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4188 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY 6U LDI NG PROJECT I DENT]FICATI ON PERMIT NUMBER 'BUILDING � APPLICATIO _ M ADDRESS �a 4188 icp v BUILDING - ELECTRICAL-PLUMBING-MECHANICAL . OWN 'S PLAN CHECK VALIDATION N M a /� R QTY. ELECTRIC PERMIT FEE V!r NE� VJ QQ CONTRACTORS _ OUTLETS-SWITCHES-RECEP 5.00/1.00 3 A E 7 1'1 (-��C, ](m NOJ LIGHTING FIXTURES 5.00/1.00 CONTRACTOR'S - APPLIANCES-RESIDENTIAL 4.00 {�cl.�gN.{YlZ•'] PANELS S.00 DATE OF APPLICATION ARCM ECT PLAN CHECK FEE P.C.NO. OR � �� SIGNS 6.00 EN IN 1� uc.No SIGNS TRANS. 3.00 ARCH,OR EL SPECIALCIRCUIT 5.00 PER MIT VALIDATION Co-CY v'2.Wm EMP.METER OR POLE INS. 15.00 APPLICANT"�PpLIRCEANT'SMOTORS SEE FEE SCH. .n �.1 J� ) k�L SERVICE CH 10.00 O o LICENSED CON'I'RAC'IORS UGCLA RATION _ Us, I hereby aft Iran that I am licensed under provisions of Chapter 9MAY I ISS U ANC OATS w Q w (contmencing with Section 7000)of Division 3 of the Businass and BLDG. ELECT. PLG. MECH. I- N z Pro,scions Com J�r��`ycense is in full f z o g - License Class --=1..L-,L Lic.Number ❑ ❑ ❑ Q z r ° Uwe 11 1.].Q_�_Cnntmct„r i City of Cu Cupertino ✓)1'11.)1 Q.J 1 p BUILDING PERMIT Q y f J k c ¢w ¢ 'NF;R-HUILDER DECLr A OR - INFORMATION wos " MISC.- REFER TO ORD 3 LL m I hereby allum that I am exempt from Ile Contractor',License VALUATION s/FT. H a_ o j Law for the following reason.(Sea 7031.5,Businesslnd Porte PERMIT ISSUANCE 6.00 Code:Any city or county which requires permit tocon9mcL alter, 2 s- 20 improve,demolish.or repair any structure,prior to its issuance,also ELEC.CONTR. LIC.NO. ELEC. / 'y Q'e' - DLL requires the applicant for such permit to file a signed statement that TOTAL 6.?-"� PERMIT TO w m he is licensed pursuant to the provisions of the Contractors License Fzi Law(Chapter 9fcommencingwith Section 7000)ofDivision 3ofthe -Lez7 ¢ Business and Professions Code)or that he is exempt therefrom and QTY. PLUMBING PERMIT FEE ¢ r Do the basis fertile alleged exemption.Any violation of Section 7031.5 STORIES TYPE CONSTR. by any applicant fora amink,abilet,the applue.uttollePilpenally ALTER-DRAIN&VENT-WATER (E/.) 4.00 of not more than five hundred dollars 15500).): ❑ Las owner of the property,or my employees with wages as BACK FLOW PROTECT. DEVICE2.00 oec.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,AREA, OND. 4.00 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 - 4.00 SO.FT FLOOR AREA TOTAL ACREAGE himself or through his own emPloyecs.Provided that such improve- memsarenotintended or offered for sale.If,however,the building GAS-EA.SYSTEM-I INC. OUTLETS 4.00 or improvement i,sold within one year of completion,the owner- GAS-EA.SYSTEM-OV R 4 IEA.1 1.00 BUILDING USE builder will have the burden oproving that he did not build or int rm'e for purpose of sale.). RE5 IND CON PB Orbm P P P INDUSTRIAL WASTE NTER. 20.00 ❑ L as owner of the property',um exclusively contracting with ❑ ❑ ❑ ❑ ❑ licensed j"Li cantrumors : construct the project(Sec. 7044,Business LAWN SPRINKLER - 1 INC 5 V.B. 5.00 assE55oRS PARCEL No. to Profession,Code:The who License s(h does not apply to an owner of property who builds or improves thereon,and who LAWN SPR IN KL S-OVER 5 (EA.) 1.00 nthe nl trantractor's License Law.Carets for such projects with a contractors)licensed pursuant to SEWER-SANIT RY-STORM EA.2001[/8.00 TRACT NO. PARCEL NO. Co C, I am exempt under Sec. .B.&P.C.lin this WATER HEA/ER W/VEN 4.00 mason Date Owner WATER SV TEM 4.00 ACC.DATE ACC.FILE NO, WORK ERS'COIdPENSA'IION DECLARA"PION WATER REATING EQUIP. 4.00 1 hereby affirm that I have a certificate of consent to self-insure. ZONING ENG.SITE NO. Icate of Work c Cnm peisuti on Insurance,or a certll'Ied copy Nsii*ub.our Policy ,,JJ11 Ipa�ty Q y❑y cr' py lshcr b'furnish FIRE SPRINK ENERGY TQ4 Z 2 Ap-ltrCnttifi Y is li • withi eaion division. ESC.- REFER TO ORD. ❑ ❑ ❑ ❑ O t Y N N DC w CERIFICA'rEOP Iixi PION'FROM WORKERS' PERMIT ISSUANCE 6.00 FLOOD ZONE LU > COMPENSATION INSURANCE PLG.CONTR. LIC.NO. PLG, 1 n I I his Section need nut be completed if the perm it is lis, in, TOTAL V[:J PIE] v❑ N❑ Z hundred dollurs($100)or less.) - U O 1 certify that in the performance of the work Ibrwhtch this per- OTY MECHANICAL PERMIT FEE FEE SUMMARY LL H mit is issued,I shall not employ any person in any manner so as to (] w become subject to the W'orkcrs'Compensation Laws of California. BUILDING d Date Appin'am ALTER OR ADD TO MECH. 4.00 } to NOI'ICL TO APPLICANT'. If,after making this Certificate of E. Z ,option,you should become subject to the Workeri Compensation APPLIANCE4.00 PLAN CHECK Vruvisions of the Labor Code, you must forthwith comply with FEE U such provisions or this permit shall be deemed revoked. AIR HANDLING UNIT(TO g00C.F.NL) 3.00 CONSTRUCTION LENDING AGENCY AIR HANDLING UNITE ER 10=C.F.M.) 5.00 SEISMIC FEE I hereby affirm that there is construction lending agency tor EXHAUST HOOD ITH DUCT) 2.00 the performance of 0 r:fo which this permit is issued(Sec. MICROFILM 3097,Civ.C.). HEATING UNI ITB 100,000 B.T.U.) 4.00 Lender's Na me HEATING IT(OVER 100,000 B.T.U.17.50 ELECTRIC Lender's Address I certify shut I have read tits application and stare that the above V ENTI L ION FAN (SINGLE) 3.00 information is emrecl. I agree to comply with all city and county' BOILE -COMP13 H.P.or 100,000 B.T.U.) 4.00 PLUMBING ordinances and state laws relating to building construction, and hereby aulhorire representatives of this city to enter upon the BOI ER-COMP IOver 100,000 BTU)SEE FEE SCH. MECHANICAL above mentioned property for inspection purposes. (k to sav indemnify and keep Ilannless the City of SC.- REFER TO ORD. Cupeins[ li i hies,)Idgments, costs and exVerses which CONST.TAX mayway :tr a 0 Ctty in co sequenc- of tiroPERMIT ISSUANCE 3.00glants Ver it MECH.CONT. LIC.NO, MECH. Cots TOTAL TOTAL Signutureof Applicant tractor lam OFFICE COPY APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY 6U LDI NG PROJECT I DENT]FICATI ON PERMIT NUMBER 'BUILDING � APPLICATIO _ M ADDRESS �a 4188 icp v BUILDING - ELECTRICAL-PLUMBING-MECHANICAL . OWN 'S PLAN CHECK VALIDATION N M a /� R QTY. ELECTRIC PERMIT FEE V!r NE� VJ QQ CONTRACTORS _ OUTLETS-SWITCHES-RECEP 5.00/1.00 3 A E 7 1'1 (-��C, ](m NOJ LIGHTING FIXTURES 5.00/1.00 CONTRACTOR'S - APPLIANCES-RESIDENTIAL 4.00 {�cl.�gN.{YlZ•'] PANELS S.00 DATE OF APPLICATION ARCM ECT PLAN CHECK FEE P.C.NO. OR � �� SIGNS 6.00 EN IN 1� uc.No SIGNS TRANS. 3.00 ARCH,OR EL SPECIALCIRCUIT 5.00 PER MIT VALIDATION Co-CY v'2.Wm EMP.METER OR POLE INS. 15.00 APPLICANT"�PpLIRCEANT'SMOTORS SEE FEE SCH. .n �.1 J� ) k�L SERVICE CH 10.00 O o LICENSED CON'I'RAC'IORS UGCLA RATION _ Us, I hereby aft Iran that I am licensed under provisions of Chapter 9MAY I ISS U ANC OATS w Q w (contmencing with Section 7000)of Division 3 of the Businass and BLDG. ELECT. PLG. MECH. I- N z Pro,scions Com J�r��`ycense is in full f z o g - License Class --=1..L-,L Lic.Number ❑ ❑ ❑ Q z r ° Uwe 11 1.].Q_�_Cnntmct„r i City of Cu Cupertino ✓)1'11.)1 Q.J 1 p BUILDING PERMIT Q y f J k c ¢w ¢ 'NF;R-HUILDER DECLr A OR - INFORMATION wos " MISC.- REFER TO ORD 3 LL m I hereby allum that I am exempt from Ile Contractor',License VALUATION s/FT. H a_ o j Law for the following reason.(Sea 7031.5,Businesslnd Porte PERMIT ISSUANCE 6.00 Code:Any city or county which requires permit tocon9mcL alter, 2 s- 20 improve,demolish.or repair any structure,prior to its issuance,also ELEC.CONTR. LIC.NO. ELEC. / 'y Q'e' - DLL requires the applicant for such permit to file a signed statement that TOTAL 6.?-"� PERMIT TO w m he is licensed pursuant to the provisions of the Contractors License Fzi Law(Chapter 9fcommencingwith Section 7000)ofDivision 3ofthe -Lez7 ¢ Business and Professions Code)or that he is exempt therefrom and QTY. PLUMBING PERMIT FEE ¢ r Do the basis fertile alleged exemption.Any violation of Section 7031.5 STORIES TYPE CONSTR. by any applicant fora amink,abilet,the applue.uttollePilpenally ALTER-DRAIN&VENT-WATER (E/.) 4.00 of not more than five hundred dollars 15500).): ❑ Las owner of the property,or my employees with wages as BACK FLOW PROTECT. DEVICE2.00 oec.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,AREA, OND. 4.00 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 - 4.00 SO.FT FLOOR AREA TOTAL ACREAGE himself or through his own emPloyecs.Provided that such improve- memsarenotintended or offered for sale.If,however,the building GAS-EA.SYSTEM-I INC. OUTLETS 4.00 or improvement i,sold within one year of completion,the owner- GAS-EA.SYSTEM-OV R 4 IEA.1 1.00 BUILDING USE builder will have the burden oproving that he did not build or int rm'e for purpose of sale.). RE5 IND CON PB Orbm P P P INDUSTRIAL WASTE NTER. 20.00 ❑ L as owner of the property',um exclusively contracting with ❑ ❑ ❑ ❑ ❑ licensed j"Li cantrumors : construct the project(Sec. 7044,Business LAWN SPRINKLER - 1 INC 5 V.B. 5.00 assE55oRS PARCEL No. to Profession,Code:The who License s(h does not apply to an owner of property who builds or improves thereon,and who LAWN SPR IN KL S-OVER 5 (EA.) 1.00 nthe nl trantractor's License Law.Carets for such projects with a contractors)licensed pursuant to SEWER-SANIT RY-STORM EA.2001[/8.00 TRACT NO. PARCEL NO. Co C, I am exempt under Sec. .B.&P.C.lin this WATER HEA/ER W/VEN 4.00 mason Date Owner WATER SV TEM 4.00 ACC.DATE ACC.FILE NO, WORK ERS'COIdPENSA'IION DECLARA"PION WATER REATING EQUIP. 4.00 1 hereby affirm that I have a certificate of consent to self-insure. ZONING ENG.SITE NO. Icate of Work c Cnm peisuti on Insurance,or a certll'Ied copy Nsii*ub.our Policy ,,JJ11 Ipa�ty Q y❑y cr' py lshcr b'furnish FIRE SPRINK ENERGY TQ4 Z 2 Ap-ltrCnttifi Y is li • withi eaion division. ESC.- REFER TO ORD. ❑ ❑ ❑ ❑ O t Y N N DC w CERIFICA'rEOP Iixi PION'FROM WORKERS' PERMIT ISSUANCE 6.00 FLOOD ZONE LU > COMPENSATION INSURANCE PLG.CONTR. LIC.NO. PLG, 1 n I I his Section need nut be completed if the perm it is lis, in, TOTAL V[:J PIE] v❑ N❑ Z hundred dollurs($100)or less.) - U O 1 certify that in the performance of the work Ibrwhtch this per- OTY MECHANICAL PERMIT FEE FEE SUMMARY LL H mit is issued,I shall not employ any person in any manner so as to (] w become subject to the W'orkcrs'Compensation Laws of California. BUILDING d Date Appin'am ALTER OR ADD TO MECH. 4.00 } to NOI'ICL TO APPLICANT'. If,after making this Certificate of E. Z ,option,you should become subject to the Workeri Compensation APPLIANCE4.00 PLAN CHECK Vruvisions of the Labor Code, you must forthwith comply with FEE U such provisions or this permit shall be deemed revoked. AIR HANDLING UNIT(TO g00C.F.NL) 3.00 CONSTRUCTION LENDING AGENCY AIR HANDLING UNITE ER 10=C.F.M.) 5.00 SEISMIC FEE I hereby affirm that there is construction lending agency tor EXHAUST HOOD ITH DUCT) 2.00 the performance of 0 r:fo which this permit is issued(Sec. MICROFILM 3097,Civ.C.). HEATING UNI ITB 100,000 B.T.U.) 4.00 Lender's Na me HEATING IT(OVER 100,000 B.T.U.17.50 ELECTRIC Lender's Address I certify shut I have read tits application and stare that the above V ENTI L ION FAN (SINGLE) 3.00 information is emrecl. I agree to comply with all city and county' BOILE -COMP13 H.P.or 100,000 B.T.U.) 4.00 PLUMBING ordinances and state laws relating to building construction, and hereby aulhorire representatives of this city to enter upon the BOI ER-COMP IOver 100,000 BTU)SEE FEE SCH. MECHANICAL above mentioned property for inspection purposes. (k to sav indemnify and keep Ilannless the City of SC.- REFER TO ORD. Cupeins[ li i hies,)Idgments, costs and exVerses which CONST.TAX mayway :tr a 0 Ctty in co sequenc- of tiroPERMIT ISSUANCE 3.00glants Ver it MECH.CONT. LIC.NO, MECH. Cots TOTAL TOTAL Signutureof Applicant tractor lam OFFICE COPY APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY BUILDING PROJECT IDENTIFICATION B IS _ PERMIT NUMBER BUILDING ICT APPLICATION & PERMIT 418 i AO DOMR hiJ, , 41 S BUILDING - ELECTRICAL-PLUMBING-MECHANICAL Fn s QVELECTRIC PERMITPLAN CHECK VALIDATION U a_ a -74a �yy S _ CoN RACTORS _ UTL ETS-SWITCHES-RECEP 5.00/1.00 _)3 UT TI NG FIXTU RES 5.00/1.00 $4 CONTRACTORS (� APPLIANCES-'RESIDENTIAL 4.00 'V� hC�ptpryp274� � PANELS 5.00 DATE OF APPLICATION AS SIGNS 6.00 PLAN CHECK FEE P.0.NO. IEk pec 3 °►� L�1 CLIC.No. SIGNS TRANS. 3.00 ARCH oR NG. SPECIAL CIRCUIT 5.00 PERMIT VALIDATION 4a CY J ;f MP.METER OR POLE INS. L15.00 r APPLICANTS MOTORS SEE FEE•SCH. CV (f Z SERVICE CHANGE 10.00' o ¢ z - 00 LICENSED CON['RAC'IDRS Df CLARATION , o u I Urchy aflinn that I am licenzed undo provisions cf Chapter 9 ISSUANCE DATE ti< (commencing with Section 7000)of Division 3 of the Business end BLDG_ ELECT. PLG-- MECH. _ F y z Professions Cod(&l(1 r 'erase is in full fotl➢mIJ d)1>7i z o w - License CP a Lk.Number DOQJ r J ❑ © El F-1o z F Date _ Contractor�I� �•a y s �� lJ I I���� BUILDING PERMIT - ¢ ¢ w a NER-BUILDER HFCLARA'I'ION INFORMATION K u F I hereby Atifm that I ma exempt front the CoannodorS License MISC.- REFER TO ORD u0sr Law for the following reason.(See.7031.5,Busincesand Professions PERMIT ISSUANCE , VALUATIONT $/FT. L - Code An cit or count 6.00 Any y county lxyuiresa permit reconstruct.altar. ¢ ¢ Qa improve,demolish.or repairam•slnlaturc priormils issuanie,also ELEC.CONTR. LIC.NO. ELEC. / '1 � a g-- y m R requires the applicant for sUCh permit 10 file a signed statement that TOTAL IO�C PERMI w he is licensed pursuant to the provisions of the Contractor s License K FriLaw(Chapter 9(commencing with Section 7000)of Division 3 of the a Business and Professions Code)or flout he is exempt therefrom and QTY. PLUMBING PERMIT FEE ¢ r D the basis fnr[Ile alleged e,zentption.Any violation of Sedion 7031.5 STORIES TYPE CONSTR. a ; by any applicant for a permit subjects the applicant to a civil penalty ALTER-DRAIN -WATER IE .14.00 of not more than five hundred dollars(5500).): O Las owner of the property,or my employees with wages as BACK FLOW PROTECT. DEVICE 2.00 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,AREA, OND. 4.00 Code:The Contractor's License Law does not apply to an owner of property who build,or i...prose,thercun,unit who docs such work FIXTURES-PER TRAP 4.00 sa.rT.PLOGR AREA TOTAL ACREAGE himself or IEvough his own CF ployces.Provided tlmt wch....Provo n.entsare net intended or offered for sale.If,however,the building GAS-EA.SYSTEM-11NC. OUTLETS 4.00 or improvement s sold within one year of comp Idiom,the owner- GAS-EA.SYSTEM-OV 4 (EA.) 100 BUILDING LIGE builder will have the burden of Arming that he did not build or int- . RES IND CON PB Omer prone for purpose of sale.). INDUSTRIAL WASTE TER. 20.00 El El El El 1:1❑ I,as owner of the property,am exclusively contracting with licensed contractors to construct Dm project(Sec.7044,Business LAWN SPRINKLER - 1 INC 5 V.B. 5.00 ASSESSORS PARCEL NO. and Professions Code:The Contractor's License Law do,,,not apply to un owner of property who builds or int Proves Ihmnun.and who LAWN SPRINKLE S-OVER 5 (EA.) 1.00 contracts fur,such projects with a contmetor(n')licenzed pursuant m the Contractor's Lie ens,Law. SEWER-SANIT - V-STORM EA. 200ft/8.00 TRACT NO. PARCEL NO. ❑ I am exempt under See.-,B.&P.C.for this WATER HEA ERW/VENT 4.00 reason Date Owner WATER SYSTEM - 4.00 ACC.DATE ACC.FILE NO. WORSERS'COMPENSA'rION DECLARAUON WATER EATING EQUIP. 4.00 I hereby affirm that I have a certificate of consent to self-insure. A ZONING ENG.SITE NO. or a ce Cate off W$ojrlke i ComPC sat ion Insurance,or u cert it icA Copy ,L`mob P. 1. •� G r\ Policy 26 pa Q ❑ esili< py'is her, furnishc FIRE SPRINK ENERGY 24 T?�Certifi y is G with't cction division. zp Appt m SC.- REFER TO ORD.' v ❑ N❑ v ❑ N❑ Fy PERMIT ISSUANCE 6.00 FLOOD ZONE A.L.uc. � CIi R'I'1 PICA'1'IS OE Ii Xli)1I 'ION FROM WORKI!RS' W � COh1PENSA'LION INSURANCE. PLG.CONTR. LIC.No.. PLG. Q. 0 ('This section need not he comPletcd if the Operant is for one TOTAL v❑ N❑ v❑ N❑ Z hundred dollms(SIDO)or Eess.) U O I certify that in the performance of the work fur which this per- QTY MECHANICAL PERMIT FEE FEE SUMMARY LL Hof is issued,I shall not employ any person in any manner so as to U become subject to the Workers'Compensation Laws of California. U a Date Applicant ALTER OR ADD TO MECH. 4.00 BUILDING - w NOTICE '1'0 APPLICANT': IL after..mking flux C,Hilicete of fx F Z Cmption,you should become subject to The Workers'Compensation APPLIANCE 4.00 PLAN CHECK provisions of the Labor Code, you must forthwith comply with FEE U such provisions or this permit shall be deemed evoked. AIR HANDLING UNIT(TO =C.F.M.) 3.00 CONSTRUCTION LENDING AGENCY AIR HANDLING UNIT( R 10=C.F.M.) 5.00 SEISMIC FEE I hereby affirm that Dmre is a construction lending agency fnr EXHAUST HOOD ETH DUCT) 2.00 the performance of the v l l fur vhich this permit is issued(Set. HEATING UNI (TO 100,000 B.T.U.) 4.00 MICROFILM _ 3097,C e.C.). 77 Lender's Name Lender's Address HEATING U)4T(OVER 100,000 B.T.U.)7.50 ELECTRIC 1 certify that I have read this application and slate that the above VE NTIL ION FAN (SINGLE) 3.00 information is correct. 1 agree to comply with all city and county PLUMBING ordinances and state laws relating to building construction, and BOILE COMP I3 H.P.or 100,000 B.T.U.) 4.00 s+" hereby mtlhorir• representatives ')I this city IU enter uPon the BOI R-COMP (Over 100,000 BTU)SEE FEE SCH. MECHANICAL above-menlinned ,,.Perry for inspects....puryosus. (We) agree.to sav - indemnify and keep harmless the City Of C.- REFER TO ORD. Cvpertinu unstli it Ties,j figments, costs and expenses which CONST.TAX may ' way a Cr again I said City in co equ f the PERMIT ISSUANCE 3.00 grantinm f Ibis pen it. MECH.CONT. LIC.NO. MECH. TOTAL TOTAL Signaturcof Applicant/Cr truer'), Dldc INSPECTOR COP