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09524 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY BUILDING PROJECT IDENTIFICATION PERMIT NUMBER ADAPPLICATION & PERMIT 09524 ADDRESS LOINS BUILDING-ELECTRICAL-PLUMBING -MECHANICAL O PLAN CHECK VALIDATION NAME• OTY. ELECTRIC PERMIT FEE 1$ PHONE same ACTORS OUTLETS-SWITCHES-RECEP 10.00/1.00 ME.No. LIGHTING FIXTURES 10.00/1.00 CON ADDRESS as PPLIANCES-RESIDENTIAL 4.00 TRA �7 "r PHONE PANELS 10.00 DATE OF APPLICATION ARCHITECT PANELS (OVER 200 AMP) 20.00 PLAN CHECK FEE P.C.NO. OR ENGINEER LIC.No. SIGNS TRANS. 3.00 moo ESS ENG. SPECIAL CIRCUIT 5.00 PERMIT VALIDATION ZIP EMP.METER OR POLE INS. 20.00 PAID ADDRESS N Ara MOTORS SEE FEE SCH. DREs SERVICE CHANGE 20.00 AUG 2 3 1985 woo LICENSED CONTRACTORS DECLARATION TEMP.POLE 30.00 a O w I hereby affirm that I am licensed under provisions of Chapter 9 T m < n (commencing with Section 7000)of Division 3 of the Business and BLDG. E E MECHr r D z Professions C. gg to I • sCJ IT full for n e O i m O License la.^I j �YE.ME moble, ❑ ❑ ❑ 0 m r j Date_ In Contractor ¢ y f BUILDING IaERMIT ¢ ¢ w c¢i OWNER-BUILDER DLC[.ARA'I'ION INFORMATION w O a v I hercb affirm that 1 um exec t from the Contractor's License MISC.- REFER TO ORD U- y p PERMIT H u Law for lite following, 7031.5,Business and Professions VALUATION $/FT.Oj 1 .0 Code:Any city or county which requimsa permit to construct,alter, ELEC.CONTR. LIC.NO. ¢ ¢ Q o improve,demolish,or repair any structure,prior to its issuance,also ELEC. 0 , requires lite applicant for such permit ID file a signed statement that TOTAL PERMIT TO n w m m he is licensed pursuant to the provisions of the Contractor's License H z a Law(chapter 9(commencing with Section 70000rDiskion 3 of file 4 O Business and Professions Code)or that lie is esempt therefrom and OTY. PLUMBING PERMIT FEE ¢ H m the basis for tile ullcgcd exemption.Any violation of Section 7031.5 STO IE TYPE CONSTR. ate _ by any applicant for a permit subjects the applicant toa civil penalty ALTER-DRAIN -WATER (EA.) 5.00 of act more than five hundred dollars(8500).1: ❑ I,as owner of the property,or my employees with wages as BACK FLOW PROTECT. DEVICE 4.00 OCG GROUP RES.UNITS their sole compensation,will do the work,and fie Structure is not intended or offered for sale (Site. 7044, Business and Professions DRAINS-FLOOR,ROOF,AR EA,COND. 5.00 Code:The Contractors License Law does not apply to an owner of Property who builds or improves thereon,and who docssuchwork FIXTURES-PER TRAP 5.00 i SO.FT.FLOORAREA TOTALACREAGE • himself or through his own employees,prrvidcd that such improee- mems are not intended oroffered formic.If,however,the building GAS-EA.SYSTEM-I INC.40UTL ETI 6.00 QU or improvement is sold within one year of completion.the owner- GAS-EA.SYSTEM-OVER 4 TL 2.00 BUILDING USE builder will have the burden o'proving that he did not build orma E IND CNG PB Omer prove for purpose of sale.). INDUSTRIAL WASTE INTER. 30.00 ❑ 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:'l rte 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 contractors)licensed pursuant to SEWER-SANITARY-STORM EA.200ft/10.00 the Contractors License Law, dV TRACT NO. PARCEL NO. O lam exempt under Se<. ,B.&P.C.for this WATER HEATER W/VENT 600 ­( 00 reason Owner Datc WATER SYSTEM 5.00 OU ACC.DATE ACC.FILE NO. WORK E RS'COMPENSATION DECLARATION WATER TREATING EQUIP. 5.00 1 hereby affirm that I have a certificate of consent to self-insure. ZONING ENG.SITE NO. or a certificate of Workers'Compensation Insurance,or a certified copy thereof(Set.3800.Lab.CJ. Policy Nn. Comp:my O ❑ Certified copy is hereby furnished FIRE SPRINK ENERGY T 24 Z 2 d Certified eopY is bled wi01 the city inspection division. O MISC.- REFER TO ORD. Y ❑ N❑ Y ❑ N❑ W CERTIFICAIFOF EXLNIRI'ION PROM WORKERS' PERMIT ISSUANCE 10.00 FLOODZONE A.L.U.C. LL > CONIPIiNSA'1'ION INSURANCE PLG.CONTR. LIC.NO. PLG, Do CL 0 (This section need not be completed if the permit is for rale TOTAL Y❑ N❑ E] N Y ❑ hundred dollars IS 100)or Tess.) U O 1 certify that in fie pcd'ornance of the work for.hid,oils pc, QTY. MECHANICAL PERMIT FEE FEE SUMMARY LL 1- mit is issued,I Shull not employ any person in any nmnner so as to Uw become subject to the Workers''Conlpensal'mn Laws of California. BUILDING Q_ Dam Applicant ALTER OR ADD TO MECH. 5.00 Go NOTICE 10 APPLICANT: IL after making this Certificate of Es- Z enption,you should bears Subject to the Workers'Cmnpensation APPLIANCE 5.00 PLAN CHECK provisions of fire Labor Code, you must forthwith comply with FEE U such provisions or this permit shall be deemed revoked. AIR HANDLING UNIT TO 10=C.F.M.) 4.00 CONSTRUCT ION LENDING ACENCY AIR HANDLING UNIT(OVER 10=C.F.M.) 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 for which this permit is issued(Sec. MICROFILM 3097.Civ.C.). HEATING UNIT(TO 100,000 B.T.U.) 8.00 r Lende 's Name LedAddreHEATI NG UN IT(OVER 100,000 B.T.U.)9.50 ELECTRIC ss I certify that I have read this application and state that the above VENTILATION FAN (SINGLE) 4.00 00 • information is correct. I agree to comply with all city and county PLUMBING ordinances and state laws relating to building construction, and BOILER-COMP(3 H.P.or 100,000 B.T.U.) 6.00 hereby authorize representatives of this city to enter upon the BOILER-COMP (Over 100,000 BTU)SEE FEE SCH. MECHANICAL above-mentioned property for inspection purposes. (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 for an/t,T�\•K•/yof fir/ is permit. [f/� MECH.CONT. LIC.NO. MECH. OV�/�QIJ_ TOTAL I�/ TOTAL Signature of Applicant/Contract r Date INSPECTOR COPY A IVT TO FILL IN INFORMATION WITHIN -RED LINES - USE BALL POINT PEN ONLY DI NG PROJECT IDENTIFICATION APPLICATION & PERMIT PERMIT NUMBER prBUILDING ELECTRICAL- PLUMBING - MECHANICAL 09524 OVINEWS NAME fS4 QTY. ELECTRIC PERMIT FEE PLAN CHECK VALIDATION PHON CUffTRACTOR'S NAMEN OUTLETS -SWITCHES -RECEP 10.0011.00 LIGHTING FIXTURES 10.0011.00NO. DATE OF APPLICATION CONTRACTOR'SPPLIANCES-RESIDENTIALAD V:PHONE M 4.00 PANELS 10.00 A CHITECT OR ENGINEER LIC. NO, PANELS (OVER 200 AMP) 20.00 PLAN CHECK FEE P.C. NO. SIGNS TRANS. 3.00 AARCH. ORDDRESS ENG. SPECIAL CIRCUIT 5.00 PERMI IDA710N ZIP EMP. METER OR POLE INS. 20.00 AUG 2 3 1985APPLICANT'S ADDRESS MOTORS SEE FEE SCH. SERVICE CHANGE 20.00 City of Cupertino LICENSED CONTRACTORS DECLARATION TEMP. POLE 30.00 I hereby affirm that I am licensed under provisions or Chapter 9 commencing with Section 7000) of Division 3 of the Business and Professions C s 'n full fo2=96rj License ,umber t6 ISSUANCE DATE BLDG. ELECT. PL MECH. Date Contractor BUILDING AMIT INFORMATION - OWNER -BUILDER DECLARATION' I hereby affirm that I am exempt from the Contractor's License Law for the following reason. (Sec. 7031.5, Businessand Professions Code: 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 MISC. - REFER TO ORD PERMIT ISSUANCE 10.00 VALUATION SIFT. ELEC. CONTR. LIC. NO.. ELEC. TOTAL PERMIT TO QTY. PLUMBING PERMIT FEE Law (Chapter 9 (commencing with Section 7000) of Division 3 of the Business and Professions Code) or that he is exempt therefrom and STOVIES TYPE CONSTR. the basis for the alleged exemption. Any violation of Section 7031.5 by any applicant rot a permit subjects the applicant toa civil penalty or not more than five hundred dollars (5500).): ALTER -DRAIN & VENT -WATER (EA.) 5.00 1, as owner of the properly, or my employees with wages as their sole compensation, will do the work, and the structure is not BACK FLOW PROTECT. DEVICE 4.00 DCC.GROUP RES. UNITS intended or offered for sale (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 does such work himself or through his own employees, provided that such improve- mems are not intended or offered for sale. If. however, the building FLOOR, ROOF, AREA, COND. 5.00 y F IXTURES - PER TRAP 5.00 V SO FT. FLOOR AREA TOTALACREAGE GAS - EA. SYSTEM -1 I NC. 4 OUTLETS 6.00 or improvement is sold within one year of completion, the owner- builder will have the burden of proving that he did not build or im- prove for purpose of sale.). 1, as owner of the property, am exclusively contracting with GAS- EA. SYSTEM - OVER 4 (EA.) 2.00 BUILDING USE IND CON PB OIl e. El PB F-1 INDUSTRIALWASTE INTER. 30.00 LAWN SPRINKLERS - 1 INC 5 V.S. 6.00l(censcd 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 ASSESSORS PARCEL NO. LAWN SPRINKLERS- OVER 5 (EA,) 1,00 contracts for such projects with a contractor(s) licensed pursuant to the Contractor's -License Law. SEWER -SANITARY -STORM EA, 200ft110.00 TRACT NO. PARCELNO. lam exempt under Sec. B.&P.C. ror this j WATER HEATER WIVENT 6.00 reason Owner Date WATER SYSTEM 5.00 ACC. DATE ACC. FILE NO. WATER TREATING EQUIP. 5.00WORKERS'COMPENSATION DECLARATION 1 hereby affirm that I have a certificale of consent to self -insure, or a certificate of Workers' Compensation Insurance, or a certified ZONING ENG. SITE NO. copy thereof (Sec. 3800, Lab.C.). Policy No. Company FIRE SPR INK Y N ENERGY T-24 Y N Certified copy is hereby furnished. Certifie o is filed wish the city inspection division. App cant j (% (E/!L MISC. - REFER TO ORD. CERTIFICATE OF EXEMPTION FROM WORKERS' PERMIT ISSUANCE 10.00 FLOOD ZONE A.L.U,C. PLG, CONTR. LIC. NO. PLG. lJ TOTAL COMPENSATION INSURANCE This section need not be completed it the permit Is for one Y N[3 Y NE] CITY. MECHANICAL PERMIT FEE FEE SUMMARY hundred dollars (5100) or less.) 1 certify that in the performance of the work for which this per- mit is issued, I shall not employ any person in any -manner so as to BUILDING become subject to the Workers' Compensation Laws of California. Irate Applicant ALTER OR ADD TO MECH. 5.00 NOTICE TO APPLICANT: If, after making this Certificate or Ex- APPLIANCE 5.00 PLAN CHECKemption, you should become subject to the Workers Compensation provisions or the Labor Code, you must forthwith comply with such provisions or this permit shall be deemed revoked. FEEAIRHANDLINGUNIT (TO 10=C.F.M.) 4.00 AIR HANDLING LIN IT(OVER 10MC.F.M.) 6.00 SEISMIC FEE_ CONSTRUCTION LENDING AGENCY I hereby affirm that there is a construction lending agency for EXHAUST HOOD (WITH DUCT) 5.00 the performance of the work for which this permit is issued (Sec. 3097,Civ.C.), MICROFILM HEATING UNIT (TO 100,000 B.T.U.) 8.00 14EATINGLIN IT (OVER 100,000B.T.U.)9.50 ELECTRIC Lender's Name Lender's Address I certify that I have read this application and slate that the above information is correct. I agree to comply with ail city and county ordinances and state laws relating to building construction, and VENTILATION FAN (SINGLE) 4.00 PLUMBING Q BOILER -COMP (3 H.P. or 100,000 B.T.U.( 6.00 BOILER -COMP (Over t00,00oBTU15EE FEE SCH. MECHANICALherebyauthorizerepresentativesofthiscitytoenteruponthe above-menlioned property for inspection purposes. MISC. - REFER TO ORD. We) agree to save, indemnify and keep harmless the City of Cupertino against liabilities, judgments, costs and expenses which may in any way accrue against sold City in consequence of the grant of is permit. f CONST. TAX PERMIT ISSUANCE 10.00 MECH. CONT. LIC. NO. MECH. TOTAL TOTAL Signature of Applicant/Contractor Date OFFICE COPY