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9299 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY BU I LDING PROJECT IDENTIFICATION - PERMITNUMBER BD,LD � APPLICATION & PERMIT 9299 BUILDING-ELECTRICAL-PLUMBING-MECHANICAL OWNER'S �'Y PLAN CHECK VALIDATION "AME OTY. ELECTRIC PERMIT FEE • PHONE CONTRACTO 'S NymEOUTLETS-SWITCHES-RECEP 10,00/1,00 l/7r LIC.No. LIGHTING FIXTURES 10.00/1.00 CONTRACTORS PPLIANCES-RESIDENTIAL 4.00 ADDRESS SVu PHONE G'1) PANELS 10.00 DATE OF APPLICATION ARCHITECT - PANELS (OVER 200 AMP) 20,00 PLAN CHECK FEE P.C.NO. ENGINEER PATI LIC.No. SIGNS TRANS. 3.00 A AARCH OR DDRESS ENG. SPECIAL CIRCUIT 5,00 JUL VALIDATION Zlv EMP.METER OR POLE INS. 20.00 UL rj '198�C AMOTORS SEE FEE SCH. DRESS E55 ADDR SERVICE CHANGE 20.00 CRY Of Cupertino 02 LICENSED CONTRACTORS DECLARATION TEMP.POLE 30.00 <v I hereby affirm that I am licensed under provisions of Chapter 9 ISSUANCE GATE 2 w (commencing with Section 7000)of Division 3 of the Business and BLDG. ELECT PLG. MECH. Di Professions Codegid my license is in full for a I e fecL ❑ ❑ ❑ Z. o Liccn��la/5s V Lic.Numbe Z.m F Dale-H cz -ConlmClo� J' Q ,2 J BUI ENG PERMIT ¢ ¢ a OWNER.BUILDER DECLARATION in w v 1 FORMATION X o n H I hereby affirm that I am exempt from the Contractor's License MISC.- REFER TO ORD �+ p VALUATION $/FT. wo¢ Law for the following reason.(Sec.7031.5,Business and Professions PERMIT ISSUANCE 10.00 fwog Cade:Any city orcounly which requires a permit to construct,alter, ¢ ¢ a;O Improve,demolish,or repair any structure,prior to its Issuance,also ELEC.CONTR. LIC.NO. ELEC. O¢ requires n e applicant for Such permit to Ole a signed actor's i that TOTAL PERMIT w w re is licensed pursuant r the provisions of the Contractor's statement License Fi> Law(CImpter9(eo,nmcnCing with Section 7000)ofDivision 3 ofthe I 4 c Business and Professions Code)or that he is exempt therefrom and OTY. PLUMBING PERMIT FEE ¢ r $ the basis for the alleged exemption.Any violation of Section 7031.5 STORIES TYPE CONSTR. u ;-, by any applicant for a permit subjects the applicant to a civil penally ALTER-DRAIN -WATER (EA.) 5.00 of not more than five hundred dollars($500).): ❑ I,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 St ruclure is not intended or offered for sale (Sec. 7044, Business and Professions DRAINS-FLOOR,ROOF,AREA,COND. 5.00 Cade:The Contractor's License Law does not apply to an owner of - property who builds or improves thereon,and who does such work F IXTUR ES-PER TRAP 5.00 SO.FT.FLOOR AREA TOTAL ACREAGE • himself or through his own employees.provided that such Improve- ments are not intended or offered for sale.If,however,(lie building GAS-EA.SYSTEM-11NC.40UTLETS 6.00 or improvement is sold within one year of completion,the owner- GAS-EASYSTEM OVER 4 (EA.) 200 BUILDING USE builder will have th . . . e burden of proving that he did not build or im- E IND CON PB Other for purpose of sale.). INDUSTRIAL WASTE INTER. 30.00 ❑ 1,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(EA.) 1.00 contracts for such projects with a contrac(ons)licensed pursuant to SEWER•SANITAR V-STORM EA.200ft/10.00 the Corr..Rar's License Law. TRACT NO. PARCEL NO. ❑ I am exempt under Sec,-,B&RC.for this WATER HEATER W/VENT 6.00 reason Owner Date WATER SYSTEM 5.00 ACG OATS ACC.FILE NO. WORKERS'COMPENSATION DECLARATION WATER TREATING EQUIP. ' 5.00 I hereby affirm that I have a Certificate ofconsent to self-insure. ZONING ENG.SITE NO. or a Certificate of Workers'Compensation Insurance,or a Certified copy thercof(Sec.3800,Lab.C.). Policy No. Company ❑ Certified copy is hereby fumis le d. FIRE SPRINK ENERGY T-24 Z Z 'J4 CetT�rIlpd Copy s ppledwit a city Ins action Ivlslon. O APPlicanL;,llT-6LlCL lb MISC.- REFER TO ORD. Y❑ N❑ Y ❑ N❑ CC w PERMIT ISSUANCE 10.00 LU CF:RTIPICCOMPE EXEMPTION TINSU OMN'ORKF:RS' FLOOD ZONE A.L.U.C. W � COMPENSATION INSURANCE PLG.CONTR. LIC.No. PLG. CL Z (This section need not be completed if the permit is for one TOTAL Y[-] N❑ Y [:] N❑ hundred dollars($100)or less.) U O I Certify that in the performance of the work for which this per- CITY. 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. d Date Applicant ALTER OR ADD TO MECH. 5.00 BUILDING } to NOTICE TO APPLICANT: If,after making this Certificate of Ex- Z emption,you should 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 10,000C.F.M.) 4.00 CONSTRUCTION LENDING AGENCY AIR HANDLING UNIT(OVER 10P000.F.M.) 6.00 SEISMIC FEE I hereby affirm that (here 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,Ci¢C.). HEATING UNIT(TO 100,000 B.T.U.) 8.00 Lender's Name HEATING UN IT(OVER 100,000 B.T.U.)9.50 Lender's Address ELECTRIC I certify that I have read this application and state that the above VENTILATION FAN (SINGLE) 4.00 . information is correct.1 agree to comply with all city and county PLUMBING ordinances and state laws relating to building construction, and •BOILER-COMP(3H.P.or100,000B.T.U.) 6.00 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 to save, indemnify and keep harmless the City of MISC.- REFER TO ORD. Cupertino against liabilities,judgments, costs and expenses which PERMIT ISSUANCE 10.00 CONST.TAX may in any way accrue against said City in consequence of the ng of[his ermit MECH,CONT. LIC.NO. MECH. /(.•-d'i TOTAL TOTAL I Signature of Applicant/�1 , Date OFFICE COPY 11-30-1993 08:29AM FROM U S P S ADM. SUPPORT TO 14156888282 P.02 FMW • We•- 7�Qf�.lOarina Halra_ Of r. 954T4. hereby appoint j.QIW r_ ^ n Lin�-W" as our attorney in fact to act in our ca - any and all of the following; Daciry to do 1: To sign on our behalf for a permit to be ioaued from the City of Cupertino that would allow for the construction of a retaining wall on or about the property line that is shared between the above two mentioned properties, 2: To grant Demise'" for acceGa to our land to the neCOssary con- tractors so that they may execute the construction of the said retaining wall. we fully understand that tha construction of this retaining wail will affect both properties and that the final structure. including • the wall itself and its footing, will occupy land on both Droper- ties_ The rights, powers, and authority of my attorney in fact to exer- cise any and all of the rights and powers herein granted shall com- mence and be in full force and effect on Ngyg 24--a333, acid shall remain in full force and effect until Lt$C}}.u8L'y 31. i 44 d ur un]eas specifically extended or rescinded earlier by eithar party. Dated, IJoV 3 0�qc�3- Signed. v _ Signed: i TOTAL P.02