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2136 O OF RTINO - APP IC-ATIO OR COMMERCIAL BUILDING PERMIT PERMIT NUMBER AND C FOR APPLICANT TO FILL IN EET ADDRESS OF PROJECT: r Plans Received By................_................._...............Date ........................ Legal Description: Tract.... ........... ... ck..-__..... LOt.. ... .... REQ.: Plans.... Survey.._ Calcs: Struc..... Energy.... Elect..... Mech..... Description of Work: ..._S ... ip_ ..... ... .. ... ........ Plans Checked By....................................................Date ......................... 1st Struct. Improvement on Par 1: Yes.... .... Area of Bldg............... Application Approved By........................................Date ......................... Separate Structure.__.'.._- or Addition/Alteration to Exist. Bldg........... ValidatedB ................... .....................................L.Date ......................... No. of Stories................ Us of ��lin ................................................ Compensation Certificate Verified By...................bate ........................ aluation of Project: $..__: _ ..._....................................................... . . , . • : • $ �S�d J-d _ Cl Owner. ..1�13 L6..CC)..............r........ Phone: (c....... Permit Fee lits penalty if applicable) p Contractor: .W.....(3.f:.bL.l:.li.r.._C.cClly Bus.Llc. M. _........._.......�..... IP P y pP ) ........................$.. 3.(..r.y. .. Plan Check Fee (less deposit of$.......... Rct. #.-........)$....._............_.: Address: .k36L_!�wtr(/'Rev.cSr....I-.S!«!1?nv.Phone:.f-E:/_zvr' Contractor - Electrical: ..... Energy Plan Check Fee q� Y1Fs. &�c ## )$__..........." City Business License e.................... Phone:.................... StrongMotion Fee ....._................._f ��.PtH �I . ........$............r.. U _........_.. Plumbing: .........................................._............_�........................... Plumbing Permit Fee .......`.� . . . . ....................$....................... City Business License .................... Phone:.................... Electrical Permit Fee ......... .1-. ...2..2..198.1._...._...$...... ................ Heating and Cooling ................................................ Mach. Htg•/Coolg. Permit $ ...............................$....................... City Business License ir.................... Phone:.................... Construction Tax..................yY��.a..�..,...�.................$....................... Architect/Designer: ...Sii inc_........................... Phone:.................... Sewer Conn. Fee .............. WateTZlegy�ee ..............$....................... Engineer: .................................................................... Phone:........ .. Landscape Fee .............. .._. Street Tree Fee ............$............_....._.. ,.,,, Unknown Lender: ...........i-!o......�......................................................�.................. Misc. Fee ........................................................................$............ "I certify that in the performance of the work for which this permit Is e , : $ 35, issued I shall not employ any person In any manner so as to become subject to the workman's compensation laws of California." Type Const......... Group........ Div......... Occ. Load........ No. Exits........ SIGNATURE OF Floor Loads: 1st.... 2nd.... Other.... SPrinklered.... Area Sep. Walls.... APPLICANT/OWNER ......................................................_...... DATE ............................ REQUIREMENTS ._,ice. I certify that as the applicant I am licensed under the provisions of 1 a ZONING Contractors License Law pnd further that my Lbenae No. 3C].6.O.E.. Environmental Status: Exempt ............ Other............... ................ in Classification ....G.-__5.................. Is in full force and effect: or Design Review Approval: Bldg Site Sign - - certify that em exempt from the "Licensed Rtion., d" provisions of the • �---- """""" """""" Contractors License Lew. (Stale baste of exemption., Use Zone ........__ P.D. Conditions .................................._................._.... I hereby acknowledge that I have read this application and state that the above Is Cond. Use Permit N...... Variance M...... Parking Spaces.... Load.Sp..... correct and agree to comply with all City Ordinances and State Laws regulating Approved BY Date ........................... building. I (We) agree to save, indemnify and keep harmless the City of Cupertino •- • against liabilities, judgments, costs and expenses which may in any way • acture against said City in cyse en oft ranting of this permit. Encroachment Permit................ _.__ Grant of Easement....................... SIGNATURE OF ^ Q �'� , eo Curb, Gutter, Sidewalk,. Driveway: Replace Repair APPLICANT/CONTRAC/TORI../y�Y!]'I�C�L. . . . . •�.. DATE ...Y...- 2.-. Sewer............ Conn. Fee $................ Water................ Meter $................ NOTE: What Proper) vW dated Ihls form constitutes a Building Penn ThN Agreement for Completion of Public Works Improvements .................. permit expires and becomes null and vola should work not be commenced wahln Plans Checked By........ Date........ Approved By........ Date............ ....... 120 days from validation data, or should authorized construction be sospenaW or abandoned for a period of 120 days atter work Is commenced. APPLICATION FOR PLUMBING PERMIT s • • PERMIT INSTALLATION NO. EACH FEE PERMIT INSTALLATION NO. EACH FEE Light Outlets............ Switches............ Fixtures............ Receptacles............ Gas Sytem with up to 5 outlets ................................... $ 4.00 ......... TOTALNUMBER(less than 1000watts) ... ............._. $ ,50 ----- Each additional outlet ................................. .......... 1.00 ............. Range........ Cooking Unit..._.... Oven......................... .... 2.00 Water System (Installation, Alt. or Repair) ................ 4.00 ............. Dryer....Garb. Dep..... Dishwasher.... 2.00 ............... Water Closet.... Water Heater.... Ld. Tray.................... 4.00.............. SERVICE OR TEMPORARY POWER to ... 2•o0 Lavatory.... Shower Pan.... Bathtub.... Sink.................. 3.00,............. 100 amp/$5.00, 200/$7.00, 500/$9.00 Wash. Mach..... Dishwasher.... Garb. Disp..... .... .......... 3.00. ............. 800/$20.00, 1200/$40.00 ................................... ............................... Sewer ............._..............___................................. .......... 8.00. ............. MOTORS,Generators,Welders, Heaters, Lawn Sprinkler Sys. $6.00 Ea. add Sys. $2.00......... ........................... per HP—KW—KVA to 1/$2.00, 5/$3.50, Vacuum Breakers ............................................ . ............ 4.50 ......---- 20/$6.50, 50/$10.00, 100/$12.00, Slop Sink........ Floor Sink........ Floor Drain ................ 4.00 ............. 500/$15.00 .......................................__._............. ............ . ....... Urinal..._ Interceptor.... Water Softener.... .......... ... 4.00 ............. Signs with I XFMR ....................................................... 2.00 . Plumbing Piping without fixtures .................................. 4.00 ............. Eachadditional XFMR/Time Clock .. ......_..... ... .50 .. ............_ Misc. ...................................._.............. ..._.............. _......._........_.............. Annual Electrical Maintenance . ............. ...25.00 .. .............- Permit Fee .................................................. ......................$ 6.00 Other (see Ordinance Current) _........_..... ............................................. TOTAL PLUMBING PERMIT FEE (plus penaltyif app. p) $ ........................................ ...........:................. .............. ........ APPLICATION FOR HEATING/COOLING PERMIT Permit Fee ................................................_...................... $ 6.00 PERMIT INSTALLATION NO. EACH FEE TOTAL ELECTRICAL PERMIT FEE (plus penalty if app.[ ) $ Forced Air Unit,.............to 100M ................................. $ 6.00 INSPECTION RECORD over 100M ............................. 10.00 ............... Comfort Cooling Unit.....to 3 ton/HP............................ 6.00 ............... Forms / Foundation......._............. By:................. Date:................ to 15 ton/HP........................... 9.50 ............... lumbingGround Work ..._.................... ............................_......... _......... to 30 ton/HP................ ..........12.00 ............... ghElectrical ............._....._.................._...._......_..... ._............_.......... to 50 ton/HP................ .......... 17.00 ............... me - Plumbing and Heating .............................................................. Space Heater........ Wall'Heater ......................................6.00 ............... nsulation / Energy............................... ........_............. ........................... Flues - other than above ................................................3.00 ............... Gas Test ........................................ ...... ................................................... Vent Fan: Kitchen........ Bath .........................................1 3.00 ............... . . . Temporary Power Gas / Elect.......... ................................................. Commercial Range Hood .. ......... „6.00 ............... .................. . Final - Electrical ........................................................................................ Misc. ............................................................................... .............------- Final - Building/ Mechanical ............... ................................................... Permit Fee ........................................................................$ 6.00 Final - Design Review / Landscaping .................................................... TOTAL Htg./ CoOlg. Permit Fee (plus penalty If app. 0) $ Final — Public Works........................................................... Sheet 2 t CITY OF CUPERTI170 BUILDING PER24IT Permit No: �� 3 Address: le)070 A . Date: BUILDING PROJECT IDENTIFICATION',�/y WORKERS'COMPENSATION DECLARATION Applicant's Nailing Address G `x— 1 hereby affirm that f have a certificate of consent to self-insure, or a certificate of Workers'Compensation Insurance,or a certified copy thereof (Sec 50t),Lab.C,�, Address of Building Policy No. Cumpany T_X.a0-q.r ems. C Certified copy is hereby furnished. 0,,ner's names ertified copy is filed with the count. building inspection Telephone No. apartment or county department. Date_'t2 2'slApplicant /Contractor's Name w Fi Fi i t-i S Cn f/ Contractor's Nailing Address 13(G 5 i— CERTIFICATE OF EXEMPTION FROM WORKERS' F2.� ✓✓IDnT �# Lic. No. 3o tom[rA6 COMPENSATION INSURANCE (This section need not be completed if the permit is for one Architect or Engineer SA Mei_. hundred dollars ($100) or less.) Architect's or Engineer's AddressI certify that in the performance of the work for which this permit Lic. No. is issued,I shall not employ any person in any manner so as to become subject to the\Sorkers'Compensation Laws of California. LICENSED CONTRACTORS DECLARATION Date Applicant NOTICE TO APPLICANT: If, after making this Certificate of I hereby affirm that I am licensed under pros isions of Chapter 9 Exemption, you., should become subject to the Workers' (commencing with Section 7000) of Division 3 of the Business and Compensation provisions of the Labor Code, you must forthwith Professions.Code,and my li�nse is in full force and effect. 8�8� comply with such provisions pr this permit shal(be deemed revoked. License Class C —'a Lic. Number Date `'"3 _g f Contractor -V- H",4 fN i Ce' CONSTRUCTION LENDING AGENCY I hereby affirm that there is a construction lending agency for the performance of the work for which this permit,is issued (Sec.3097, Civ.C.). OIVNER-BUILDER DECLARATION Lender's Name sry6/ /V7_ Lender's Address 1 hereby affirm that I am exempt from the Contractor's License • Law for the following reason (Sec.70315, Business and Professions 1 certify that I have read this application and stale that the above Code: Any city or county which requiresa permit toconstruct.alter, information is correct. I agree to comply with all city and county improve,demolish,or repair any structure,prior to its issuance,also ordinances and state laws relating to building construction, and' requires the applicant for such permit to file a signed statement that hereby authorize representatives of this county to enter upon the he is licensed pursuant to the provisions of the Contractor's License above'-mentioned property for inspection purposes. Law(Chapter 9(commencing with Section 7000)of Division Sof the Business and Professions Code) or that he is exempt therefrom and Signature of Applicant or Agent Dam the basis for the alleged exemption. Any violation of Section 7031.5 by any applicant for a permit subjects the applicant to a civil penalty of not more than five hundred dollars (S500).): "OWNER-BUILDER VERIFICATION ❑ I,as owner of the property,or my employees with wages as their sole compensation, will do the work,and the structure is not Property Owner. on"Attenti intended or offered for sale (Sec. 7044, Business and Professions "Attention r-builder' building permit has been applied for in Code: The Contractor's License Law does not apply to an owner of our name ars-bearin property who builds or improves thereon,and who does such work Y g your signature. himself or through his own employees, provided that such "Please complete and return this information in the envelope improvements are not ini ended or offered for sale.If,however,the provided at your earliest opportunity to avoid unnecessary delay building or improvement is sold within one year of completion,the in processing and issuing your budding permit No building permit owncrbuilder will have the burden of proving that he did not build will be Issued until this verification is received. or improve for the purpose of sale). 1. I personally plan to provide the major labor and materials for E] 1, of the proposed properly improvement (yes or no) 1,as owner of the property,am exclusively contracting with licensedcontractors to construct theproject (Sec.7044,Businessand 2 L (have/have not) signed an application for a Professions Code: The Contractor's License Lase does not apply to buildin ( th an owner of property who builds or improves thereon, and who g permit for e pro posed work contracts for such projects with a contractor(s) licenxed pursuant toa I Lave mntracled with the following p�rson(firm)to provide the Contractor's License Law.). Name— the proposed construction: I an, exempt under Sec. , B.&P.C. for this Address ress City Phone Contractors License No. Date Owner 4. I plan to provide portions of the work, but 1 have hired the following person to coordinate,supervise,and provide the major work: Name Address City Phone Contractors License No. 5' 1 will provide some of the work but I have contracted(hired) the following persons to provide the work indicated: Name Address Phone Typc of Work Signed: Properly owner Social Security number Date: _ i -