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C7274ra + �r .- O Z Z FO OC - W > CL O Z) Z 0 LL I- 0 O L) 6 F- 0 s APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY BU I LDI NG PROJECT I DENTI FICATI ON APPLICATION &PERMIT BUILDING - ELECTRICAL- PLUMBING - MECHANICAL PERMIT NUMBER ���� D ADRESSILDIN 0610 L� F. OWNER'S PLAN CHECK VALIDATION NAME zgldr- haw N • L W `1 73 PHONE J V> QTY. ELECTRIC PERMIT FEE CONTRACTOR'S S NAMEG�753 UTLETS - SWITCHES -RECEP 5.00/1.00 LIC,�. c. No(,..% LAC LIGHTING FIXTURES 5.00/1.00 CONTRACTOR ADDRESSDRESS ST �j7l- APPLIANCES - RESIDENTIAL 4.00 PANELS 5.00 ZZ C n n V PRONE J I DATE OF APPLICATION ARCHITECT OR ENGINEER Llc. NO, SIGNS 6.08 PLAN CHECK FEE D.C. NO. SIGNS TRANS. 3.00 ARCH 08 ENG. ADDRESS SPECIALCIRCUIT 5.00 PERMIT VALIDATION TEMP. METER OR POLE INS. 15.00 elp f y APPLICANTS ADDRESS MOTORS SEE FEE SCH. �k/ �/ /x�/ SERVICE CHANGE 10.00 LICP.NSI'D CONTRACTORS DECLARATION ga-T .�� e / /�f G`� I hereby affirm that I am licensed Older provisions of Chapter 9L[' (commancinB with Section 7000) of Division 3 of the Business and Prote"unis Code, and my license is in full fore and ISI'cet. License ClassLie Number ISSUANCE DATE BLDG. p ELECT. ❑ PLG. MECH. ❑ ❑ Uatc.�>olfJt Contractor O L BUILDING PERMIT INFORMATION OWNER -BUILDER DECLARATION I hereby affirm that I am exempt fromthe Contract or s License Law for the following erminessanstruct, aloin (Sec. 703sa permit ountyreason. which t n construct, suan e, dIso Code: Any c of sh eau my which structure p prior any structure, prior to its iatement, also improve, demolish, or repair such thedpun,milfor Suchrevisit ID tile of(aG Constatement ithat lie is hC IS Chaptercensed 9 (Com en the withprovisions ecti OC Ibl: folsiContractor's 3 of e ncing Cde) with Section is exempt theieftom the Law(ChapterProfessions Business and Professions Code) or that he is exempt Ihcio,G70 and MISC. REFER TO ORD . - PERMIT ISSUANCE 6ter,.00}Fr,'' VALUATION V f"O-,a,�0 J $/FT. ELEC. GONER. -LIG NO. ELEC j �i:a TOTALQ[-O PERMIT TO QTY. PLUMBING PERMIT FEE STORIES V gGy¢ONSTR. the basis for the alleged exemption. Any cion 70715 ALTER-DRAIN-WATER(EA.)4.00 tto a by any or the fora permit dollatsthea).): mmacivil penalty applicant of not more than five hundred dollars (5500).): - ❑ I, as owner of the property, or my employees with wages as sole cunlpensalion, will dr the work, and the slnwlurc is not BACK FLOW PROTECT. DEVICE 2.00 oCC. GROUP RES. UNITS DRAINS -FLOOR, ROOF, AREA, COND. 4.00 immaded or offered for sole (See. 7044, Business and Professions Code: The Contractor's License Law does not apply to an owner of FIXTURES - PER TRAP 4.00 SO. FT. FLOOR AREA TOTAL ACREAGE Property who build% or improves thereon, and who docs such work himself or through his own employees, provided that such improve- ments are not intended or offered for sale. If, however, the building GAS- EA. SYSTEM- 1 INC. 4 OUTLETS 4.00 or improvement is sold within one year of completion, the owner- builder will have the burden of proving that he did not build or ire- prove for pupwse ol'sulcf. ❑ I, as owner of tile property, am exclusively contracting with GAS - EA. STEM -OVER 4 (EA.) 1.00 BOLDING USE RES IND CON PB Omer ❑ ❑ ❑ ❑ ❑ INDUSTRIA WASTE INTER. 20.00 licensed contractors to constmel the project (Sec. 7044, Business and Professions Code: The Cnntmctnr's License Law docs not apply to an owner of property who builds or improves thereon, and who contracts for Cs projects licensed puralant to the tractsContor Such License Law. LAWN SPR INKLERS - 1 INC 5 V.B. 5.00 LAWN SPRINKLERS -OVER 5 (EA.) 1.00 ASSESSORS PARCEL No. .� SEWER -SANITARY -STORM EA. 200f1/8.00 TRACT No. PARCEL NO. ❑ Iamexemptundcr Sec. ,B.&P.C. for this I'a,.G WATER HEATER W/VENT 4.00 Owner Dale WATER SYSTEM 4.00 ACC. DATE ACC. FILE NO. WATER TREATING EQUIP. 4.00 WORKERSCOMPENSA I ION DECLARATION 1 hereby affirm that 1 have a ... tificete of eomint m sclfdnsure. or a cerlificate W Workers' Com Pcnsation Insurance, or a certified copythere�f�� S�ec.��IqpjL Lab C.1 I'ollcy No15lLL- V rQo5ltp:r * (� WSEIf r crw 21:0-0 u ` ZONING ENG. SITE NO. �p- �l�,j� Tn2 �a✓� O rx FIRE SPRINK v❑�*yN❑ ENERGY T-24 Y❑ NCD ❑ Certified copy is hereby furnished ❑ CerhijlcA4 py iz fled wish the 'ity inspection3 division. Applicant PrP G L*-� LsT�O-yca1P.00S.5_ ~PERMIT MISC.- REFER TO ORD. CER 'I'I17CAT'li EXEMI'T']ON FROM WORKIikS' ISSUANCE 6.00 //� _ L7 FLOOD ZONE AL.D c. PLG.CONTR. LIC NO. PLG. a76 UL TOTAL COMPENSATION INSURANCE (This section need not be completed if the permit is for ane Y ❑ N ❑ v ❑ N ❑ hundred dollar, IS 100) or less.) 1 certify that in the performance of the work for which this per- mit is issued, 1 shall not employ any person in any manner so as to QTY. MECHANICAL PERMIT FEE FEE SUMMARY BUILDING //0,3`0 become Subject to the Workers' Compensation Laws of Calif omia. Dal° Appliont NOTICE 'I'O APPLICANT'. It, after making this Certificate of E,, ALTER'OR ADD 70 MECH. 4.00 �' APPLIANCE4.00 4G 6A 4 PLAN CHECK colplion, you should become subject to the Workers' Compensation provisions of the Labor Code, you must forthwith comply with such provisions or this permit shall be deemed revoked. FEE AIR HANDLING UNIT (TO 10,000C.F.M.) 3.00 AIR HANDLING UNIT (OVER IQOWC.F.M.) 5.00 SEISMIC FEE OJ �- CONSTRUCTION LENDING AGENCY I hereby ancien that there f banding agency for EXHAUST HOOD (WITH DUCT) 2.00 which this the performance of the work for which this vermis is issued (Sec p MICROFILM HEATING UNIT (TO 100,000 B.T.U.) 4.00 HEATINGUNIT(OVER100,000B.T.U.)7.50 ELECTRIC c99 (/ ' IL. _ Lender's Name Lead is Nam Lender's Addle s I certify that 1 have read this applicutiun and Slate that the above information is correct. I agree to comply with all city and CountyPLUMBING ordinances and stale laws relating to building construction, and V ENTILA ON FAN (SINGLE) 3.00 BOILER-cow(3 H. P. or 100,0008.T.U.) 4.00 BOILER -COMP (Over 100.000BTU)SEEFEESCH. MECHANICAL epv hereby uuthnnic representatives of this city to enter upon the above-mentioned property for inspection purposes. MISC. - REFER TO ORD. (We) agree to save, indemnify and keep harmless the City of CuPel Dan against liabilities, judgments, costs and expenses which may in any way accrue auga' hal said City in Cvnscyuence of the CONST. TAX PERMITISSUANCE 3.00 ° granting of lits permit 6 MECH. CONT. LIC. NO. MECH. TOTAL ' / TOTAL Omtor Da -_1 Signature of App ICanl me INSPECTOR COPY CITY OF CUPERTINO INSPECTION RECORD n (OFFICE COPY) 7m o�oCr APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY BUILDING PROJECT IDENTIFICATION •APPLICATION &PERMIT • .. BUILDING - ELECTRICAL- PLUMBING -'MECHANICAL PERMIT NUMBER -. n G I (� ^ n "A I U ADILOI DRESS • ofogo J -\f �� f. OwrvER'a - NAME V� I LOIx�)•l `fit lhi^I Z PHONE /''') .3 - QTY ELECTRIC PERMIT FEE PLAN CHECK VALIDATION , . . CONTRACTOR'S NAME r- S3 UTLETS -SWITCHES-RECEP 5.00/1.00 �j �, uc. NO.Z7 _. DATE OF APPLICATION LIGHTING FIXTURES 5.0017.00 CONTRACTOR'S ADDRESS S �Z Ca A V PHONE 371r� APPLIANCES-RESIDENTIAL 4.00 PANELS 5.00 ARCHITECT OO OR ENGINEER ' uc. No. SIGNS. 6.00 PLAN CHECK FEE P.C. NO. - SIGNS TRANS_ 3.00 ARC OR ENG. aooaESs zip SPECIAL CIRCUIT 5.00 'PERMIT VALIDATION , TEMP. METER OR POLE INS. 15.00 'APPLICANTS ADDRESS .. ` - MOTORS SEE FEE SCH. SERVICE CHANGE, 10.00 LICENSED CONTRACTORS DECLARATION'- as sr� - E'- �'� "`v'-" '� Ov I hereby afOrm that Lam licensed under provisions of Chapter 9 (commencing with Section 7000) of Division 3 of the Business and Professions Code, and my li5¢nse is in fulb(or ^end eife t License Class Lic. NumberL Dale2JW(FA- Common, ISSUANCE DATE BLDG. ELECT. -PLG. MECH. JAMIX OWNER -BUILDER DECLARATION I hereby affirm that I am exempt from the Contractor's License Law for the following reason. (Sec. 7031,5, Business and Professions Cade: Any city or' county which requires a permit to construct, alter, improve, demolish, or repair any structure, prior to its issuance, also, requires the applicant for such permit to file a signed statement that. he is licensed pursuant to the provisions of the Contractor's License Law (Chapter 9 (commencing with Section 7000) of Division 3 of the Business and Professions Code) or that he is exempt therefrom and the basis for the alleged exemption. Any violation of Section 7031.5 byanyapplicant for a permit subjects the applicant toa civil penally of not mom than five hundred dollars ($500).): - BUILDING PERMITr:r.;,y: . INFORMATION �i �,"` misc. - RiWE TdTNff" PERMIT ISSUANCE 6.00 - 0 VALUATION LS/FT. JA..1..n' , , _ / v n ' ELEC. CONED. ". LIC. NO. ELEC. OC..V/ p1! TOTAL ERMIT TO .✓• OC" QTY. PLUMBING PERMIT FEE STORIES I. ALTER-DRAIN&VENT-WATER (EA.) ❑ .I; asowner of the property, or my employees with wages as their sole compensation, will do the work, and the structure is not BACK FLOW PROTECT. DEVICE 2.00 OCC. GROUP -RES. UNITS intended or offered for sale (Sea 7044,, Business and Professions. Code: The Contractor's License Law docs not apply to an owner of property who builds or improves thereon, and who does such work himself or through his own employees, provided that such improve- memsarenotintendedorofferedforsale. If, however, the building DRAINS -FLOOR, -ROOF, AREA, COND. 4.00 F IXTUR ES - PER TRAP ( 4.00 GAS-EA.SYSTEM-1 INC.40UTLETS 4,00 SO, FT. FLOOR AREA - TOTAL ACREAGE - or improvement is sold within one year of completion, the owner- builder will have the burden of proving that he did not build or im- prove for purpose of Sale.). ❑ I, as owner of the property, am exclusively contracting with GAS'- EA. SYSTEM, -'OVER .'VER 4 (EA.). RES IND CON PB - Other. 13 El El0 Ellicensed INDUSTRIAL WASTE INTER. 20.00 contractors to construct the project (Sec. 7044, Business and Professions Code: The Contractor's License Law does not apply to an owner of property who builds or improves thereon, and who contracts for such projects with a cantractorts) licensed pursuant to (he Contractor's License Law, ❑ I am exempt under Sec:_, B,&P,C, for this reason' LAWN SPRINKLERS- 1 IN V:B.L` 5.00 LAWN SPRINKLERS - OVER 5 (EA.)7,00 - -'" ASSESSORS PARCEL NO. - SEWER -SANITARY -STAG M_ W200ft%8.00 TRACT NO. - PARCEL NO. WATER HE W/VENT ._4.00 Owner Date WgTER SYSTEM Uri �. Cit O p - O ACC.DATE ACC. FILE NO. - WORKF.RS'COMPENSATION DECLARATION ,' WATER TREATING EQUIP. 4.00 ' 1 hereby affirm that I have a certificate ofcrnsent to self -insure, ZONING .' ENG. SITE NO. or a Certificate of Workers' Compensation Insurance, or certified lT�' 7 a1, O d L copy there f ec. 31kl Lap 1 ,, Policy No. ' f.0 tQ'dnPais �Lj 9-P''Y ie. ' -r ❑, Certified copy is hereby furnished. 4 ❑ Cer�t:fied c py is,filed witlthe cit inspection division. ApplicanlLr) I �a x trzaal' homer r'r�IVM.L:$- '- FIRE SPRINK Y 0 N� .. - ENERGY T 24 Y Q NE] MISC. - REFER TO ORD. CERTIFICATE OF EXEMPTION FROM WORKERS' .• COMPENSATION INSURANCE - '('this section need not be Completed if the permit is for one PERMIT ISSUANCE, 6.00 FLOOD ZONE Y E] NE A.L.U.C. _ Y ❑ NEJ PLG. CONTR. LIC_. NO. PLG. TOTAL �-' honored doll Ors (5 100) or less.) ' I certify that in the performance of the work mr which this per- mit is issued, I shall not employ any person in any manner so as to become subject to the Workers' Compensation Laws of California. Date Applicant - QTY. MECHANICAL PERMIT FEE - FEE SUMMARY BUILDING ��Q s}"O ALTER OR ADD TO M,ECW.Tn 4.00 �� NOTICE TO APPLICANTr If, after making this Certificate of Ex- APPLIANCE 4.00 PLAN CHECK FEE emption, you should become subject to the Workers' Compensation provisions of the Labor Code, you must forthwith comply with such provisions or this permit shall be deemed revoked. AIR HANDLING UN Ta(TO 1Op00GF�M.')7 3.00 CONSTRUCTION LENDING AGENCY AIR HANDLING UNI MOR iQ000CEM.). 5.00 SEISMIC FEE t'• OJ" �-- EXHAUST HOOD ( ITFj UCT),ertln 2.00 I hereby affirm that there is a construction lending agency for lire performance of the work for which this permit is issued (Sec. 3097, Cie.C.). MICROFILM HEATING UNIT (TO • D0,000 B.T.U.) 4.00 Lender's Name Lender's Address HEATING UNIT 100,000 B.T.U.)7.50 ? ELECTRIC -y KO I certify that I have read this application and state that [be above information is correct. I agree to comply with all city and county ordinances and state laws relating to building construction, and VENTILATION FAN (SINGLE) 3.00 PLUMBING BOILER- COMP (3 H:P. or 100,000 B.T.U.) 4.00 hereby authorize representatives this of ths city to enter upon the above-mentioned property for inspection purposes. ' BOILER -COMP (Over 100.000 BTU) SEE FEE SCI -1. MECHANICAL (We) agree to save, indemnify and keep harmless the City of MISC. - REFER TO ORD: Cupertino against liabilities, judgments, casts and expenses which may in any way accrue .against said City in consequence of The granting of this permit. O PERMITISSUANCE' 3.00 CONST. TAX , MECH. CONT. LIC. N0, a (' MECH. TOTAL 0-0, TOTAL - :gnats are of App roan! Contractor Uate - OFFICECOPY , CITY OF CUPERTINO INSPECTION RECORD n (OFFICE COPY) 7m o�oCr APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY BUILDING PROJECT IDENTIFICATION •APPLICATION &PERMIT • .. BUILDING - ELECTRICAL- PLUMBING -'MECHANICAL PERMIT NUMBER -. n G I (� ^ n "A I U ADILOI DRESS • ofogo J -\f �� f. OwrvER'a - NAME V� I LOIx�)•l `fit lhi^I Z PHONE /''') .3 - QTY ELECTRIC PERMIT FEE PLAN CHECK VALIDATION , . . CONTRACTOR'S NAME r- S3 UTLETS -SWITCHES-RECEP 5.00/1.00 �j �, uc. NO.Z7 _. DATE OF APPLICATION LIGHTING FIXTURES 5.0017.00 CONTRACTOR'S ADDRESS S �Z Ca A V PHONE 371r� APPLIANCES-RESIDENTIAL 4.00 PANELS 5.00 ARCHITECT OO OR ENGINEER ' uc. No. SIGNS. 6.00 PLAN CHECK FEE P.C. NO. - SIGNS TRANS_ 3.00 ARC OR ENG. aooaESs zip SPECIAL CIRCUIT 5.00 'PERMIT VALIDATION , TEMP. METER OR POLE INS. 15.00 'APPLICANTS ADDRESS .. ` - MOTORS SEE FEE SCH. SERVICE CHANGE, 10.00 LICENSED CONTRACTORS DECLARATION'- as sr� - E'- �'� "`v'-" '� Ov I hereby afOrm that Lam licensed under provisions of Chapter 9 (commencing with Section 7000) of Division 3 of the Business and Professions Code, and my li5¢nse is in fulb(or ^end eife t License Class Lic. NumberL Dale2JW(FA- Common, ISSUANCE DATE BLDG. ELECT. -PLG. MECH. JAMIX OWNER -BUILDER DECLARATION I hereby affirm that I am exempt from the Contractor's License Law for the following reason. (Sec. 7031,5, Business and Professions Cade: Any city or' county which requires a permit to construct, alter, improve, demolish, or repair any structure, prior to its issuance, also, requires the applicant for such permit to file a signed statement that. he is licensed pursuant to the provisions of the Contractor's License Law (Chapter 9 (commencing with Section 7000) of Division 3 of the Business and Professions Code) or that he is exempt therefrom and the basis for the alleged exemption. Any violation of Section 7031.5 byanyapplicant for a permit subjects the applicant toa civil penally of not mom than five hundred dollars ($500).): - BUILDING PERMITr:r.;,y: . INFORMATION �i �,"` misc. - RiWE TdTNff" PERMIT ISSUANCE 6.00 - 0 VALUATION LS/FT. JA..1..n' , , _ / v n ' ELEC. CONED. ". LIC. NO. ELEC. OC..V/ p1! TOTAL ERMIT TO .✓• OC" QTY. PLUMBING PERMIT FEE STORIES I. ALTER-DRAIN&VENT-WATER (EA.) ❑ .I; asowner of the property, or my employees with wages as their sole compensation, will do the work, and the structure is not BACK FLOW PROTECT. DEVICE 2.00 OCC. GROUP -RES. UNITS intended or offered for sale (Sea 7044,, Business and Professions. Code: The Contractor's License Law docs not apply to an owner of property who builds or improves thereon, and who does such work himself or through his own employees, provided that such improve- memsarenotintendedorofferedforsale. If, however, the building DRAINS -FLOOR, -ROOF, AREA, COND. 4.00 F IXTUR ES - PER TRAP ( 4.00 GAS-EA.SYSTEM-1 INC.40UTLETS 4,00 SO, FT. FLOOR AREA - TOTAL ACREAGE - or improvement is sold within one year of completion, the owner- builder will have the burden of proving that he did not build or im- prove for purpose of Sale.). ❑ I, as owner of the property, am exclusively contracting with GAS'- EA. SYSTEM, -'OVER .'VER 4 (EA.). RES IND CON PB - Other. 13 El El0 Ellicensed INDUSTRIAL WASTE INTER. 20.00 contractors to construct the project (Sec. 7044, Business and Professions Code: The Contractor's License Law does not apply to an owner of property who builds or improves thereon, and who contracts for such projects with a cantractorts) licensed pursuant to (he Contractor's License Law, ❑ I am exempt under Sec:_, B,&P,C, for this reason' LAWN SPRINKLERS- 1 IN V:B.L` 5.00 LAWN SPRINKLERS - OVER 5 (EA.)7,00 - -'" ASSESSORS PARCEL NO. - SEWER -SANITARY -STAG M_ W200ft%8.00 TRACT NO. - PARCEL NO. WATER HE W/VENT ._4.00 Owner Date WgTER SYSTEM Uri �. Cit O p - O ACC.DATE ACC. FILE NO. - WORKF.RS'COMPENSATION DECLARATION ,' WATER TREATING EQUIP. 4.00 ' 1 hereby affirm that I have a certificate ofcrnsent to self -insure, ZONING .' ENG. SITE NO. or a Certificate of Workers' Compensation Insurance, or certified lT�' 7 a1, O d L copy there f ec. 31kl Lap 1 ,, Policy No. ' f.0 tQ'dnPais �Lj 9-P''Y ie. ' -r ❑, Certified copy is hereby furnished. 4 ❑ Cer�t:fied c py is,filed witlthe cit inspection division. ApplicanlLr) I �a x trzaal' homer r'r�IVM.L:$- '- FIRE SPRINK Y 0 N� .. - ENERGY T 24 Y Q NE] MISC. - REFER TO ORD. CERTIFICATE OF EXEMPTION FROM WORKERS' .• COMPENSATION INSURANCE - '('this section need not be Completed if the permit is for one PERMIT ISSUANCE, 6.00 FLOOD ZONE Y E] NE A.L.U.C. _ Y ❑ NEJ PLG. CONTR. LIC_. NO. PLG. TOTAL �-' honored doll Ors (5 100) or less.) ' I certify that in the performance of the work mr which this per- mit is issued, I shall not employ any person in any manner so as to become subject to the Workers' Compensation Laws of California. Date Applicant - QTY. MECHANICAL PERMIT FEE - FEE SUMMARY BUILDING ��Q s}"O ALTER OR ADD TO M,ECW.Tn 4.00 �� NOTICE TO APPLICANTr If, after making this Certificate of Ex- APPLIANCE 4.00 PLAN CHECK FEE emption, you should become subject to the Workers' Compensation provisions of the Labor Code, you must forthwith comply with such provisions or this permit shall be deemed revoked. AIR HANDLING UN Ta(TO 1Op00GF�M.')7 3.00 CONSTRUCTION LENDING AGENCY AIR HANDLING UNI MOR iQ000CEM.). 5.00 SEISMIC FEE t'• OJ" �-- EXHAUST HOOD ( ITFj UCT),ertln 2.00 I hereby affirm that there is a construction lending agency for lire performance of the work for which this permit is issued (Sec. 3097, Cie.C.). MICROFILM HEATING UNIT (TO • D0,000 B.T.U.) 4.00 Lender's Name Lender's Address HEATING UNIT 100,000 B.T.U.)7.50 ? ELECTRIC -y KO I certify that I have read this application and state that [be above information is correct. I agree to comply with all city and county ordinances and state laws relating to building construction, and VENTILATION FAN (SINGLE) 3.00 PLUMBING BOILER- COMP (3 H:P. or 100,000 B.T.U.) 4.00 hereby authorize representatives this of ths city to enter upon the above-mentioned property for inspection purposes. ' BOILER -COMP (Over 100.000 BTU) SEE FEE SCI -1. MECHANICAL (We) agree to save, indemnify and keep harmless the City of MISC. - REFER TO ORD: Cupertino against liabilities, judgments, casts and expenses which may in any way accrue .against said City in consequence of The granting of this permit. O PERMITISSUANCE' 3.00 CONST. TAX , MECH. CONT. LIC. N0, a (' MECH. TOTAL 0-0, TOTAL - :gnats are of App roan! Contractor Uate - OFFICECOPY ,