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1673 (2) C«ITYZO ' CUPER INO ____ PITY OF A PLIC- TION FOR CO MT, Mill BUILDING IT PERMIT NUMBER ?� A D r CER Ifl TE OF OCCUPANCY DEC � ' APPLICANT TO FILL IN STREET ADDRESS OF PROJECT: 39.E if'�,(/c�'i���.._.... iz'��.................. Plans Received By.... ..............._............_..._.........Date ........................ Legal Description: Tra / Block�C.r.. 0t... —.d REQ.: Plans.... Survey.... Calcs: Struc..... Energy.... Elect..... Mach._ � . .. Description of Work: p .�q/CI�G....._/[; ., ..Li..d.'1�-....... Plans Checked By.................._.... Date ....., ... 1st Struct. Improvement on Parcel:Yes.... No .. Area of Bldg.0.. Application Approved By...........ti2a.�.c._.._....._.. Date .� !!.��... Separate Structure........... or Addition/Alt rrratii to xis Bldg._........ Validated By......................................._..............._....Date ..........._........._. No. of Stories.''rVkI... Use f Building lY+T"c..✓ T 9G.C-....... Compensation Certificate Verified By.................... Date ......................... Valuatio ro'e $.. �O..0 v....................... ......... ........... ) �^ ,fes ...... EKWWF •. • . . E Owner: .... . .GL- A67 3 ............_......... PhOne"�J..I°.Wf Permit Fee (plus penalty If applicable) .......... ...........$ ......... Contractor: . ............. .... .......... City Bus. Lic.#............................. Address: ................._........ . . .. P o e:...._l Plan Check Fee (less deposit of $........_ Rct. #...... $........._..._....... rrII '/ Energy Plan Check Fee (Dep. of $........ Rct. #...... $............._...._.. Contractor - Electrical:Business yLcen f...... �.r.L .:? ? �. StrongMotion Fee ........._...................._................__.....$....................... City Business Licen9e #,�.F .�Q... Phane:T.4•.7t,/f... Plumbing: ................................ ................................................... Plumbing Permit Fee ................................................$..... . . City Business License #.................... Phone:.................... Electrical Permit Fee ..........................................._........$. Heating and Cooling ............ ....... Mach. Htg./Coolg. Permit $ ..............................$....................... City Business LiCense #.................... Phone:.................... Construction Tax............................................. $.............-......... Architect/Desi ner: .. g .. ./l.........._................ Phone:.................... Sewer Conn. Fee .............. Water Conn. Fee ..............$....................... /1/� Engineer. ..........._........ /t:........_...._.._........_.._..... Phone:.../kriowri Landscape Fee ............ Street Tree Fee ...._......$............. ....... Lends ...._........... [ill Misc. Fee ___....._......._..........._.................._.... ._........$....._..._._........ "1 certify that in the performance of the work for which this pamII la EWMNEKVTITNOMI . , , ; $ issued I shall not employ any person in a manner so es become subject to the workma��lnn ' s of fa ilia." Type Const......... Group........ Div.... .. Occ. Load........ No. Exits........ SiGNATURE,OF Floor Loads: 1st.... 2nd.... Other.... Sprinklered.... Area Sep. Walls.... APPUC9Wf/OWNER, ._'....._V-'Iv.DATE ... �(� certify that licensed un r the prqvi f••�it Contractors License Lbw �i rther that my License No. .(..) rilc. Environmental Status: Exempt............ Other............... in Classification ........L:.:.. ..(/............... is In full force and§ilea: or I certify that I am exempt from the "Licensed Req.'•ed" provisions of the Design Review Approval: Bldg. ............ Site .._....._. Sign . .... Contractors License Law. (State basis 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 #...... Variance #...... Parking Spaces.... Load. SIP..... 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 exp e es which ay In any way acture against said City in c encs ranti of this per it.. Croachment Permit............ Grant Of Easement..............._.._... SIGNATURE OF 9/!Re .. .I /• - Curb, Gutter, Sidewalk„ Driveway: Replace Repair APPLICANT/CONTRALTO .L "� .. DATE ....... Sewer............ Conn. Fee $................ Water................ Meter $................ NOTE: When properly validated Ih orm consgtutes a Building Pe N. Thls Agreement for Completion of Public Works Improvements .................. permit expires and becomes null sold should work not be commenced wlthln Plans Checked By........ Date........ Approved By........ Date.................... 120 days from validation dere, or Mould authorized construction be laspendsd or abandoned for a period of 120 drys after work Is commenced. • • • 171 Insist� APPLICATION FOR PLUMBING PERMIT PERMI'j,INSTALLATION(('' NO. EACH FEE PERMIT INSTALLATION NO. EACH FEE Light Out t ......1`... Switchesl.,f,J.... / Sytem with up Fixtu TOTAL NUM Receptacles ... � $ 50 3.J.0 Gas Each additionalo 5 outlet flats .$ 1.00 ......._.... TOTAL NUMBER(less than 1000 watts),... . Range........ Cooking Unit........ Oven........... ........ .... 2.00 . .............. Water System (Installation, Alt. or Repair) ................ 4.00 ............. Dryer.... Garb. Disp..... Dishwasher.... ........ ................. 2.00 ............... Water Closet.... Water Heater.... Ld. Tray.......... ......... . 4.00.............. SERVICE OR TEMPORARY POWER to ... ... 2.00 . .............. Lavatory.... Shower Pan.... Bathtub-... Sink.................. 3.00.............. . ........... 100 amp/$5.00, 200/$7.00, 500/$9.00 ) ( //�J Wash. Mach..... Dishwasher.... Garb. Disp..... .............. 3.00 ............. 800/$20.00, 1200/$40.00 ....... ......L...... ....J/{�U .._s7...'."!! 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, 00 Slop Sink........ Floor Sink..'..... Floor Drain .... ............ 4.00 ,............ 500/$15.00 ............................................... /OC...... ./�I.�... ..I . .... Urinal.... Interceptor.... Water Softener.............................4.00............... Signs with 1 XFMR ....................................... ............. .. 2.00 -1 Plumbing Piping without fixtures ....................... -. 4.00 Each additional XFMR/Time Clock .................... .50 ................ Misc. ..........................._.......... Annual Electrical Maintenance . ................25.00 .. .......-...... Permit Fee ..........................................................................$ 6.00 Other (see Ordinance Current) ....... ....... .. ............. I TOTAL PLUMBING PERMIT FEE (plus penalty if app. p) $ .............._..................._ ..............._........._................. .................................... APPLICATIONO. HEATING/COOLING .. .... Permit Fee ........................................................................ $ 6. PERMIT PERMIT INSTALLATION NO. EACH FEE TOTAL ELECTRICAL PERMIT FEE(plus penalty if app.�) E Forced Air Unit...............to 100M ............._.................. $ 6.00 ... INS. • RECORD over 100M ............................. 10.00 --------------- Comfort Cooling Unit.....to 3 ton/HP............................ 6.00 ............... Forms / Foundation....................._........ ............ Date:................, to 15 ton/HP_..._......... ........... 9.50 ............... Plumbing Ground Work""."..1l...... .. ........h. � .... to 30 ton/HP..........................12.00 ............... ough Electrical ..... cw... .. ...1P...1.-.?..- .....$f... to 50 ton/HP.......................... 17.00 ............... me - Plumbing and Hes g .................... ......... Space Heater........ Wall Heater ......................................6.00 ............... ulation / 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 .............................. ... ........ 1 TOTAL Htg./ Coolg. Permit Fee (plus penalty if app. O) $ Final -' Public Works...........a,.... ... ........... —_';lam _ • r2 _ F�?...t' ,8�......� 2o..r,_ lig- �cF�d...�-__1�/ . Sheet 2 OF CUPERTINO BUILDING PErVIT 10 Permit No: r Address: /c7t-9am- Date: BUILDING PROJECT IDENTIFICATION WORKERS' COSIPENSATION DECLARATION Applicant's Mailing Address 1 hereby affirm that I have a certificate of consent to self-insure, or a certificate of Workers'Compensation Insurance,or a certified copy thereof (Sec SW,Lab.C.�. Address of Building , Policy No. Cumpany U/rvf(i(� v ❑ Certified copy is hereby furnished4//l � 3 V Owner's name _ � Certified copy is filed with the county oil ing ins coon Telephone No. — // department or county department. Date Applicant Contractor's Name Contractor's Mailing Address eel CERTIFICATE OF EXEMPTION FROM WORKERS' .- COMPENSATION INSURANCE Lic. No. (This section need not be completed if the permit is for one 'Architect or Engineer - hundred dollars (SIW) or less.) Architect's or Engineers AddressI certify that in the performance of the work for which this permit Lic. No. is issued,1 shall not employ any person many manner so as to become subject to the Workers'Compensation Laws of California. LICENSED CONTRACTORS DECLARATION Date Applicant NOTICE TO APPLICANT: If, after making this Certificate of 1 hereby affirm that I am licensed under provisions 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 ry I' nse is in full force and effect. �f-f 9 �- comply with such provisions or this permit shal(be deemed revoked. License Class Lit. Number .7 ✓`���?�G Date Contractor CON'STRU'CTION LENDING AGENCY 1 I hereby affirm that there is a construction lending agency for the performance of the work for which this permit.is issued (Sec.3097, OWNER-BUILDER DECLARATION Lender's Name 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 state that the above Code: Any city or county which requires a permit to construct,alter, information is correct. 1 agree to comply with all city and county - r 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 70W)of Division 3of the Business and Professions Code) or that he is exempt therefrom and Signature or Appkant or Agent Date 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 (S300).): - ••OWNER-BUILDER VERIFICATION 1,as owner of the property,or my employees with wages as their sole compensation,will do the work,and the structure is not intended or offered for sale (Sec. 7044, Business and Professions "Attention Property Ow' Code: The Contractor's License Law does not apply to an owner of '"An 'owner-builder' building permit has been applied for in Property who builds or improves thereon,and who does such work your name and bearing your signature. himself or through his own employees, provided that such "Please complete and return this information in the envelope improvements are not in]ended or offered for sale.If,however,the provided at your earliest opportunity to avoid unnecessary delay in processing and issuing your budding permit.No building permit building or improvement is sold within one year of completion,the will be issued until this verification is received. owner-builder will have the burden of proving that he did not build 1. 1 personally plan to provide the major labor and materials for or improve for the purpose of sale.). construction of thero 1,as owner of the property,am exclusively contracting with P posed properly improvement (yes or no) licensed contractors to construct the project (Sec.7044,Business and 2 [. (have/have not) signed an application for a Professions Code: The Contractor's License Law does not apply to buildingemit ice the proposed an owner of property who builds or improves thereon, and who a pro sed work 0, 1 have contracted with the following Person(firm)to provide contracts for such projects with a contractor(s) licensed pursuant to the proposed construction: the Contractor's License Law.). F] I am exempt under Sec. , B.hP.C. for this Name reason _— Address City- Phone Contractors License No. Date Owner 4. 1 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 1 have contracted(hired) the following Persons to provide the work indicated: Name Address ,Phone Type of Work Signed: Property owner Social Security number Date.