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7066APPLICANT TO FILL IN INFORMATION WITHIN REDLINES - USE BALL POINT PEN ONLY BUILDING PROJECT I DENTIFICATI ON APPLICATION & PERMIT BUILDING - ELECTRICAL- PLUMBING - MECHANICAL PERMIT NUMBER O BILGING nouss P& 6U6i�S OWNER'S.;}Y'x NAME QTY:.•"„'ys "ti.°. ELECTRKC ' RMIT° •_"e `: " -•s `,`FE_E`: PLAN CHECK VALIDATION ' AA G�--�• O/L P H 0 N 'may_ '-1` CONTRACTOR S • ONTACTOR'S �- OUTLETS - SWITCHES -RECEP 5.00/1.00HAMS �6o.�Tl/WbS7>�i /� uc. No 8a�-5,7 ILIGHTING FIXTURES 5.00/1.00 CONI ADDRESS GTDRs h APPLIANCES - RESIDENTIAL 4.00 N6 �/j/N;Dz 4_' PHONE 77-7637 DATE OF APPLICATION PANELS 5.00 ARCHITECT ENGINEER OR .- A/� uc. NO. SIGNS 6.00 PLAN CHECK FEE P.C. NO., SIGNS TRANS. 3.00 ADDRESS Edo' SPECIAL CIRCUIT' 5.00 J - PERMIT VALIDATION EMP. METER OR POLE INS. 15.00 ZIP / ( AvvLicnNTs ADDRESS MOTORS P SEE FEE SCH. 8/E AP,e/COT ISERVICECHANGE 10.00 !'J j`0 s LICENSED CON "f RACfORS DECLARATION IA i• I hereby affirm did l am licensed under provisions of Chapter 9 (commencing with Section 7000) of Division 3 of the Business olid Professions Co& anti y license ism full for a of c License Class Lic. Num her 1 ,/ 'A (•'JJr h ISSUANCE DATE BLDG, ' ELECT. PLG. MECH. Date _/ /0- C'ontractnr _ OWNER -BUILDER DECLARATION I hereby infirm Om1 1 am exomm pt front [he Contractor's LicenseMISC. License Law for the following reason(Sec_ 7031.5, Businessand Professions Code: Any city or county which requires a permit to construct, alter, �.✓ , . �if5 '."PERMIT " 'BUILDING INFORMATION * - REFER TO ORD PERMIT ISSUANCE •6.00 VALUATION S/FT. ELEC. CONTR. LIC. NO. EL /! EC. - TOTAL V - • --. OTY..- . PLUMBING PERMIT `'FEE' improve, demolish, or repair any structure, prior to its issuance, also requires the upplicmit for such permit to file a signed statement that he is licensed pumtant to the provisions of the Contractor's License Law (Chapter 9(commencing with Section 7000) of Division 3 of the Business and Professions Code) or that he is exempt therefrom and PER TO , �[.`sC7 the basis for the alleged exemption. Any violation of5ection 7031.5 by any applicant for a permit subjects file applicant too civil penalty afoot more than fuse hundred dollars (E500)J: - ' STORIES TYPE CONSTR. gLTER-DRAIN-WATER (EA.) 4.00 01, as owner of the properly, or lily employees w ir role comith wages as thepensation, will do the work, and the structure is net BACK FLOW PROTECT. DEVICE 2.00 OCC. GROUP RES. UNITS DRAINS -FLOOR, ROOF, AREA, COND. 4.00 intended or offered for sale (Sec. 7044, Business and Professions Code: The COD t error's License Law does not apply to an owner of FIXTURES-- PER TRAP 4.00 GAS - EA. SYSTEM -1INC. 4 OUTLETS 4,00 property will builds Or improves thereon, and who does such work Himself or through his own employees, provided that shell improve- mentsarenotintendedorofferedforsale. If, however, the building 50. FT. FLOOR AREA TOTAL ACREAGE 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- GAS - EA. SYSTEM -OVER 4 (EA.) 1.00 BUILDING USE prove for purpose of sale.). ❑ I, as owner of the property, am exclusively contracting with RES IND CON PB Other ❑ ❑ ❑ ❑ ❑ INDUSTRIAL WASTE INTER. 20.00 licensed contractors to condoner the project (Sec. 7044, Business and Professions Code:'line Contractor's License Law does not apply to an owner of property who builds or improves thereon, and who LAWN SPRINKLERS- 1 INC 5 V.B. 5.00 LAWN SPRINKLERS - OVER 5 (EA.) 1.00 ASSESSORS PARCEL NO. - contracts for such projects with a contractor(s) licensed pursuant to the Contractor's License Law. SEWER -SANITARY -STORM EA. 200ft/8.00 TRACT NO. PARCEL NO, CI IamexemptunderSec. ,B.&P.Cforthls reason WATER HEATER WIVENT 4.00 Owner Date WATER SYSTEM 4.08 ACC. DATE ACC. FILE NO. WATER TREATING EQUIP. 4.00 WORK ERS'COMPISNSA'1']ON DECLARATION 1 hereby of Erm that I have a certificate of consent Io self -insure. or a certificate of Workers' Compensation Insurance, or a certified ' ZONING ENG. SITE NO. copy thereof Bc. 3.C.). Policy No/17lO SyLSny_.. ❑ Certilicd co h by famished. JaA�VI Certilicd y dedbit h inspection divieinn. Alrlrlie:In FIRE SPRINK Y ❑ NE] ENERGY T44 Y ❑ N❑ MISC. - REFER TO ORD. C: 1'IFICA71SOF fix EMPTION FROM WORKERS' PERMIT ISSUANCE 6.00 FLOOD ZONE A.LU.C. - I This Section need not be compiNSJ eted if tiro permit is for one Y ❑ N❑ Y ❑ N❑ PLG. CONTR. LIC. NO. TOTAL hundred dollars(E 100) or less.).,..,._ I certify that in the performance of the work for which this per- mit is issued, I shall not employ any person in any manner so as i OTV< '• `• MECHANICAL.PERMIT'.;4". d ': F,EE;' , ; YFEE SUMM . AIRY 'BUILDING - beconm subject to the Workers' Compensation Laws of California. Date Applicant NOTICE, TO APPLICANT: If, after making this Certificate of lis ALTER OR ADD TO MECH. 4.00 APPLIANCE 4.00 AIR HANDLING UNIT (TO 10MC.F.M.) 3.00 PLAN CHECK FEE oniption, you, should become suhject In Die Workers' Compensation provisions of the Labor Code, you must forthwith comply with such provisions or this permit shall be deemed revoked. AIR HANDLING UNIT (OVER 10,000C.EM.) 5.00 SEISMIC FEE C.ONS'1'RUCTION LENDING AG17NCY 1 hereby affirm that there is a construction lending agency for EXHAUST HOOD (WITH DUCT) 2.00 the performance of the work fir which this permit is issued (Sec. 3097, Civ.C.). MICROFILM _ HEATING UNIT (TO 100,000 B.T.U.) 4.00 Leader's Name Lender's Address HEATI NG UN IT E R 100,000 B.T.U.)7.50 ELECTRIC �- VENTILATION FAN (SINGLE) 3.00_ I certify that 1 have read this application and state that the above information is mrreet. 1 agree to comply with all city and county ordinances and state laws relating to building construction, and PLUMBING BOILER- COMP(3 H.P. or 100,000 B.T.U.) 4.00 hereby authorize representatives of this city to enter' upon the above-mentioned property for inspection purposes. BOILER -COMP (Over 100,000 BTU) SEE FEE SCH. MECHANICAL (We) agree t save, indemnify and keep harmless the City of MISC. - REFER TO ORD. Cupertino agui liabhhhhJJJJrrrr�111ISS, judgments, costs and expenses which may in any he against said Cit in consequence of rhe grunting of per PERMIT ISSUANCE 3.00 CONST. TAX MECH. CONT. LIC. NO. MECH. TOTAL TOTAL It ureof pplicant/Canlmctor DDaate' OFFICE COPY r APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-= USE BALL POINT PEN ONLY BUILDING PROJECT IDENTIFICATION APPLICATION & PERMIT BUILDING - ELECTRICAL- PLUMBING -MECHANICAL PERMIT NUMBER 7066 BUILDING ADDRESS ,0-0 OWNER'S NAME PTY, ELECTRIC PERMIT FEE PLAN CHECK VALIDATION G O/G PRONE -T CONTRACTORS `> NAME OUTLETS - SWITCHES -RECEP 5.00/1.00 -- LIGHTING FIXTURES 5.00/1.00 L7 caIG:ST6.Q/.J LIC. NO, CONTRACTOR ADDRESSDRESS PPLIANCES-RESIDENTIAL 4.00 PANELS 5.00 )e0TI�VMPAFPHONE %%- %6 7 DATE OF APPLICATION ARCHITECT OR SIGNS 6.00 PLAN CNECK FEE P.C. NO. ENGINEER .t/ uc. NO. SIGNS TRANS. 3.00 AARCH OR DDRESS ENG SPECIAL CIRCUIT 5.00 - PERMIT VALIDATION TEMP. METER OR POLE INS. 15.00H. ZIP APPLICANT'S E55 H. MOTORS SEE FEE SC SERVICE CHANGE 10.00 9/9 opwleer B / vP E'ZL LICI>NSEU CONTRACTORS DECLARATION I hereby affirm that I am licensed under provisions of Chapter 9 (commencing with Section 7000) of Division 3 of the Business and Professions Code and my license is in full force and effect License Class ?7_111 Lic. Number s Date 8r- Contractor ISSUANCE DATE BLDG. ELECT. El E] PLG. MECH. E]❑ v BUILDING PERMIT INFORMATION OWNER -BUILDER DECLARATION I hereby affirm that I um exempt from the Contractor's License Law for the following reason. (See. 7031.5, Businessand Professions Code: Any city or county which requiresa permit WConstrict, alter, improve, demolish, or repair any structure, prior to its issuance, also rcquires the applicant for such permit to file a signed statement that he is licensed pursuant to the provisions of the Contractor's License Law (Chapter 9 (commencing with Section 7000) of Division 3 of the Business and Professions Code) or that he is exempt therefrom and MISC.- REFER TOORD •6.00 VALUATION $/FT. PERMIT ISSUANCE / G ELEC. CONTR. LIC. NO. ELEC. / TOTAL / v0 '� PERMIT TO PTV. PLUMBING PERMIT FEE STORIES TYPE CONSTR. the basis for the alleged exemption. Any violation of Section 7031.5 by any applicant for a permit subjects the applicant loo civil penalty of not more than five hundred dollars (S500).): ALTER -DRAIN & VENT -WATER (EA.) 4.00 ❑ 1, as owner of the property, or my employees with wages as their sole compensation, will do the work, and the structure is not BACK FLOW PROTECT. DEVICE 2,00 OCC. GROUP RES. UNITS DRAINS -FLOOR, ROOF, AREA, COND. 4.00 intended or offered for sale (Sec. 7044, Business and Professions Code: The Contractor's License Law does not apply loan owner of property who builds or improves thereon, and who does such work FIXTURES - PER TRAP 4.00 So. FT FLOOR AREA TOTAL ACREAGE himmlf or through his own employees, provided that such improve- meretsorenotintendedoroffered for sale, If, however. the building GAS - EA. SYSTEM -11NC. 4 OUTLETS 4.00 r improvement is sold within one year of Completion, the owner- builder will have the burden of proving that he did not build or im- for purpose of sale.). ❑ 1, as owner of the property'. am exclusively contracting with GAS - EA. SYSTEM -OVER 4 IEA.) 1.00 BUILDING USE RES IND CON PB Other ❑ ❑ ❑ ❑ ❑ INDUSTRIAL WASTE INTER. 20.00 SPRINKLERS - 1 INC 5 V.B. 5.00 LAWN SPRINKLERS - OVER 5 (EA.) 1.00 ASSESSORS PARCEL NO. licensed contract.,, to construct the project (Sec 7044, BusinessLAWN and Professions Code:' Ihe Contractor's License Law does riot apply to an owner of property who builds or improves thereon, and whor- contracts for such projects with a contme trxds)licensed pursuant to the Contractor: License Law. SEWER -SANITARY -STORM EA. 200ft/8.00 TRACT NO. PARCEL NO. O Iwo exenlpl under See ,B.&P.C. fie thisWATER nasal HEATER W/VENT 4,00 Owner Date WATER SYSTEM 4.00 ACC.DATE ACD. FILE NO, WATER TREATING EQUIP. 4.00 WORK ERS'COMPENSATION DECLARATION I hereby albrm that I have n certificate of consent to self -insure. ur certificate of Workers' Compensation Insurance, or a certified a ZONING ENG. SITE NO. copy thereof(See. 3800. La¢.C.). Policy No 00 ' FIRE SPRINK v ❑ N ❑ ENERGY T -aa v ❑ rv❑ ❑ Ccrtilied ro0l+ s h •! y (unnshcd. Certified -6 y led villi Ili • u inspection division. sV{plicam MISC. - REFER TO ORD. CE 'IFICATli 01' EXEMPrI0 FROM WORKERS' PERMIT ISSUANCE 6.00 FLOOD ZONE A.L.U.C. PLG.CONTR. LIC. NO.PLG. TOTAL COM PENSATION INSURANCE If his Section need not be completed if the permit is for one Y ❑ N❑ v ❑ N❑ hundred dollars (S 100) or les.) 1 certify that in the performance of the work for which this per- mit is issued. I shall not employ any person in any manner m as to PTY. MECHANICAL PERMIT FEE FEE SUMMARY BUILDING heannc subject to the Workers' Compensation laws of California. Dale Applicant NOTICE TO APPLICANT: If, after making this Certificate of Ex- ALTER OR ADD TO MECH. 4.00 APPLIANCE 4.00 PLAN CHECK emption, you should become subject to the Workers' Compensation provisions of the Labor Code, you most forthwith comply with such provisions or this permit Shall be deemed revoked. FEE AIR HANDLING UNIT (TO 1O=C.F.M.) 3.00 AIR HANDLING UNIT (OVER 10=C.F.M.)5.00 SEISMIC FEE CONSTRUCTION LENDING AGENCY I hereby affirm that there is a construction lending agency for EXHAUST HOOD (WITH DUCT) 2.00 tine ped irrtrance of the work for which this permit is issued (Sec. 3097, Civ.C.). MICROFILM HEATING UNIT (TO 100,000 B.T.U.) 4.00 HEATING UNIT (OV ER 100,000 B.T.U.)7.50 ELECTRIC Lender's Name Lender's Address s' 1 certify That 1 have read this application and state that the above VENTILATION FAN (SINGLE) 3.00 id'onnation is correct I agree to comply with 111 City and County ordinances and stale laws relating to building construction, and PLUMBING BOILER-COMP(3 H.P. Or 100,000 B.T.U.) 4.00 BOI LER-COMP (Over 10.000 BTU) SEE FEE SCH. MECHANICAL hemby authorize representatives of this city to enter upon the above-mentioned property for inspection purposes. MISC. - REFER TO ORD. (We) agree to save, indemnify and keep harmless the City of Cupertino agail bald 'I bs, I.oil nls, costs and expenses which may in any a ac against said Cit n consequence of the CONST. TAX PERMIT ISSUANCE 3.00 grannngof Is >e t pI� MECH. CONT. LIC. NO. MECH. TOTAL TOTAL col' pplicant Contractor Dale INSPECTOR COPY