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09549APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY BUILDING PROJECT I DENTIFICATI ON APPLICATION & PERMIT BUILDING - ELECTRICAL -PLUMBING -MECHANICAL PERMIT NUMBER ^ . 0 PUILDING adaREss U, NAME /� �s• ` S7/^ - HONE 0 QTY. ELECTRIC PERMIT FEE PLAN CHECK VALIDATION NAME ActORs OUTLETS-SWITCHES-RECEP 10.00/1.00 .No. /, LIGHTING FIXTURES 10.00/1.00 . ry ACTdAs a00RE APPLIANCES -RESIDENTIAL 4.00 PANELS 10.00 PIaoNE 7 DATE OF APPLICATION A.1NIIIELI OR ENGINEER LIC. No. PANELS (OVER 200 AMP) 20.00 PLAN CHECK FEE P.C. NO. SIGNS TRANS 3.00 ARCH, OR ENG, SS SPECIAL CIRCUIT 5,00 PERMIT VALIDATION TEMP. METER OR POLE INS. 20.00 ZIP PAID APPLICANTS ADDRESS MOTORS SEE FEE SCH. SERVICE CHANGE 20.00 AUG 23 lJU 1,9JR5 J LICENSED CONTRACTORS DECLARATION TEMP. POLE 30.00 I hereby affirm Thal I am licensed under provisions of Chapmr9 (commencingwith Section 7000) of Division 3 Lithe Business and Professions Cod and y license is in full force a e�f�fej L License Class - Lit. Number SS ANCE DATE BLEr!" E MECH. e ❑ ❑ ❑ Dam_ Contractor BUILDING PERMIT INFORMATION OWNER -BUILDER DECLARATION I hereby affirm (hal I am exempt from the Contractor's License Law for the following reason.(Sec. 7031.5. Businessland Professions Code: Any city or county which requires a permit to construct, alter, Improve, demolish, or repair any structure, prior to its issuance, also re(p ire5 the applicant tin such peridt t0 file a signed statement that he is licensed pursuant 10 the provisions .1 the Contractor's License M ISC.- REFER TO ORD VALUATION SIFT, PERMIT ISSUANCE 10.00 ELEC. CONTR. LIC. NO. ELEC. TOTAL HE T OTY. PLUMBING PERMIT FEE Law (Chapter 9 (commencing with Section 7000) oiDivision 3 Lithe Business and Professions Code) or duet he is exempt therefrom and ST9 TYPE DN$TR. the basis for the alleged exemption. Any violation Lf Section 7031.5 by any applicant for a permit subjects the applicantwacivil penally .1 not more than five hundred dollars f5500)J. ALTER -DRAIN & VENT -WATER (EA.) 5.00 ❑ I, as owner of the property, or my employees evilh wages as their sole compensalion, will do the work, and the structure is nol BACK FLOW PROTECT. DEVICE 4.00 OCC. GROUP RES. UNITS DRAINS -FLOOR, ROOF, AREA, COND. 5.00 intended or offered for sale (Sec. 7044, Business and Professions Code: The Contractor's License Law does not apply 10 an owner Of property who builds or improves (hereon, and who does such work Iimself or through his own employees, provided (hal such improve- memsarcnot mended or offered for sale. If, however, the building L7 FIXTURES - PER TRAP 5.00 (J sQ FT. FLOOR AREA TOTALACREAGE GAS - EA. SYSTEM -1 INC.4 OUTLETS 6.00 OU 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 4 (EA.) 2.00 BUILDING USE IND CON PB ower ❑ ❑ ❑ ❑ INDUSTRIAL WASTE INTER. 30.00 LAWN SPRINKLERS- 1 INC 5 V.B. 6.00 licensed contractors to construct the project (Sec. 7044, Business and Professions Code: life Contractors License Law does not apply 10 an owner of properly who builds or improves thereon, and who ASSESSORS PARCEL NO. LAWN SPRINKLERS - OVER 5 (EA.) 1.00 contracts for such projects %i(hacon(mctorls) licensed pursuan(10 the Contractors License Law. TRACT NO. PARCEL NO. SEWER -SANITARY -STORM EA. 200ftI10.00 )Q ❑ l am exempt under Ser.-, B &P.C. for this WATER HEATER W/VENT 6.00(0 reason Owner Date WATER SYSTEM 5.00 r[X) ACC. DATE ACC.FILE NO. WATER TREATING EQUIP. 5.00 WORK ERS'COMPENSA'I' ION DECLA RAT ION. I hereby affirm that I have a certificate ofconsent to self-insurv. or a certificate of Workers' Compensation Insurance, or a certlfird ZONING ENG. SITE NO. copy thereof(Sec. 3800, Lab.C.). Policy No. Company FIRESPRINK Y❑ N❑ ENERGY T-24 Y❑ N❑ ❑ Certified copy is hereby furnished. pJ}.'Certified� py '-/ yfsled w'th t le city inspection division. Applicant ifr-•��I�•5 MISC.- REFER TO ORD. CERTIFICATE OF EXEMPTION FROM WORKERS' PERMIT ISSUANCE 10.00 DO FLOODZONE A.L.U.C. PLG. CONTR. LIC, NO. PLG, 'p V- TOTAL LA.1 COMPENSATION INSURANCE Im (This section need 1 be completed if the permit is for one Y ❑ N❑ Y ❑ N❑ Hundred dollars 1$ 100) or Icss.) I 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 QTY. MECHANICAL PERMIT FEE FEE SUMMARY BUILDING become subject to the Workeri Compensation Laws of California. Date ApplicantALTER OR ADD TO MECH. 5.00 NO'I'ICIi TO APPLICANT: If, octet making this Certificate of lix- emption, you should become subject to (lie Workerv'Compensatiou APPLIANCE 5.00 PLAN CHECK provisions of (he Labor Code, you must forthwith comply with such provisions or this permit shall be deemed revoked FEE AIR HANDLING UNIT (TO 10.00DC.F.NL) 4.00 AIR HANDLING UNIT (OVER 10=C.F.M.) 6.00 SEISMIC FEE CONSTRUCTION LENDING AGENCY I hereby affirm that there is u construction lending agency for EXHAUST HOOD (WITH DUCT) 5.00 the performance of life work for which this permit is. issued (Sec. 3097, Civ.CJ. MICROFILM HEATING UNIT (TO 100,000 B.T.U.) 8.00 Lender's Name Lender's Address HEATI NO UN IT (OVER 100,000 B.T.U.) 9.50 ELECTRIC I certify that I have read this application and slate that the above information is correct. I agree 10 comply with all city and county ordinances and riam laws relating to building construction, and VENTILATION FAN (SINGLE) 4.00 PLUMBING _ J' Com/ BOILER-COMP(3 H.P. or 100,000 B.T.U.) 6.00 601 LER-COMP (Over 100,000 BTU) SEE FEE SCH. MECHANICAL hereby authorize representatives of this city to enter upon the above-mentioned property for Inspection purposes. MISC. - REFER TO ORD. , (We) agree 10 save, indemnify and keep harmless the City of Cupertino against liabilities, judgments, costs and a Penses which may in an Y/�way accru}}}��� lgains( said City in consequence of the CONST. TAX PERMIT ISSUANCE 10.00 grupttm; of/[n , MECH. CONT, LIG NO. MECH. �permitJ �`/ TOTAL TOTAL Sl]U na eof APP cal t/ o76 for Dae INSPECTOR COPY Pf PPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY O Z _ 0 CC LU n- 0 00 UOw arn I— z A BUILDING PROJECT IDENTIFICATION APPLICATION &PERMIT ELECTRICAL --PLUMBING — MECHANICAL PERMIT NUMBER 09549BUILDING Ap E 4BUILDING NAME L V r PHONE '/ 7 QTY. ELECTRIC PERMIT FEE PLAN CHECK VALIDATION CONTRACTOR'S N E OUTLETS -SWITCHES -RECEP 10.0011.00 LIGHTING FIXTURES 10.0011.00e.Np. DNTRAcrG s AD R PPLIANCES- RESIDENTIAL 4.00 ELS 10.00PHON '10PAN DATE OF APPLICATION RCHITECTPANELS ORENGINEER Lie, ND. OVER 200 AMP) 20,00 PLAN CHECK FEE P.C.NO. SIGNS TRANS. 3.00 ARCH. ORADDRESS ENG SPECIAL CIRCUIT 5,00 PERMIT VALIDATION PAJUTEMP. METER OR POLE INS. 20.00zip rUG APPLICANT'S ADDRESS MOTORS SEE FEE SCH. SERVICE CHANGE 20,00 23 7988 It /, n /1 Wi4SS1NQU6 LICENSED CONTRACTORS DECLARATION TEMP. POLE 30.00 1 hereby affirm that 1 am licensed under provisions of Chapler 9 commencing with Section, 7000) of Division 3 of the Business and Professions Cod an lcense is in full force a e, t License ass Lie. Number } Date Contractor BLDG. ELECT. PLG. MECH. BUILDING PERMIT INFORMATIONOWNER -BUILDER DECLARATION thereby affirm that I am exempt from the Contractor's License Law for the following reason. (See. 7031.5, Business and 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 VALUATION SIFT. PERMIT ISSUANCE 10.00 ELEC. CONTR. LIC. N0, ELEC. TOTAL P G 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 S RIS 7YP ONSTR. 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 (5500).): ALTER -DRAIN &VENT -WATER {EA.) 5,00 1, as owner of the property, or my employees with wages as their sole compensation, will do the work, and the structure is not BACK FLOW PROTECT. D EVICE 4.00 OCC. GROUP RES. UNITS intended or offered for sale (Sec. 7044, Business and Professions' Coder 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- ments are not intended or offered for sale. If, however, the building DRAINS -FLOOR, ROOF, AREA COND. 5.00 FIXTURES - PER TRAP 5,00 41 TO SO_ FT. FLOOR AREA TOTAL ACREAGE GAS - EA. SYSTEM -1 INC.4 OUTLETS 6.00 COO 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 Other INDUSTRIAL WASTE INTER. 30.00 LAWN SPRINKLERS- 1 INC 5 V.B. 6.00licensedcontractorstoconstructtheproject (See. 7044, Business and Professions Code: The Contractor's License Law does not apply to an owner of property who builds or improves thereon, and wlro ASSESSORS PARCEL NO. LAWN _SPR IN KLERS - OV ER 5 (EA.) 1.00 contracts for such projects with a contractors) licensed pursuant to the Contractor's License Law. SEWER -SANITARY -STORM EA. 2DOFt1] 0,00 TRACT NO. PARCEL NO. 1 am exempt under Sec. BAP.C. for this WATER HEATER WIVENT 6.00 reason Owner Date WATER SYSTEM 5-001B ACC. DATE ACC, FILE NO. WATER TREATING EQUIP, 5.00WORKERS'COMPENSATION DECLARATION I hereby affirm that I have a certificate 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 FIRESPRINK Y N ENERGY T-24 Y H rZ Certified copy is hereby furnished. Certified p s le w h e city inspection division. Ap' phcant lY/_/ _6;db MISC. - REFER TO ORD_ CERTIFICATE OF EXEMPTION FROM WORKERS' PERMIT ISSUANCE 10.00 FLOOD ZONE A.I.XX. PLG. CONTR. LIC, NO, PLG, TOTAL COMPENSATION INSURANCE This section need not be completed if the permit is for one Y [:] ME) N[3 MECHANICAL PERMIT FEE FEE SUMMARY hundred dollars (S 100) or less.) I certify that. in the performance of The work for which this per -QTY. 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. Date Applicant ALTER OR ADD TO MECH50x7 NOTICE TO APPLICANT: If, after making this Certificate of Ex- APPLIANCE 5.00 PLAN CHECKemption, you should became subject to the Workers' Compensation provisions of 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 UNIT (OVER 10DWC,F.M.) 6.00 SEISMIC FEECONSTRUCTIONLENDINGAGENCY 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 HEATING UNIT (OVER 100,000B.T,U.)9.50 ELECTRIC Lender's Name Lender's Address I certify that 1 have read this application and state that the above information'incorrect. Iagree tocomply with all city and county ordinances and state laws relating to building construction, and VENTILATION FAN (SINGLE) 4.00 PLUMBING BOILER-CDMP(3H,P,or100,ODOB.T.U.) 6.00 BOILER COMP (Over 100,000 BTU) SEE FEE SCH. MECHANICALherebyauthorizerepresentativesofthiscitytoenteruponthe above-mentioned 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 an- ace against said City in _consequence of the tgr o tis per[iri CONST. TAX PERMIT ISSUANCE 10.00 MECH. CONT. LIC. NO. MECH. TOTAL TOTAL ignature of Applicant/Contractor Date OFFICE COPY