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9370 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY BUILDING PROJECT IDENTIFICATION PERMIT NUMBER 1 A,DRES937E UILDI- G APPLICATION & PERMIT A r BUILDING -ELECTRICAL-PLUMBING-MECHANICAL i O E PLAN CHECK VALIDATION ANAME ELECTRIC PERMIT FEE COeo Ile a C. NAAMERAcroRs ! UTLETS-SWITCHES-RECEP 10.00/1.00 / -1C- ua NO. LIGHTING FIXTURES 10.00/1.00 O croR's Sud pp LIANC ES-RESI DENTIAL 4.00 ADDRESS 1 HONE PANELS 10.00 DATE OF APPLICATION OR T PANELS OVER 200 AMP) 20.00 PLAN CHECK FEE P.C.NO. ENGINEER S1 LIG.No. SIGNS TRANS. 3.00 ARCH.OR ENG. PERMIT VALIDATION ADDRESS SPECIAL CIRCUIT 5.00 PAI® ZIP ADDRESS SEMP.METER OR POLE INS. 20.00 Al , AMOTORS SEE FEE SC ORE SERVICE RANGE 20.00 SEP 0 51986 t 00 LICENSED CONTRACTORS DECLA RATIO. TEMP.POLE ^30.00 City of Cupertino ri w I hereby affirm that I am licensed under provisions of Chapter 9 CI ISSUANCE DATE ¢ a (commencing with Section 7000)of Division 3 of the Business and BLDG. ELEC PLG. MECH. H y i 1'ml'esswms Cade nd my license is'in full force and effec E] ❑ ❑4 z 0 H - License Cla [.it.Number •� O r 0 Dat, Contractor a y W BUILDING PERMIT ¢ ¢o n OOWNER-BUILDER DECLARATION INFORMATION w ; n y I hereby affirm that 1 am exempt from the Contractors License MISC.- REFER TO ORD LL0¢ Law for the following reason.(Sec.7031.5.Business and Professions PERMIT ISSUANCE 10.00 VALUATION $/FT. L• Code:Any city orcounty which requires a permit to construct,alter, N LI ELEC.CONTR. C. 0. QQ ¢ p improve,demolish,Or repair any structure,prior to IIS issuance,31WELEC. or CLL requires the applicant for such permit to Nle a Signed statement thatTOTAL P MIT TO r w aiwl Ire is licensed pursuant to the provisions of the Contractor's License H z a Law(Chapter 9(commencingwith Section 7000)of Division 3 ofthe Business and Professions Code)or that he is exempt therefrom and QTY. PLUMBING PERMIT /TT-- ¢ =$ the basis for the alleged exemption.Any violation of Section 7031.5 STOR TYPE CONSTR. n ; by tiny applicant for a permit objects the applicant to a civil penalty ALTER-DRAIN -WATER IEA.) 5.00 of mol mor,than five hundred d Vllurs(5500).): \�,..�� 0 I,as owner of Hre 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 structure is not intended or offered for sale(Sec. 7044. Business unit Professions DRAINS-FLOOR,ROOF,AR EA,COND. 5,00 / Code:The Contractor's License Law does not apply to an owner of property who builds or improves thereon,and who does such work FIXTURES-PER TRAP 5.00 Sp.FT.FLOOR AREA TOTAL ACREAGE.' himself re through his own employees,provided that such improve. + mems are not intended w thinoffered one yearsale.lC mplefhowever.it" ti building GAS-EA.SYSTEM-1 1NC.4 OUTLETS 6.00 or improvement is sold within one year a he did ion,the owner- GAS-EA.SYSTEM-OVER 4 IEA.) 2.00 ' BUILDING USE builder will have the burden of pronng flint he did not buil)or ice- prove for purpose ofsale.). INDUSTRIAL WASTE INTER. 30.00 RE IND CON PS Omer ❑ I,as owner of the property,am exclusively contracting with NM ❑ ❑ ❑ ❑ 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 eonlractorfs)licensed pursuant In the Contractor's License Law. SEWER-SANITARY-STORM EA.200tt/10.00 TRACT NO. PARCEL NO. ❑ 1 a exempt under Sec.-,B&P.C.for this WATER HEATER W/VENT 6.00 -f reason Ower Date WATER SYSTEM 5.00 ACC.DATE ACC,FILE NO. 3cvtc 41,7144PENSATION DECLARATION WATER TREATING EQUIP. 5.00 I hereby aflum that 1 have a certificate of consent to,self-Insure' • ZONING ENG.SITE NO. or a certificate of Workers'Compensation Insurance,or a certified copy BlereoflSea.3800,Lab.C.). // Policy No. Conrpaliy Awl e- f It Q ❑ Certified alpy i5 hcrchydumis lc ,T FIRE SPRINK ENERGY T 24 Z Z Certific c I Is filed w' r the city' inspection division. MISC.- REFER TO ORD. O .1 licall ;-a r Y❑ N❑ Y ❑ N❑ w CERTIFICATE 01'EXEMPTION FROM WORKERS' PERMIT ISSUANCE 10.00 FLOOD ZONE A.L.U.C. LU > COISIPENSATION INSURANCE PLG.CONTR. LIC.NO. PLG. CL Z (this section need not be completed if the permit is for one TOTAL Y❑ N❑ Y El ❑ Nr hundred dollars IS 100)or less.) T U 0 1 certify mut In the performance of the work for which this per. QTY. MECHANICAL PERMIT FEE FEE SUMMARY LL H mit is issued. I shall not employ any person in any manner so as to U become subject to the Workers'Compensation Laws of California. l Go Dam Applicam BUILDING 1 } 0NOTICE TO APPLICANT: If,after making this Certificate of Ex- ALTER OR ADD TO MECH. 5.00 F 2 eruption,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 pmvisions or this permit shall be deemed revoked. AIR HANDLING UNIT(TO 10=C.F.M.) 4.00 CONST RUCTION LENDING AGENCY AIR HANDLING UNIT(OVER 19=1C.EM.) 6.00 SEISMIC FEE I hereby affirm that mere 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.F I HEATING UNIT(TO 100,000 B.T.U.) 8.00 Lender's Name H EATING UNIT(OV ER 100,000 B.T.U.)9.50 i Lenders Name ELECTRIC 1 certify that I have read this application andstate that the above VENTILATION FAN (SINGLE) 4.00 • information is correct. I agree to comply with u11 city and county' PLUMBING ordinances and etu, laws relating to building construe ion, and BO -COMP . or100,000B.T.U.) 6.00 hereby authorize representatives of this city m enter upon the BOILEILERR-COMP(3(HP.Over 100,000 BTU)SEE FEE SCH. MECHANICAL above-mentioned property for inspection purposesco . (We) agrto save, indemnify and keep harmless the City of MISC.- REFER TO ORD. Cupertino against iia 'hies,judgments, costs and expenses which PERMIT IS 10.00 CONST.TAX may in any way a rue against said City in Consequence of the granting o this ped it. -D MECH.CONT. LIC.NO. MECH OTAL TOTAL Slgl orAfthTanTiConfliaeocir a e INSPECTOR COPY Otczoo Q 2 w N N H y'Z Z O N - 0 y H W 2sw0iaOac w w 1 O 4 y i W S guJ axo W m N Ezo a w Z z P w 1r - LU 7 d z Uo 1.L U Ow a- Z U APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALLPOINT PEN ONLY r BUI LDING,PROJECT I DENTI FICATION APPLICATION & PERMIT BUILDING - ELECTRICAL-- PLUMBING - MECHANICAL PERMIT NUMBER Jj 7 V 3 l 0 BUILDING AaekleADOES u GT O/ I OWNER'S NAM p /- ELECTRIC PERMIT FEE PLAN CHECK VALIDATION i{ PRDN DATE OF APPLICATION CONTRACTOR'S N r , C, uc.NO. OUTLETS -SWITCHES -RECEP 10.0011.00 e LIGHTING FIXTURES 10.0011.00 7, `eoADDRESS 57, v PPL{ANCES - RESIDENTIAL 4.OD PANELS 10.00 AflCHITECT ORENGINEER LIC. NO. PANELS(OVER260AMP) 20,00 PLAN CHECK FEE P,C.Np. SIGNS TRANS: 3.00 ADDRESSS ENG' SPECIAL CIRCUIT 5,00 P q)taffDATION i't1E EMP. METER OR POLE INS. 20.00 /7mvZIP U j City ,Qf Cupertino ADDRESS TS ]] MOTORS e. SEE FEE SCK-1;150SEP SERVICE CHANGE 20.00 LICENSED CONTRACTORS DECLARATION TEMP. POLE 30,00 I hereby affirm that 1 am licensed under provisions of Chapter 9 commencing with Section 7000) of Division 3 o the Business and Professions Cod nd y license, is in full for f€ / License s -' Lic. Number 5 Date Contractor ISSUANCE DATE 8LpG. EL LN I PLG. MECH, BUILDING PERMIT INFORMATTIONIONOWNER -BUILDER DECLARATION 1 hereby affirm that 1 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 Contractors License Law (Chapter 9 (commencing with Section 7000) of Division 3 of the Business and Professions Code) or that he is exempt therefrom and MISC, - REFER TO ORD V ALUATION SIFT. PERMIT ISSUANCE 10.00 EL CO T A, LIC. N0. r P G ELEC. TOTAL CITY. PLUM13ING PERMIT FEE STORIts. TYPE CONSTR. 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 Bt 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 intended or offered for sale (Sec. 7044, Business and Professions BACK FLOW PROTECT. DEVICE 4,00 OCC. GROUP RES. UNITS DRAINS -FLOOR, ROOF, AREA, COND. 5.00 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- ments are not intended or offered for sale. If, however, the building FIXTURES - PER TRAP 5.00 SEL FT. FLOOR AREA TOTALACREAGE GAS - EA. SYSTEM -1 INC.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.). E3I„as owner of the property, am exclusively contracting with GAS - EA. SYSTEM -OVER 4 {EA.) 2.00 BUILDING USE RE 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 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, SEWERSANITARYSTORM EA. 200ft/10.00 TRACT NO. PARCEL NO. 0 tam exempt under Sec. B.&P.C. for this WATER HEATER W/VENT 6.00 reason Owner ¢ Q Date VANIJ'[AKIRENSATIONDECLARATION WATER SYSTEM 5.00 ACC, DATE ACC. FILE NO. WATER TREATING EQUIP. 5.00 1 hereby affirm that 1 have a certificate of consent to self -insure, or a certificate of Workers Compensation Insurance, f a certifiedcopythereof (Sec. 3800, Lab.C.). 1iGm p QY Policy No, Company / ZONING ENG. SITE NO, FIRE SPRINK Y' N ENERGY T-24 Y N Certified copy is hereby furnished. CertiCmd/cy y = ' h h city inspection division. AIV. Cet misc. - REFER TO ORD, CERTIF[CATE OF EXEMPTION FROM WORKERS" PERMIT ISSUANCE 10.00 FLOOD ZONE A.L.u,C. PLG, CONTA. LIC. NO, PLG TOT.AL COMPENSATION INSURANCE This section need not be completed if the permit is for one Y N Y N CITY. MECHANICAL PERMIT FEE FEE SUMMARY hundred dollars (S 100) or less.) I 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 BUILDING become subject to the Workers' Compensation Laws of California. Date Applicant NOTICE TO APPLICANT: Ir, after making this Certificate of Ex- ALTER OR ADD TO MECH. 5,00 APPLIANCE 5.00 PLAN CHECKemption, 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. FEEAIRHANDLINGUNIT (TO 10=11F.M.) 4.00 AIR HANDLING UNIT(OVER101MC.F,M.) 6.00 SEISMIC FEECONSTRUCTIONLENDINGAGENCY 1 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 100,000 B,T.U.)9.50 ELECTRIC Lender's Name Lenjg:rAddress-- VENTILATION FAN (SINGLE) 4.00 PLUMBING 1 certify that I have read this application and state that the above information is correct. 1 agree, to comply with all city and county ordinances and state laws relating to building construction, and BOILER -COMP (3 H.P, or 100,000 B.T.U.) fi.00 BOILER -COMP (0ver100,000BTU)SEE FEESCH, MECHANICALherebyauthorizerepresentativesofthiscitytoenteruponthe above-mentioned property for inspection purposes. MISC. - REFER TO ORD. We) agree to save, indemnify and keep harmless the City of Cupertino against . ttes, judgments, costs and expenses which may in any way true agains Id in consequence of the granti th' CONST. TAX PERMIT ISSUANCE 10.00 ECH.CONT. LIC.NO, MECH. TOTALegTOTAL Signa of AppGcantlCantractor ate OFFICE COPY Otczoo Q 2 w N N H y'Z Z O N - 0 y H W 2sw0iaOac w w 1 O 4 y i W S guJ axo W m N Ezo a w Z z P w 1r - LU 7 d z Uo 1.L U Ow a- Z U APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALLPOINT PEN ONLY r BUI LDING,PROJECT I DENTI FICATION APPLICATION & PERMIT BUILDING - ELECTRICAL-- PLUMBING - MECHANICAL PERMIT NUMBER Jj 7 V 3 l 0 BUILDING AaekleADOES u GT O/ I OWNER'S NAM p /- ELECTRIC PERMIT FEE PLAN CHECK VALIDATION i{ PRDN DATE OF APPLICATION CONTRACTOR'S N r , C, uc.NO. OUTLETS -SWITCHES -RECEP 10.0011.00 e LIGHTING FIXTURES 10.0011.00 7, `eoADDRESS 57, v PPL{ANCES - RESIDENTIAL 4.OD PANELS 10.00 AflCHITECT ORENGINEER LIC. NO. PANELS(OVER260AMP) 20,00 PLAN CHECK FEE P,C.Np. SIGNS TRANS: 3.00 ADDRESSS ENG' SPECIAL CIRCUIT 5,00 P q)taffDATION i't1E EMP. METER OR POLE INS. 20.00 /7mvZIP U j City ,Qf Cupertino ADDRESS TS ]] MOTORS e. SEE FEE SCK-1;150SEP SERVICE CHANGE 20.00 LICENSED CONTRACTORS DECLARATION TEMP. POLE 30,00 I hereby affirm that 1 am licensed under provisions of Chapter 9 commencing with Section 7000) of Division 3 o the Business and Professions Cod nd y license, is in full for f€ / License s -' Lic. Number 5 Date Contractor ISSUANCE DATE 8LpG. EL LN I PLG. MECH, BUILDING PERMIT INFORMATTIONIONOWNER -BUILDER DECLARATION 1 hereby affirm that 1 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 Contractors License Law (Chapter 9 (commencing with Section 7000) of Division 3 of the Business and Professions Code) or that he is exempt therefrom and MISC, - REFER TO ORD V ALUATION SIFT. PERMIT ISSUANCE 10.00 EL CO T A, LIC. N0. r P G ELEC. TOTAL CITY. PLUM13ING PERMIT FEE STORIts. TYPE CONSTR. 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 Bt 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 intended or offered for sale (Sec. 7044, Business and Professions BACK FLOW PROTECT. DEVICE 4,00 OCC. GROUP RES. UNITS DRAINS -FLOOR, ROOF, AREA, COND. 5.00 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- ments are not intended or offered for sale. If, however, the building FIXTURES - PER TRAP 5.00 SEL FT. FLOOR AREA TOTALACREAGE GAS - EA. SYSTEM -1 INC.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.). E3I„as owner of the property, am exclusively contracting with GAS - EA. SYSTEM -OVER 4 {EA.) 2.00 BUILDING USE RE 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 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, SEWERSANITARYSTORM EA. 200ft/10.00 TRACT NO. PARCEL NO. 0 tam exempt under Sec. B.&P.C. for this WATER HEATER W/VENT 6.00 reason Owner ¢ Q Date VANIJ'[AKIRENSATIONDECLARATION WATER SYSTEM 5.00 ACC, DATE ACC. FILE NO. WATER TREATING EQUIP. 5.00 1 hereby affirm that 1 have a certificate of consent to self -insure, or a certificate of Workers Compensation Insurance, f a certifiedcopythereof (Sec. 3800, Lab.C.). 1iGm p QY Policy No, Company / ZONING ENG. SITE NO, FIRE SPRINK Y' N ENERGY T-24 Y N Certified copy is hereby furnished. CertiCmd/cy y = ' h h city inspection division. AIV. Cet misc. - REFER TO ORD, CERTIF[CATE OF EXEMPTION FROM WORKERS" PERMIT ISSUANCE 10.00 FLOOD ZONE A.L.u,C. PLG, CONTA. LIC. NO, PLG TOT.AL COMPENSATION INSURANCE This section need not be completed if the permit is for one Y N Y N CITY. MECHANICAL PERMIT FEE FEE SUMMARY hundred dollars (S 100) or less.) I 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 BUILDING become subject to the Workers' Compensation Laws of California. Date Applicant NOTICE TO APPLICANT: Ir, after making this Certificate of Ex- ALTER OR ADD TO MECH. 5,00 APPLIANCE 5.00 PLAN CHECKemption, 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. FEEAIRHANDLINGUNIT (TO 10=11F.M.) 4.00 AIR HANDLING UNIT(OVER101MC.F,M.) 6.00 SEISMIC FEECONSTRUCTIONLENDINGAGENCY 1 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 100,000 B,T.U.)9.50 ELECTRIC Lender's Name Lenjg:rAddress-- VENTILATION FAN (SINGLE) 4.00 PLUMBING 1 certify that I have read this application and state that the above information is correct. 1 agree, to comply with all city and county ordinances and state laws relating to building construction, and BOILER -COMP (3 H.P, or 100,000 B.T.U.) fi.00 BOILER -COMP (0ver100,000BTU)SEE FEESCH, MECHANICALherebyauthorizerepresentativesofthiscitytoenteruponthe above-mentioned property for inspection purposes. MISC. - REFER TO ORD. We) agree to save, indemnify and keep harmless the City of Cupertino against . ttes, judgments, costs and expenses which may in any way true agains Id in consequence of the granti th' CONST. TAX PERMIT ISSUANCE 10.00 ECH.CONT. LIC.NO, MECH. TOTALegTOTAL Signa of AppGcantlCantractor ate OFFICE COPY