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3198 APPLICANT TO FILL IN INFORMATION.VVITHIN.RED LINES - USE BALI. POINT PEN ONLY BUILDING i PROJECT IDENTIFICATION APPLICATION & PERMIT . �-d3�- ED I . -- ER ITN B LOING DADRESS QBUILDING_ELECTRICAL-PLUMBING -MECAL 98 ^t OWNER'S AN CHECK VALIDATION i I NAME 7>4 r7>4i TY. ELECTRIC PERMIT FEE i /-�a /P NFa %-.7/4 CONTRACTOR'S \\�I,NAME _ OUTLETS-SWITCHES-RECEP 5.00/1.00 •LC.NO. LIGHTING FIXTURES 5.00/1.00 CONTRACTOR ADDRESS PPLIANCES-RESIDENTIAL 4.00 AD - O /'���:�5. � 1 vHONE PANELS 5.00 DATE OF APPLICATION ARCHITECT SIGNS 6.QQ PLAN CHECK FEE P.G NO. OR ENGINEER A 'uc.NO. SIGNS TRANS. 3.00 ADDRESS ENG. SPECIAL CIRCUIT 5,00 PERMIT VALIDATION nP EMP.METER OR POLE INS. ' 15.00 AEMOTORS SEE FEE SCH. (J • ADDRESS EF J a SERVICE CHANGE 10.00 G�.•5•� woo LICENSED CONTRACTORS DECLARATION rt v u I hereby affirm that 1 um licensed under provisions of Clmpter s/ ISSUANCE DATE ,,Q u Iconimencing with Section 7000)of Division 3 of the Business and BLDG. ELECT. PLG. MECH. F D z Professions Code,;end n I'cense is in lull fort�alW effe t 4 ❑ z o m - Limn ass Lic.Number T Y'9TO O y F Ume Contractor 4'4 s g ' BUILDING PERMIT ¢ ¢ w a OWNER-BUILDER DECLARATION INFORMATION A o N " MISC.- REFER TO ORD w 3 a. r- I hereby affirm that I am exempt Imo the Contractor's Licensr yn LygTION 5/FT. r u. o¢ Law for the following reason.(Sec,7031.5.Business and Professions PERMIT ISSUANCE 6.00 (/Z�/\ m0J Code:Anycity orcounty which requires a permit toconstruct.alter, - ¢ aQ improve,danmlish,or repair any structure,prior to its iscsuvse,also ELEC.CONTR. - LIC.NO. ELEC. G u requires the applicant for such,penaif to file a signed statement that TOTAL PERMIT TO ' wm L_ he is licensed pursuant to the provisions of the Contractor's License F z r. Law(Chapter 9(commencing with Section 7000)of Division 3 ofthe a Business and Professions Code)or that he is exempt therefrom and DTV. PLUMBING PERMIT FEE ¢ o the basis for the alleged exemption.Any violationof beai70315 1 STORIES TYPE CONSTR. aim by any applicant for a permit subjects the applicant toa civil penalty ALTER-DRAIN& VENT-WATER (EA.) 4.00 - of not more than five hundred dollar,(55000r: ❑ I,as owner of the property,or my employees with wages as BACK FLOW PROTECT. DEVICE 2.00 their sole compensation,will do the work,and the structure is not OCC.GROUP RES.UNITS intended or offered for ,to (Sec.7044, Business and Professions DRAINS-FLOOR,ROOF,AR EA,COND. 4.00 Code:The Contractor's License Law does not apply 10 un owner of property x'h0 builds or improves thereon,and who dues such work F I XTUR ES-PER TRAP 4.00 50,FT,FLOOR AREA TOTAL ACREAGE himself or through his own employees.provided that such imt!rovr- �' ments are not intended or offered for sale.If.however.the budding GAS-EA.SVSTEM-11NC.40UTLETS 4.00 or improvemm�t is sold within one year of coripletion, The-owner GAS-EA.SYSTEM-OVER 4 IEA.) 1.00 BUILDING USE _ builder will have the burden of proving than he Aid not build or im- - RES IND CON ED Omer prove for purpose of sale.). INDUSTRIAL WASTE INTER. 20.00 ❑ ❑ ❑ ❑ El . ❑ I,as owner of the Property,am exclusively Contracting wide _ licensed contractors to construct lite project(Sec. 7044,Business LAWN SPRINKLERS-1 INC 5 V.B. 5.00 ASSESSORS PARCEL NO. anA Professions Code:The Contra,tor's License Law dogs not apply -to an owner of property who builds or improves thereon,and who LAWN SPRINKLERS-OVER 5(EA.) 1.00 - contracts forsuch project,with a contraetods)licensed pursuant to the Contractor's License Law. . SEWER-SANITARY-STORM EA.200ft/8.00 TRACT NO. PARCEL NO. ❑ Irmcsrmptunder Sec. .B.&P.C.for this WATER HEATER W/VENT 4.00 reason Date Owner WATER SYSTEM 4.00 ACC.DATE ACC.FILE No, N'ORKERS'COAIPENSATION DECLARATION WATER TREATING EQUIP. 4.00 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(S,,.3800.Lab.CJ. Policy No. ' Company " O ❑ Certified copy is hereby furnished. / FIRE SPRINK ENERGY T-24 Z Z ❑ Certified copy is filed with the city inspection division. O Applicant MISC..- REFER TO ORD. Y ❑ N❑ �Y ❑ N CC = CERTIFICATE OI'EXEMPITON FROM WORKERS' 'PERMIT ISSUANCE 6.0016 .� FLOOD zONE A.L.u.c. LU > - COUPENSAT10N INSURANCE: - PLG.CONTR. LIC.NO. PLG. Y N Y E] N❑ 1 O TOThis section need not be completed if,the permit is for one TAL ❑ - ❑ Z) Z hundred dollars(5100)or Ices.) U O 1 certify that in the performance of Bre work for which this per- QTY. MECHANICAL PERMIT FEE FEE SUMMARY ly f- mit is issued,1 shall not employ any person in any manner so as to becorrrry�x5'bbj!V�,t.yy y�1e Workers'Con ensation Lu 's - " mia. BUILDING UateS�X°.3'Applicant � 4�._- ALTER OR ADD TO MECH. 4.00 ` }. NOTICE 'IO APPLICANT'. If,after mak s Certificate of :x- Z emption,you should become subject to 01e Workers'Compensation APPLIANCE 4.00 PLAN CHECK provisions of the Labor Code, you must forthwith comply with FEE such provisions or this permit shall be deemed revoked AIR HANDLING UNIT(TO 10=C.F.M.) 3-00 s CONSTRUCTION LENDING AG17NCY AIR HANDLING UNIT(OVER 10=C.F.M.) 5.00 SEISMIC FEE I hereby affirm that there is a construction lending agency for EXHAUST HOOD(WITH DUCT) 2.00 the performance of the work for which this permit is issued(See. MICROFILM 3097,Civ.Ca. HEATING UNIT(TO 100,000 B.T.U:) 4.00 Lender's Nome I HEATING UN IT(OVER 100,000 B.T.U.)7.50 ,ELECTRIC Lender's oda cc I certify that 1 ha' r ad thisapphc t and -t t that t1 'above VENTILATION FAN (SINGLE) 3.00 pec information n correct 1 agree to comply with all coy and Donny PLUMBING �y e oNmances and state I el tnb to bulling construction, and BOILER-COMPI3 H.P.or 100,000 B.T.U.) 4.00 `1 d'- f� hereby authoriie r p u tat s of the, city to coorupon the BOILER-COMP (Over 100,000 BTUI SEE FEE SCH. MECHANICAL I� 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 CONST.TAX may in any way accrue against said City in consequent, of the PERMIT ISSUANCE 3.00 - gnnlingofthisPennli. '' MECH.CONT. LIG NO. MECH. _�i�//o��t� 7 ^•ZY P� �J DTA TOTAL Signature of Applicant/Contrag r ' Uate OFFICE COPY OFFICE f - CITY OF CUPERTINO COPY GAS SERVICE NOTICE 19 9 3 To You are hereby authorized to connect the GAS service for I Owner or Tenant �w ^ —• ' �� �'Y7 I • At /n Al9 I — _� New Service No. of Meters Reconnect No. of Add. Meters Move Service Move Meter PLUMBING INSPECTOR OFFICE CITY OF CUPERTINO COPY GAS SERVICE NOTICE 4nQ , 19 8 � fi To You are hereby authorized to connect the GAS service for Owner or Tenant rJD-�✓t_� v �1.r�.,..., .,� :i At New Service No. of Meters Reconnect { No. of Add. Meters { Move Service - Move Meter, PLUMBING INSPECTOR I _.