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8527 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY • BUILDING PROJECT IDENTIFICATION PERMIT NUMBER BUILDING APPLICATION & PERMIT AOOREss 2 �,JD i D UILDING -ELECTRICAL-PLUMBING-MECHANICAL 8527 OWNER' �ry PLAN CHECK VALIDATION NAME QTY. ELECTRIC PERMIT FEE • c�rC• h N G FHONE ^A 'V AMTRAcaGRs NAME UTLETS-SWITCHES-RECEP 10.00/1.00 N & C 1(Milc.No,� a LIGHTING FIXTURES 10.00/1.00 ADDRESS OR$_. � I"WCli5,0 APPLIANCES-RESIDENTIAL 4.00 DQj T Lt. ` PHONE PANELS 10.00 DATE OF APPLICATION ARCHITECT PANELS (OVER 200 AMP) 20.00 PLAN CHECK FEE P.C.NO. O OR ENGINEER LIC.No. SIGNS TRANS. 3.00 nooa ESS ervc. SPECIAL CIRCUIT 5.00 PERMIT VALIDATION ZIP TEMP.METER OR POLE INS. 20.00 APPLICANTS ADDRESS MOTORS SEE FEE SCH. SERVICE CHANGE 20.00 w o O LICENSED CONTRACTORS DF-CLARA'1'ION TEMP,POLE 30.00 a v u 1 hereby affirm that I am licensed under provisions of Chapter 9 ISSUANCEATE y Q w (commencing with Section 7000)of Division 3 of the Business and - BLDG. I ELECT. PLG. I EDH, r o z Professions =d 'cense is in full fore•� 11241 9 ❑ ❑ ❑ z O H - License Class_ Lie.Number 1� o m w Dale ContractorI)- an w ¢ OWNER-BUILDER Ufl INFORMATIO MISC.- REFER TO ORD w 3 u m I hereby al firm that I um exempt from the Contractor's License VALUATION $/FT. H LL j Law for the following reason.]Sec.7031.5,Business and Professions PERMIT ISSUANCE 10.00 I y w Y Code:Any city or county which requires a permit toconstruct,a ter, ELEC.CONTR. LIC.NO. ¢ ¢o improve,demolish,or repair any structure,prior to its issuance,also ELEC. ¢ requires the applicant for such permit to file a signed statement that TOTAL P RMIT TO d w m" he is licensed pursuant to the provisions of the Contractor's License F z a Law(Chapter 9(commencing with Section 7000)of Division 3 ofthe Business and Professions Code)or that he is exempt therefrom and OTV. PLUMBING PERMIT FEE K =$ the basis for lire alleged exemption.Any violation of Section 7031.5 STORIES TYPE CONSTR. i ; - by any applicant for a permit subjects the applicant to a civil penalty ALTER-DRAIN&VENT-WATER (EA.) 5.00 of not more than five hundred dollars($500).): ❑ 1,as owner of the property,or my employees with wages as BACK FLOW PROTECT.DEVICE 4.00 OCC.GROUP RES.UNITS their sole compensation,will do the work,and the structure is not intended or offered for sale (Sea. 7044, Business and Professions DRAINS-FLOOR,ROOF,AR EA,COND. 5.00 Code:The Contractor's License Law does not apply to an owner of property who builds or improves thereon,and who does such work FIXTURES-PER TRAP 5.00 So.FT.FLOOR AREA TOTAL ACREAGE himself re through his own employees,provided that such improve mentafo not hroug his onsffercclemplo employees, sale.provided thathowevsuch building GAS-EA.SVSTEM-11NC.40UTLET$ 6.00 or improvement is sold within one year of completion,the owner. GAS-EA.SYSTEM-OVER 4(EA.) 2.00 BUILDING USE builder will have the burden of proving that be did not build or im prove for purpose of sale.). INDUSTRIAL WASTE INTER. 30.00 RES IND CON PB Omar D 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 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 MA.) 1.00 contracts for such projects with a contractor(s)licensed pursuant to lire Ccatm,mr's License Law. SEWER-SAN ITARV-STORM EA.200ft/10.00 TRACT NO. PARCEL NO. ❑ I am exempt under Sea .B.&P.C.for this WATER HEATER W/VENT 6.00 reason Owner Dale WATER SYSTEM 5.00 ACG DATE ACG FILE N0. WORK ERS'COMPENSATION DECLARATION WATER TREATING EQUIP, 5.00 1 hereby affirm that I have a certificate of consent to self-insure. 20NING or a certificate of Workers'Compensation Insurance,or a certified ENG.SITE NO. copy there-of(Sec.3800,Lab.C.). /�n��L CLobe PO Ic Na Company -„�-j O Cert dcopy tcalif IaritIfi FIRE SPRINK ENERGY LPC Z 2 D CertIo) BIII� 6i s etion division. MISC.- REFER TO ORD. O APPlicamt Y E] N❑ v ❑ N❑ Hy CE IEICATE PERMIT ISSUANCE 10.00 FLOOD ZONE A.L.U.C. > C'OMPf: LU I'NSAT]SAPT ION FROM WORKERS' UJ _ 7lON INSURANCE: PLG.CONTR. LIC.NO. PLG. CL O ("this section need not be completed if the permit is for one TOTAL YE] N E] Y [:JNE]D 2 hundred dollars($]00)orlees.) U O I certify that in the performance of the work for which this per- QTY. MECHANICAL PERMIT FEE FEE SUMMARY m LL F- il is issued,I shall not employ any person in any manner so as to U become subject to the Workers'Compensation Laws of California. BW d Date Applicant ALTER OR ADD TO MECH. 5.00 LDING } m NOTICE 10 APPLICANT: If,after making this Certificate of Fs. 2 emption,you should become subject to the Workeri Compensation APPLIANCE I 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=CF.M.) 4.00 CONSTRUCTION LENDING AGENCY AIR HANDLING UNIT(OVER IQOODCEM.) 6.00 SEISMIC FEE I hereby affirm that there is a construction lending agency for EXHAUST HOOD(WITH DUCT) 5.00 the performance of the work lot which this permit is issued(Sec. MICROFILM 3e97, HEATING UNIT(TO 100,000 B.T.U.)' 8.00',Name ^� LenderrNaHEATING UNIT(OVER 100,000 B.T.U.)9.50 ELECTRIC Lender's Address I certify that 1 have read this application and state that the above VENTILATION FAN (SINGLE) information is correct. I agree to comply with all city and county BOILER-COMP(3 H.P.or 100,000 B.T.U.) 6.00 PLUMBING ordinances and stale laws relating to building construction, and hereby authorise representatives of this city to enter upon the BOILER-COMP ]Over 100,000 BTU)SEE FEE SCH. MECHANICAL above-mentioned properly for inspection purposes. (We) agree to save, indemnify and keep harmless the City of MISC.- REFER TO ORD. Ci ertino against liabilities,judgments, costs and expenses which CONST.TAX in any w accrue against said City in consequence of the PERMIT ISSUANCE 10.00 ling i ormail. MECH.CONT. I LIC.NO. MECH. 231348 TGTpg�� TOTAL igr lure,of pplica t Conine or Date ` a OFFICE COPY l APPLICANT{TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY BU I LDING'PROJECT I DENTIFICATI ON - PERMIT NUMBER BUILDING APPLICATION & PERMIT ADDRESE ,�1 '.��///t IA 10 'BUILDING - ELECTRICAL-PLUMBING-MECHANICAL8527 PLAN CHECK VALIDATION NAME VVV •11ff QTY. ELECTRIC PERMIT FEE I TORS PRONE co rRAcrons NAME UTLETS-SWITCHES-RECEP 10.00/1.00 LIc.No. LIGHTING FIXTURES 10.00/1.00 " Nr ActonG I`.1 `' / PPLIANCES-RESIDENTIAL 4.00 ADDRESS .�� r4A% U"Al)G� I/J •�NPHONE PANELS 10.00 DATE OF APPLICATION ACTEC HIT 0 1PANELS (OVER 200 AMP) 20.00 PLAN CHECK FEE P.C.NO. OR ENGINEER uc.NO. SIGNS TRANS. 3.00 ARCH.OR ENG, SPECIALCIRCUIT 5,00 PERMIT VALIDATION ESS ZIP rrEMP.METER OR POLE INS. 20.00 APPLICANTS rs APPLICA MOTORS SEE FEE SCH. )� SERVICE CHANGE 20.00 F o o LICENSED CONTRACTORS DECLARATION•` TEMP.POLE -30.00 .< L, u I hereby affirm that I am licensed under provisions of Chapter 9 ISSUANCE DATE n (emorumiag with Section 7000)of Division 3 of the Business and BLDG. ELECT. PLG. MECH. H w 1sis COJe,and my IiceniIin full force ad effect-vA z o License Lie.Number El lass oy w Uu1e _ Contractor t ¢m ¢w a BUILDING PERMIT U ys.J OWNER-BUILDER DE 1$Qlv'Mlt$rAl� INFORMATION T I hereby ant affirm that I aexempt from the ContractorREFER Contractor's License MISC.- .\O ORD VALUATION /$/FT. F a.O.iE Law for the following reason.(Sec.7031,5.Busimessand Professions PERMIT ISSUANCE 10.00 Nw � Code:Any City,or county which requires a permit to construct,alter, Qas Q Q,2 m+rOve,demolish,Or repair any structure.prior 10 Its Issuance,also ELEC.CONTR. LIC,NO. EIEC. - G ¢rte Ircrtuires the applicant for arch permit In file o signed statement that TOTAL WPs Ps he is licensed pursuant to Ilse provisions of the Contractor's License PERMIT TO Hir Law(Chapter 9(commencing with Section 7000)of Division 3ofihe •- a Business and Professions Code)or that he is exempt therefrom and QTY. PLUMBING PERMIT Z FEE ¢ f o the basis for 111E alleged exemption.Any violation Of Section 7031,5 STORIES aim by any applicant for a Demist subjects lire applicant to a civil penalty ALTER-DRAIN& VENT-WATER (EA.) 15.00 of not more it....five hundred dollms(S500 J.. ❑ L as owner of the proputy,or my employe..with wages as BACK FLOW PROTECT. DEVICE 4.00 OCC.GROUP RES.UNITS their sole compensation,will do the work,and the structure is not intended or offered for sale (Sec. 7044, Business and Professions DRAINS-FLOOR,ROOF,AR EA,CON D. 5.00 Code The Contractor's Licen.c Law does not apply to an owner of Property who holds or improves thereon,and who does such work FIXTURES-PER TRAP 5.00 SO.FT.FLOOR AREA TOTAL ACREAGE himselforthrough his own employees.pnwf,ho that such improvo- ments intended his..a for sale.ILhowevegdue building, GAS-EA.SYSTEM-1INC.4OUTLETS 6.00 or improvement is sold within one year of completion,the owner GAS-EA.SYSTEM-OVER 4 IEA.) 2.00 BUILDING USE builder will have the burden of proving that he did not build or im- RES IND CON PB Omer prove for purpose ofsale.). INDUSTRIAL WASTE INTER. 30.00 El 1, El ❑ El ❑ ElI,as owner of the property, exclusively contracting with ]icens.J contractors to construct the project(Seo. 7044,Baines LAWN SPRINKLERS- 1 INC 5 V.B. 6.00 ASSESSORS PARCEL NO. and Professions Codc:The Contractor's License Law does not apply to an owner of properly who builds or improves thereon,and who LAWN SPRINKLERS-OVER 5(EA.) 1.00 contracts for such projects with a ecntractimo licensed pursuant 10 SEWER-SANITARY-STORM EA.2001[/10.00 the Contractors License Law. TRACT NO. PARCEL NO. ❑ I am exenmt under Sec. .11.&l'.0.for this WATER HEATER W/VENT 6.00 reason Owner Date WATER SYSTEM 5.00 ACC.DATE ACC:FILE NO, WORKERS'COMPENSATION DECLARATION WATER TREATIN-G•EQUIP: 5.00 1 hereby Mills, that 1 have a certificate of consent to,self-insure. ZONING Far a certificate of Workers'Compensation Insurance,or a certified ENG.SITE NO. copy thereof(Sec.3800,Lab.C.1. -/ Policy No. Company ��(��-L�/��{��$ - z QF CerC •d copy is h reby fun s e / - FIRE SPRINK ENERGY T 24 Z Z Q^Cert fid cop fI11 stir the city x ,etion division, O Applicant - MISC.- REFER TO ORD. Y❑ N❑ Y ❑ N❑ ccN CE IFICATE OF EXEMPTION FROM WORKERS' PERMIT ISSUANCE 10.00 FLOOD ZONE A.L.U.c. UJ > COMPENSATION INSURANCE PLG.CONTR. LIC.NO, PLG. EL Z ('Phis section need not be completed if the permit is for one TOTAL Y[:] NE] Y ❑ N❑ hnndre,]dollars(S 100)or 111,1 U O 1 certify that in the performance of the work for which this per, OTY. MECHANICAL PERMIT FEE FEE SUMMARY LL U mit is issued,I shall not employ any person in any manner so as 10 become subject to the Workers'Compensation Laws of California. i D°'° Applm°nt ALTER OR ADD TO MECH. 5.00 B ILDING } W NOTICE TO APPLICANT: If,after making this Certificate of Ex. F 2 emotion,you should become subject to the Workers'Compensation APPLIANCE 5.00 PLAN CHECK provisions of the Labor Code, You must forthwith complywith ! U FEE such provisions or this permit shall be deemed revoked. AIR HANDLING UNIT(TO 10,000C.F.M.) 4.00 ! d CONST RUCTION LENDING AGENCY AIR HANDLING UNMOVER IOMC.F.M.),6.00 iiSEISMIC FEE I hereby.affirm that there is a construction lending agency for EXHAUST HOOD(WITH DUCT) 15.00 the performmoec of the work for which this permit is issued(Sec. - MICROFILM f 3097.CigC.l. 11 HEATING UNIT(TO 100,000 B.T.U.)_;8.00 r r Lendcr:s Addre - HEATINGUNIT(OVER100,000B.T.U.)9.50 Lalder's Address -E L'ECTfl IC lcertify:tbwlhave reudHhis upDlicufion and state that the uhovc VENTILATION FAN (SINGLE)/ '4.0 information is correct.'I agree to comply with all city and county PLUMBING ordinances and slate laws relating.to.building.conshoction. and BOILER-COMPI3H.P.or100,0006. .) 6:00 hereby authorise\representatives of this-city to enter upon the BOILER-COMP(Over 100,000 BTU)SEE FEE SCH. MECHANICAL above-mentioried property'for inspection purposes. (We) o911ee to .avec inllemnify and keep harniless the City of MISC.- ^ REFER TO ORD. Cupertino a g.i.sAliabi'lities,judgments, costs and exp.nses which CONST.TAX 1 in any,wa accrue against said City in consequence of the PERMIT ISSUANCE 10.00 ` \ a lingo const. MECH.CONTLIC.NO. MECH. I TOTAL - TOTAL is Ig rc p ra Date l ; Q KVIEMOR cove