-EA.SVSTEM-11NC.40UTLETS 6.00 or improvement is sold within one year of completion, the owner- GAS EASYSTEM-OVER 4 IEA ) 200 autLotNG USE builder will have the burden of proving that he did not build or inn- - . . . RES INO CON PB OhM1ar prove for purpose of sale.). INDUSTRIAL WASTE INTER. 30.00 ❑ I,as owner of the properly,.m exclusively contracting with ❑ ❑ ❑ ❑ licensed contractors Io construct the Project(Sec. 7044,Business LAWN SPRINKLERS-1 INC 5 V.B. 6.00 ASSESSORS PARCEL NO. and Professions Code:The Contractor's Lirense Law does not apply to an owner of property who (milds or improve,thereon,and win. LAWN SPRINKLERS-OVER 5 (EA.) 1.00 contracts for such Prgicels with a contractuds)licensed pursuant to the('.of...or's Ltcensc Law. SEWER-SANITARY-STORM EA.200ft/10.00 TRACT NO. PARCEL NO. ❑ I ani exempt under Sec. .B.&P.C.for this WATER HEATER W/VENT 6.00 rcnsnn � � n Owuer Ofd Ilam WATER SYSTEM 5.00 ACC.DATE ACC.FILE NO. WORKFRS'COMPENSA rlON DECLARATION IWATER TREATING EQUIP. 5.00 1 hereby affirm that I have a Certificate of consent tO sell.in sure. ZONING or a certificate of Workers'Compensation Insurance or a certified ENG.SITE NO. copy thcrcof(Sri.3800,Lxb.C). Policy Nn. Consp.ny O ❑ Ceninel copy I,hereby furnished. FIRE SPRINK ENERGY T 24 Z Z ❑ CtRified copy is filed with the city inspeclion division. O Applicant MISC.- REFER TO ORD. Y ❑ N❑ Y ❑ No I= rA CERT IFICA'I'1!OF EXEMPT ION FROM WORK ERS' PERMIT ISSUANCE - ^Lcn 10.00 .lr.cz FLOOD ZONE A.L.U.C. LU > COMPFNSATION INSURANCE PLG.CONTR. LIC.NO. PLG. /13'j ..��yy�� CL O IT section need not be coo,lend if the Permit is for one TOTAL '(00 Y 1:1N❑ Y ElNEI Z hundred d ullaos(SIBG)or less.) U O 1 certify tial in the performance of the work for which this per- QTY. MECHANICAL PERMIT FEE FEE SUMMARY LL F mit is issued, I shall not employ any Person in any manner or as to u become subject lO the Workers'Con,pn,salbn Laws of C.lifomia. O w Dam Applicant BUILDING 7 / a ALTER OR ADD TO MECH. 5.00 r� GG �" } GO NO1ICIi TO APPLICANT: If,after making this Certificate of Ex- F' Z emption,you should become subject to the Workers'Conhpensatton APPLIANCE 5.00 PLAN CHECK provisions of the Labor Conic, you loud I'orthwillh comply with FEE U such provisions or this permit shall be deemed revoked. AIR HANDLING UNIT(TO 10,000C.F.M.) 4.00 AIR HANDLING UNIT(OVER IO,000C.F.M.I 6.00 SEISM IC FEE O CONSTRUCTION LENDING AGENCY 2+ I hereby affirm that there is a construction lending agency for EXHAUST HOOD(WITH DUCT) 5.00 the errfforflh,a)nce of the work for which this permit is issued(Sec. HEATING UNIT(TO 100,000 B.T.U.) 8.0 MICROFILM --• Lender's Name H EATING UN IT(O V ER 100,000 B.T. 0 L--%� Lender's Address ELECTRIC �IJ� • I certify Ihln I have read this uPpli,trion and slate(hal IIIc above VENTILATION FAN (SINGLE) 4. 02„ information is correct. I agree to comply with all city and county BOILER- H.P.Or 100,000 B.T.U.) 6.00 PLUMBING 23 t Zfinances and state laws relating to building construction, and T heby autlnorve representatives of this city to enter upon the BOILER-COMP (Over 100,000 BTU)SEE FEE SCH. MECHANICAL Cl above-nnentioned property for inspection purposes. (We) agree to snvc, indemnify mud keep harmless the City of MISC.- REFER TO ORD. 'upertinu .,.fast liabilities,jud,mcmts, costs and expenses whichCONST.TAX �- may in any way accnm against said City in consequ•nct of Uhf PERMIT ISSUANCE '1� 30.G0 ranting of this perm,it MECH.CONT. LIC.NO. ECH, i� �� TMOTA�O TOTAL .Signature of APplicantJGminclur One U OFFICE COPY