3568 (2) 20689-96 CELESTE CR
3568
F
DE ANZA PROPERTIES
SCANNED BOX # 783
CERTIFICATE OF COMPLETION
BUILDING INSPECTOR'S OFFICE
CITY OF CUPERTINO S 6
DATE.S. a��• 19._. BLDG. PERMIT NO.
O
THE BLDG. LOCATED AT 2. 0 689-7 6 c /P.cTP CIU •
�n ol -Y,�I
OWNED BY U1 P �- In Ld /�j � / n
HAS BEEN COAABLETEDDFOR USE AS g U IA I
(ALTERED)
Ca lti
•
B ILDING INSPECTOR
•
. -> S .: CITY OF CUPERTLNO INSPECTIOt! RECORD (Office_Copy) J 0
3568 Lot 4, Bldg. 6 20689 - 96 Celeste Circle
011100 rEPd1IT NO. SANITARY DIST. NO. LOT NO. ADDRESS --
Const. 8 Units DeAnza Properties '
PROJECT OWNER JOB SITE PHONE NO.
PERMIT ISSUED Date ELECTRICAL
But]ding _ 5/]]/83 Date Insp.
Electrical Power Pole
Plumbing Underground
Mechanical Rough Wiring 9-17.. 8 I-
TGas/Elect. IJal-1s
Solar . Ceiling.
Fire Sprinkler ' Fixtures Int/Ext
Sign Motors
Grounding . _
Misc. Temp. Power
Other
FINAL INSPECTIONS Not Approved
Date I . p.
r,;78 /?19-$ PLUMBING
Electric 'j 1-C
Plumbing 4-2-My Date Insp.
Backflow
Mechanical /a- - Underground
Solar Underfloor
Pool Partial Rough D— 5- T" �„.
• Grading Rough Complete i6-Pa?-8c( 17
Planning Solar Rough _
Fire Dept. SP Ors ec.D Water & Insulation
health Dept. Main Drain S/t-Yf F_`yi;
Building l ^7— 1- at. R/of/S Drain
Other Gas ).- -A"
Other -.
BUILDING Not A. roved
Date Insp.
Pad Certification
MECHANICAL
FoundationOttc44-R J Y+kY� Date Insp.
Pr i �fl �'l 3-ri (.Q Underfloor S.M.
Slab-Membrane Ducts & Insulation y -.
Bond Beam Fire Dampers
l �
Underfloor Girders 6-74 �v` -S
Fireplace f ' -"y 7E
Floor Steel Grease Duct & Hood
Tiedowns One Hour Shaft
Diaphram pt ,Thadc /0-1-kr Condensate Drain
Seismic Bracing Equipment Anchorage
Walls-Panels Flues & Comb. Air —
Frame 1 p-42.-4W4 Other
Lath
11- 24 cz31.1 Not Approved
Wallboards Int/Ext. (/ d
FirewallsciA irrRya toy ear c-dr.
Other .
Not Approved
f �5 �e , z _/
611 _. .
J CGv�GL
(lCew
` .w
tfi
•
p
BUILDING
• I
S �_q)
e
ELECTRICAL
PLUMBING
•-
MECHANICAL
MISCELLANEOUS
APPLICANT TO FILL IN INFORMATION. ITHIN RED,LINES - USE BALL POINT PEN'ONLY
{ ;•,� -BUI LD,I NG PROJECT•I DENTI FICATIO r� f V' - FERN ER
ADgggILDING rel-G�ATION & PERMIT �,�Q
'Tele?
• $ �j rL'(�/r<j,i/ j-. LDING —ELECTRICAL—PLUMBING'—MECHANICAL U
o NERs 7 .!/I' 7(p licec��c PLAN CHECK VALIDATION
• NAME •'��,{'/('// On. • ELECTRIC PERMIT FEE
CONT qq 0 / _ ..
NAME ^ OUTLETS.-SWITCHES-.RECEP 5.00I7.00
S E L_ tL1C.NO. LIGHTING-FIXTURES 5.00/1.00
-
•
CONTRACTORSADOflE55 APPLIANCES-RESIDENTIAL 4:00
..
PHONE PANELS- - 5.00 - DATE OF APPLICATION
•
ARCHITECT PLAN CHECK FEE
- ' OR - SIGNS 6.00 ����
• ENGI •Q
¢ �4a. SIGNS-TRANS. • , 3:00'
ADDRESS'
NG. - ER IT VALIs- ON '
ADOREss SPECIAL CIRCUIT 5.00 //�� '
•
zip EMP.METER"OR.POLEINS 15.00
��%�
APPLICANTS MOTORS SEE FEE BCH.
ADDRESS'
4 0 ./ , ,Ar __ ./ _ _I_ J17.1 SERVICE CHANGE 10.00 SERVICE CHANGE ' l�,pO
ra
w oro L ENSED CONTRA CORS' ECLARATIO . .//
•
<u W. I hereby affirm'that I am licensed under provisions of,Chapter 9 i - ISSUANCE GATE
1-,„a (commencing with Section:7000)of Division 3 of the Business and SLOG. LECT. PLG. 'MECH.
r D z Prdfesslons Code,and my license is hitting-owe and-effect ❑ Q .s
o_i V,G License Class •L¢:Number
H w. Date Contractor
F.N.b.J
a,,Q a C ' :OWNER-BUILDER DECLARATION BUILDING PERMIT
'Ord° MISC.- REFER TO-ORD I • INFORMATION •
x ; - 1 hereby-affirm that 1 am'exempt from'the Contractors License
VALUATION' �$/FT.
o¢ 'Law for the following reason.(Se 7031 5 Business and Professions
-w�. PERMIT ISSUANCE '6.00o��
3 w'rF Code Any aity:orcounty which requires permit[oconstructalteq -
G a ¢:° 'improve,demolish,or repair any structure,prior to its issuaOce,also ELEC.CONTR. LIC.N0. ELEC. r
w ° requires the applicant for such perms to file signed statement that I TOTAL- PERMIT TO
w;“.,F- La is licedsed(Chapter
9(commencing
to Ing prows ons of the Cont visj n 3 icenseof the - - meg' -�1
¢ Business andProfessions Cod)wIth orshall heis p0002mpof Dtheafromransd QTY. PLUMBING PERMIT FEE y/ALB/fler /11'
E IA
,aI- 0 the basis teethe alleged exemption Any vuolation,of Sectiom703 L5• STORIES TYPE CONSTR.
u 3 m by any applicant fora pemtit subje is theapplicant to civil penalty
of not more than five hundreddollars(5500).): ALTER-DRAIN.B:IVENT-WATER (EA./'400 a cr40
0 I,as-owner of the property,or my employees with wages as BACK FLOW PROTECT:DEVICE
their sole compensatian,.will-do the work,and the structure is not 2.00 • OCC.GROUP RES:UNITS-
• .intended or offered for sale (Sec.7044, Business'and Professions DRAINS-FLOOR,•ROOF;AREA,COND. 4:00 T—/ r
Code-The Contractors License Law does not apply to an owner of - V
,property who bands or improves thereon.and who dues such work FIXTURES-PER TRAP 4.00 - so.-FT.FLOOR REA TOTAL-ACREAGE•
himself or,through his own employees provided that such improveEN
-
ments are not intended or offered for sale:It however,the building GAS:EA.BYSTEM-1 INC.4 OUTLETS 4.00 4/,A /d/ �� .
•_ or improvement Is sold within one year of completion.the owner- (// ye:budder will have:the burden of proving that he did notbuild orim. GAS-EA.SYSTEM.-oyE9 4 CEA./ '1.00 BUILDING USE
provq for-purpose of sale.0 - INDUSTRIAL-WASTE INTER.. REr-s�� ❑ ❑,PEI• Other❑
Y.C,I as owner of the property,um exclusively contracting with - 20.00 I(7 LJ
Ilfen_sed:contractor&to construct the project ISec 7044,Business LAWN SPRINKLERS-1 INC 5 ViB. 5.00. ASSESSORS PARCEL NO.
.and Professions Code The Contractors License Law does not apply
to-an-owner of:property who:builds or improves thereon and who LAWN SPRINKLERS-OVER 5(EA,) -7.00 Sad-es-4e '
eontractsfor such projects with a contractonsl licensed pursuant to
the C�on•.taractor's Lie- se L w. SEWER-SANITARY-STORM EA.200ft/8.00 TRACT N . PA CEL NO.
re❑soA 1me empt JLer,S a 7°�f B. P.C. rlhis WATER HEATER W/VENT 4,00
•
Dare 1 `\ r�rs WATER.SYSTEM +�� •
4.00 ACC.DATE ACC NO.
WORKERS' •COMPENSATION DECLARATION- WATER TREATING EQUIP. 4:00 �..........., 4,..... ---
- Iuhereby affirm that I have a certificate or consent to se1P-insure. • .
or:a certificate of Workers'Compensation_Insurance,or i certified �NING
1tENG:SITE NO:
- _E
copy thereof(Sec.3800,Lab.C.). . U s/1 . ' v �1
Policy'No. Company /I r tTy♦: I
O ❑ Certified copy is hereby furnished. FIRE SPRINK ' ENERGY T.24
' Z-Z• ❑ Certified;copy is filed.with- the city inspection division. . .
FO Applicant MISC. REFER TO ORD: - ,fir N� AT No
CCN CERTIFICATE OF EXEMPTIONIFROM WORKERS' PERMIT ISSUANCE 6.00 FLOOD ZONE `6
UJ "COMPENSATION INSURANCE PLG.CONTR. LIC.NO; . ��,,�
18 (This section need not be completed if the permit is for one. - TOTAL • v❑ IN - Jg.
- 2 hundred dollars(5100).or less.) - -
1 certify Chapin the performance of the work for which—this per- pTV MECHANICAL PERMIT FEE FEE SUMMARY
u f mit is issued.I shall not employ any person hi any manner so as to
0 W became subject to the Workers'Compensation Laws of California. - W498 _
a Date Applicant '•BUILDING
}'w 'NOTICE TO APPLICANT If,after making this Certificate of Ex- ALTER OR ADD TO MECH. 4.00 •
I- Z emption,you'should become subject to the WorkersCompensation APPLIANCE -4:00 PLAN CHECK
'provisions of the Labor Code, you,mull.forthwith comply with
•
C:> such provisions or this permit shall'be deemed revoked: AIR HANDLING UNIT(T010FEE
,000C.F.M.)- 3.00
CONSTRUCTION-LENDING AGENCY AIR HANDLING UNIT(OVER 10p000F.M.) 5.00 - SEISMIC,FEE 94
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(Sec.
3097 CIv.C.). HEATING UNIT(TO 100,000 B.T.U.) 4.00 MICROFILM
• Lenders Name
'Lender's Address' -, ' , HEATING UNIT COVER100;000B:T.U:17:50 . ELECTRIC •
Icrtify;that I have.read this application and state thaiihe above VENTILATION FAN'ISINGLE) 3:00 _
information is cslate .I agree to comply with all city and countyiii
PLUMBING
ordinances and state laws relating to isbuilding iyconstruction,and BOILER-COMP(3 H.P.Or 100,0008.T.U:) 4:00
hereby authorize representatives of thus city to enter upon the
above mentioned properly for inspection purposes. BOILER-COMPIOverI DD,0008TU1 SEE FEE SCH. MECHANICAL
(We) agree toosave; indemnifyand'keep harmless the'Cityof MISC.- REFER TO ORD.
•
Cupertino against liabilities,judgments,costs and expenses which
may in any-way',cc - 'against said City'in'consequence Of'the PERMIT ISSUANCE- • ' ' 3.00 • CONST.TAX
ting•fthis'pe I:
` 1 MECH_CONT. LIG N0. MECH.-
`sVA► •
6—aal1 1 • TOTAL TOTAL
S'i.. ere of AAPlicantjContractor llaD' //�."�a -'��
•
OFFICE COPY •
I! - APPLICANT TO FILLIN INFORMATION'WITHIN_RED LINES•=USE BALLPOINT PEN ONLY
- BUILD!NG PROJECT I DENTS FICq T, Iq N :PERMIT NUMBER
'BUILDING - til fr APPLICATION & PERMIT
OREss •
' -“i ittgt..ec d,`,.CtA BUILDING-ELECTRICAL-PLUMBING—MECHANICAL
/�✓k•+O wee% _ •
OWNERS - - -. - - ' "- • PLAN CHECK VALIDATION
•
• QTY- • ELECTRICPERMIT FEE
MME
/'j/; P,..61 P. •
fS vxoxe
c •
xrRAcrofls � OUTLETS-SWITCHES'-RECEP 5.00/1.00
N ME
-IA r, r F/-
•.LIeNO7d
- y- RLIGHTING'FIXTURES 5.00/1.00 ,
CONTRACTOR'S •
• PPLIANCES-RESIDENTIAL 4.00
ARCHITdaeECT
4/Jve earioNE 37S� J/C.- PANELS ' • 5.00 ' DATE OF APPLICATION
ARCHITECT ^'lam/ i PLAN CHECK,FEE
.OR •SIGNS 6.00
ENGINEER •
LIC.NO. SIGNS TRANS.
ARCH.eR ENG.'r , PERMIT VALIDATION
ADDRESS ' SPECIAL CIRCUIT '5:00
ZIP , TEMP.METER:OR-POLE-INS. 15.00 (
APPLICANTS - MOTORS SEFEE SCH. 4.A .5-
ADDRESS'
- SERVICE CHANGE - • 10.00 ' ``�/
tw o o LICENSED CONTRACTORS DECLARATION - 7/�3/ - T
<u u I hereby affirm that I-amlicensed under provisions of Chapter 9 • ISSUANCE DATE
1,7,,1a A g-wi
�"' (commencin th Section 70007of, on'Divisi3 of the Business and
BLDG: ELECT, PLG. 'MECH.
Professions COr-in tilicense is in full fo epn ff�c
0 0 gii- Liccn Cla sk--L y Lic.Number/•6 -4�� 0 D.
ip
Z`I-in-w Date /� 'C=fi 9--'Contractor a,y„ • _ I+(-'
err _, . - BUILDING PERMIT
re' < OWNER-BUILDER DECLARATION INFORMATION, '
F.w 3` w I herebyaffirm that I am'exempt from the Contractor's License MISC.- REFER TO ORD
a.oa Law for;the following reason.(Sec.7031.5;Business and Professions PERMIT ISSUANCE VALUATION SIFT..
Fm'r.- Code:Any city or county which requires a permit to construct.alter. 6-�
us cc 0 a0 improve,demolish or repair any structure,prior to its issuance,-also ELEC.CONTR, . LIC:NO: ELEC. •
'0 u requires the applicant for.such permit to file a signed statement.that TOTAL' PERMIT T
w''5 y he is licensed pursuant to she provisions of the Contractor sLicense - •
�i.> La (Chapter9(commencing with Sect ion 7000)of Division l of the ` - ,
s s.'a ss
Busin 'and,Profes lone Code)or that iseicmpt therefrom and QTY, • •P_LUMBING'P.ERMIT 'FEE '
w s a the basis for the alleged ciempt ion.Any violation of Section 7031.5 1 _• STORIES TYPE CONSTR.
Ag'0 by any applicant for a permit subjects the applicant to a civil penalty
of not.morc,than Ove hundred dollars(5500).): ALTER-DRAIN -WATER (EA.1'.4.00 •
•
❑^I;as owner of thc'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 sale (Sec. 7044, Business and Professions DRAINS-FLOOR,ROOF,AR EA,COND. 4.00
Code:The.Contractor's License Law does not apply to an owner of - - r .
• property.who'builds or improves thereon,and who does such work FIXTURES-PER TRAP 4.00 '50,FT:FLOOR AREA TOTAL ACREAGE
• himself Or through his own employees,provided that such improve.
ments are.dot intended or (fered for sale.IL however„the building GAS-EA.SYSTEM-1 INC.4 OUTLETS 4.00
or Improvement G sold within'onc year of complelion.;the owner- GAS-'EA:SYSTEM-OVER 4.(EA.) 1,00 'BUILDING USE
budder will have the burden of proving that he did not build or im-
prove for purpose ofsaid.). - • INDUSTRIAL WASTE INTER. 2000 ' ,RES IND CON PB Other
❑ I,as owner of the property,am-exclusively contracting with ❑ ❑ ' ❑ ❑ ❑
licensed contractors toconstruct the project(Sec.7044,Business LAWN SPRINKLERS-'1 INC 5 V.B. .5.00 1 ASSESSORS PARCEL NO.
and Professions Code:The Contractor's License Law does not apply
to an owner of property,who builds or ibsproves thereon:and who LAWN SPRINKLERS-OVER'5(EA.) 1.00 '
contracts for such projects wills a contractods)licensed pursuant to - -
theContractor's•LicenseLaw. ' - SEWER-SANITARY-STORM EA.200ft/8.00 TRACT NO: PARCEL NO.
reas
am exempt under Sec. ,B.&P.C.forthis
. WATER HEATER W/VENT - 4.00
Owner _ Date WATER SYSTEM 4.00 ' ACC.DATE • ACC.FILE NO. •
. !WORKERS'COMPENSATION DECLARATION ' WATERTR EATING,EQUIP. • . '
'I nereby:aflirm that.l have a certificate of consent to self-insure, '
'or acertificate of.Workera'Compensation Insurance.ora certified 52/1, ZONING ' ENG.SITE NO.
' copy thereot,(Sec.3800.Lab.C-1. `[/ L - • •
Policy No. Company k^4 Lor - /1.-Z457,-' , -
(� ,Lj, Certified copy is hercbydurnished FIRE SPRINK' ENERGY T.24
Z Z . erbfi���gqq,4____�����n���pY� pyyy led with 'the city inspection.division.
F,O Applicant / 440 . MISC.- REFER TO ORD. y❑ N'❑ v ❑ N❑
cr W • •
CERTIFICATE OF EXEMPTION FROM WORKERS' PERMITiSSUANCE 6.00 FLOOD ZONE . 'A:b.U.0 . '
W'› COMPENSATION INSURANCE PLO.CONTR. sec.NO. PLC.
d O IThis,seetion'need not be completed•if the permit is for one TOTAL Y❑, N❑ Y 0 NO
•V.ZZ hundred dollars($100)or less.)
I certify that,in the performance of the work.for which this per- an' MECHANICAL PERMIT FEE FEE SUMMARY
LL U mit is;issued„Cxhall notemploy any person in any manner so as to ,,
become subject to the Workers'Compensation Laws of California.
17a ill Date Applicant ALTER OR ADD TO'MECH.PAID. 4.00 BUILDING -
} N NOTICE TO,APPLICANT: If•.after making this Certificate,of Es-
Z emption,you should'become subject to.the Workers Compensation APPLIANCE. lit PLAN CHECK.
provisions of the Labor Code, you must forthwith comply with JJ,, .
U such provisions or this permit shall be deemed revoked: AIR HANDLING UNIT ITE78 gFQA,I964O .-FEE ,
CONSTRUCTION LENDING AGENCY AIR HANDLINGUNIT(OV/DR 1�00000CF-M-) 5.00 .'SEISMIC FEE
I hereby affinu Mat there in.construction lending agency for • 'EXHAUST HOOD(WITO&U&CUnertia6D /t'` . ..
the.perfonnance of-the:work for which this permit is issued(Sec. - ' MICROFILM
3097,Civ.C.). ” HEATING UNIT(TO 100,000 B,T.U.) 4.00 32_
• Lender's Name -
LcnderiAddress ” • HEATING UNIT(OVER 100,000B.T.U.)7.50• .ELECTRIC ,
I certify Mkt.'have read this application and state that the above ,'W VENTILATION FAN(SINGLE) • ' - ;3.00 it�.-
. information is unreel:1 agree to comply with all city knd_county PLUMBING.
ordmanLes and slate.laws relating to building construction;and BOlLt3i-OOWP I3 H.P.or 100,000 B.T.U:1 4-00 s
•
hereby aulhorrtt representatives of this city to enter upon the ,BOILER-COMP(Over 100,000 BTU)SEE FEE SCH.
bove-mentioned property far inspection purposes. :MECHANICAL 7��
(We)Agree to save, indemnify and keep harmless the City of •MISC.- _ REFER TO ORD.
Cupertino,against liabilities,judgments,costs and expenses'-which
may.in any way accrue against said City in consequence of the PERMIT ISSUANCE 300 3 CONST.TAX -
7-#4.ing of this pe i - MECH.CONT. -LIC.NO. MECH.
/�iZ�L s:. ilia )� L3 S • TOTAL e� TOTA• L
Signature of
...S
nt/Contractor Date - 7J
'-OFFICE COPY " -
•
• APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE'BALL POINT PEN ONLY
•BUILDINPROJECTIDENTIFICATION
PERMIT NUMBER - '
G'
BUoBUILDINGBUILDING -r�06(yC `. (f 3c 1LJ„w G • ABPLICATION'.&.PERMIT.
•(9‘13•7• rLQ ies6e_crf•.. BUILDING—ELECTRICAL—PLUMBING-MECHANICAL 5 7 9 6
OWNER'Sa° . PLAN CHECK VALIDATION
O4(XCj OTY. ELECTRIC PERMIT FEE
fli
-0HONE
NwME ' -T- '- �� /�q OUTLETS-SWITCHES'-.RECEP 5.00/1.00 ,
bC'/TZ9 thied,4Ef'LIc;Noo2crO 1 . LIGHTING FIXTURES • 5.00/1.00
CONTRACTOR'S APPLIANCES-RESIDENTIAL 4.00 '
ADDRESS P-.�-
RcL°.../07139,A�o-1 IMHONE GI. 2 2/` 7 - PANELS - 5.00 DATE OF'APPLICATION
ARCHITECT
N _ `� /. SIGNS ,6•�. PLAN CHECK FEE P.C.NO.
'ENGINEER
uc.No. SIGNS TRANS. • 3.00 ,
ADDREOR SS ENc. - ' SPECIAL CIRCUIT '5.00 :PERMIT VALIDATION
.zm ,•
TEMP.METER OR POLE.INS. 15.00'
'APPLICANT'S MOTORS SEE FEE SCH.
SERVICE CHANGE 10.00 •
( p'Q���J
+ w•boa LICENSED CONTRACTORS DECLARATION . 7 e/�-'y
•
a,u I hereby affirm that Iain licensed under provisions of Chapter 9, ISSU NCE DATE
(commencing with Section 7000)of Division:,3 of the Business and. •
BLDG.. ELECT. PLG.' MECH.r. al.
0 0 L ecru ash Lm.Number •-
o N L 5' Date 'p `j- -Contrzaor /lrf`ZTr7!/ ,,i�P •
z ex OWNER:BUILDER DECLARATION r, BUILDING PERMIT
- oa°' - - - INFORMATION
x ;..it.. I hereby affirm that 1 am exempt from'the Contractor's License MISC. REFER TO ORD
'o to j' -Law for the following reason.(S c 7031.5.Business and Professions VALUATION I S/FT.
E-- PERMIT ISSUANCE - 6;00
Code Any city or countywhich requirese permit construct.-alter. '
2 ww¢Q
improve de applic,or repair any SINUUre,prior tO its atommice.also
ELEC.CONTR. LIC:NO. - !ELEC. '
y O- requires licensed
pursuant
for such permit.to file a signed statement that TOTAL
- K 8 he is licensed pursuant to the provisions of the Contractors License PERMIT TO
-,o Business atdrProl'esions Code)with
or that he is e0)of Division!xempt therefromfand OTY. PLUMBING PERMIT FEE •
in
PaLGI/�y$iNC-
et P'$ the basis for the alleged exemption.Any violation of Section 70315' - STORIES TYPE CONSTR.
i,; _ by any applicant furs permit subjects the applicant tovcivil penalty ALTER-DRAIN 4.00 •
arm'moMthan five hundred Collars(SSOD),K .
0 I,as owner of the,propert;or my employees with wages as- BACK FLOW PROTECT.DEVICE -
Ihcirsole compensation,will do the work,and the.structure IS not - 2-� .00C.GROUP RES:UNITS
intended or offered for sale (Sec” 7044, Business and Professions SC DRAINS-FLOOR;ROOF,'AR EA,COND. 4100A0144.--.. -
• Code:The Contractor's License Law does not apply to an owner of
property wor
ho builds or improves thereon,and,who does such-wk. FLOOR' FIXTURES-;PER TRAP 4.00 SG.FT. AREA TOTAL ACREAGE
himself or through his own employees,provided that such improve-
.; mens are not intended or offered for sale.If;.however,the building / GAS EA.SYSTEM-l1 INC:4 OUTLETS 4.00
or improvement is sold within one year of completion,the owner •
•
budder will.have the burden of proving that he did not build or.im: GAS-EA.SYSTEM'-OVEfA1.00 " BUILDING USE
• prove for purpose ofselea. INDUSTRIAL WASTE INTE � RES IND' CON'. . PB ' Other
01.I.as owner of the property am exclusively contracting with 20.00 0 , U ❑ ,. U O
licensed contractorsto construct the.project(Sec 7044.-Business LAWN SPRINKLERS- 1 C V.B.it �nowoo . " . ASSESSORS PARCEL NO.
- and Professions Code'The Contractors License Law does not apply
fS1 4
to an•owner of property who builds Or improves thereon,and who - LAWN SPRINKLERS (EA, 1.00
coniructsfor such'Pmlects with a•contranolls)licensed pursuant to -
theContractor's License Law. - r SEWER-SANITARY-ST/TM EA 2001/8.00 4— TRACT NO. PARCEL NO.
❑ I am exempt under sok ,B.&P.C.for, I WATER HEATER W/V1_IWf of tivertifp00 —
Owner •
Date / WATER SYSTEM •• '.4.00 a/74ACC.DATE •ACC.FILE NO.
, WORKERS'COMPENSATION'DECLARATION WATER TREATING EQUIP.. , 4.00 .
•
I hereby affirm that I have a certificate of consent to self-insure, • . - ' .
•
or a certificate of Workers Compunsation,lnsuranee,or certified' - - ZONING ENG.SITE NO.
copy(hereof(Sec 3800.Lab.CJ ./. �✓1 s .f.Y /I".L[/-7 i •
• Policy No. - Company /in/10u/- //$,J/�('{?�'� Lr 1-Y / -D i/ '• .
0 ❑ Certified copy is hereby furnished. ',./ !' b Y�v 636
' Z Z' ❑ Cerlifi�• opypp filed'with th• c'y inspe 'on division.. - FIRE SPRINK ENERGY T-24
O Applicant / 1l1 Z/�� n[/.� MISC-- . 'REFER TO ORD. • Y Q'• `N� Y ❑, No
0= 12 CERTIFICATE OF EXEMPTION FROM WOR FRA'� . PERMIT'ISSUANCE - ' • '6.00 G' FLOOD ZONE ,A.LU.0
W ' COMPENSATION INSURANCE PLG,CONTR. LIC.NO,. PLG. , -
0_ C (This.section need not be completed if the permit is for one . - _ - .. TOTAL ( -Y❑ .. N Y D. N❑'
D Z hundred Joliet-v(5 100)or less.)' '
V O 1 ttrtJy,that.m thq performance oLlhe work for which This per QTV FEE'SUMMARY '
LL.0 mit Ise ued,.t shall not employ any•parson in a of California.r so as to MECHANICAL PERMIT' FEE _ •
O.W become subject to the Workers'Compensation Laws of Ca .,
D, 'Date ' Applicant ' ALTER'OR-ADD TO:MECH. q;00 BUILDING
} to NOTICE TO APPLICANT: Wafter making this Certificate'of Ea-
f.7,Z :emption,You should become subject La the Workers'Compensation - APPLIANCE '4.00 _ PLAN.CHECK
provisions of.Else-Labor.Code, you'must.forthwith comply'with
Li such provisions or this permit shall be deemed revoked.. AIR HANDLING UNIT(TO'10p60C.F:M) 3.00 FEE •
•
•
CONSTRUCTION LENDING AGENCY AIR HANDLWGUNRIOVER 10p00C,FM) 5.00' SEISMIC FEE
I hereby:affirm that Biere'is a construction lending agency for EXHAUST HOOD-(WITH.DUCT) • ,2.00 '- - •
the performance of,the:work:forrwhich this permit is.issued(Sec. •
3097:Ci¢C).' ' - '.HEATING UNIT(TO 100,000 B.T.U.) 4.00 MICROFILM.
lender's Name
Lcnder'sAddress HEATING UNIT(OVER 100,000B,T-Ui)7,50 ' ELECTRIC '
I c rtify'that.!hive read this appl tion and stat that the above VENTILATION-FAN (SINGLE) . 3,00 . •
. m
1 information is correct:I agate to comply with-all city and county. - PLUMBING p2 ' ,
ordinances and state laws relating to building construction, and BOILH76 CONiP(3 H.P.or 100,000 B.T.U.) 4.00
hereby authorize representatives of this city to enter upon the
i above-mentioned propegyfor inspection-purposes, BOILER-COMP(Over 1®,000 BTU(SEE.FEE SCH: .
'MECHANICAL
- (We).agree to save, ties-the.pe ;costs and expenses which ••
may in any w keno against said-City in consequence of the PERMIT ISSUANCE . 3.00 - • CONST(TAX '
Blmg�t(Ihi crtnil. /rte �• MECH.CONT. LIC NO. MECH. s -
////1 p. �O' '� • • TOTAL TOTAL
, Signature Applicant/ ontractor Date •
I. -
OFFICE'COPS' - .. r.
APPLICANT:TO FILL IN INFORMATION WITHIN RED LINES -7 USE BALL POINT PEN ONLY ' .
BUI LDI NG PROJECT I DENTI FICATION PERMIr.NUMBER`
BUILDING• - -APPLICATION &"PERMIT ��� 0
' ,- -ADDRESS ,. .
7-0(0.S1 .� 144., c-r\ BUILDING-ELECTRICAL-PLUMBING-MECHANICAL
. OWNER'S (iP� • - ' PLAN CHECK VALIDATION
NAME fI�Y� • .72.-Ce-Lig LA-)an'. ELECTRIC PERMIT FEE PA N
• CONTRACTOR'S •UTLETS-'SWITCHES-RECEP 5.00/1.00 Lb
N •
AME
� 11 7 1 G.I UZ4)313 •
Rest- ilei-Ari" 1 Lic.No. LIGHTING FIXTURES , 5.00/1.00 �j — - AUG E� 7 1984'
CONTRACTOR'S PPLIANCES-RESIDENTIAL 4.00 g —
1
ADDRESS '
• 24'7Za4U c� /�}t�
Zycl (Y1�C17p�1 .S� aHoxE PANELS 5.00 d !' DX�Yop�i(6LIB
ARCHITECT , / PIAN CHECK FEE .I P C.NO. •
OR SIGNS' 6.00 '
'ENGINEER - '
uo.ND. SIGNS TRANS: • 3:00
• exame a ENG. •
SPECIAL CIRCUIT _ 5.00 PERMIT.VALIDATION
•
• ZIP EMP.METER OR POLE INS. .• 15.00 • '
•
'APPLICANT'S V.
MOTORS SEE FEE 0.00 ��) bl/Pil ADD«ess ` '
Z q ML px c.+ -.sxn Loci SERVICE CHANGE 10.00
IO.ts LICENSED CONTRACTORS DECLARATION
<u E thereby affiml that I am licensed under provisions of Chapter 9 , . . . • ISSUANCE DATE
I-2 i (commencing with Section 7000)of Division-3 of he Business and '-
I-D z Professions Cods and license is in Tull forgeand'effcd BLDG. E E T. PLG: MECH.
r o e- License Class C 1 Lie Number'2(0 I-j I . •
- 0
O I-m Date' ¢-' ommclor 0.
. .
•
ixx 5 _b.. -
2 m a OWNER-BUILDER DECLARATION B ILDINO'P ION
O Ay ORD' INFORMATION
'x g N.. •
. I hereby affirm that am exempt from the.Contractors License • REFER TO -
F!uy J Law for the following reason.(Sec.7031.5,Business and Professions PERMIT ISSUANCE 600 'VALUATION S/FT.
-,a.� -, Code:Any city.or county which requires a permit construct,alter. -
2¢ a O, improve,demolish,or repair any structure,prior to its issuance,also ELEC.CONTR. LIC.NO. ELEC. 5.t..,
'A OLL. requires the applicant for to file.a signed statement that ,1, q/er e1PZfe/cz3 TOTAL JL P RMIT TO
•
w,B ' he Is heartier(pursoant to the provrsions of the Contractor's Licen ` L // J=.
• z_a, BusiLawness(Chapter
Prof cions Cod)-o Shat he iseexxemptt theiefromfand QTY. . PLUMBING PERMIT ' FEE.
a _'$ :the basis for the alleged exem tion.Anyviolation of Section 7031:5
g P STORIES TYPE CONSTR.
s ; by' any applicant for a permit subjects the applicant to civil penalty'
- ofnotmore than fivehundreddollars(55001.11 ALTER-DRAIN&VENT-WATER'IEA.14.00
• 0 L 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 sale•(Sec.I7044, Business and Professions DRAINS-FLOOR,ROOF,-AREA,CONDI'4.00
Code:-The Contractor's LIcense'Law.does not apply to an owner oft
properly who builds or improves thereon,and who does such work FIXTURES,.PER TRAP . ' - 4'-00 SO.FT.PLODR AREA TOTAL ACREAGE
himself or through his own employees,provided that such improve-
mentsarenotintendedoroffered forsale.If,however,the building
GAS-EA.SYSTEM-1 INC:4 OUTLETS 4.00
or improvement is sold'wiltiin•ane•year of completion.the owner-
budder will have the burden of proving that he did not build or im- GAS n EA.SYSTEM::OVER 4 MAI 1:00 BUILDING USE
provo for purpose of sale.). INDUSTRIAL WASTE INTER. 20:00 E IND" CON Pe Other
❑ I.as owner of the'property e
am exclusively contracting with. 0 0 0 ❑
licensed contractors to construes the project I Sec. 7044.Business LAWN SPRINKLERS-1 INC 5.V.8. 5.00 - ASSESSORS PARCEL NO.
and Professions Code:The Contractor's LicenseLaw does not apply
to an oner ofpoperty whobuilds or improves thereon,and,who LAWN SPRINKLERS-OVER5(EA.) 1.00 `
ontructs for such projects with a Lontractof sl licensed pursuant to -
•• theContrador'sLicenseiuw. SEWER-SANITARY-STORM EA.200ft/6.00 TRACT NO: PARCEL NO,
• ❑ I am exempt under Sec. ,B.&P.C.'.for this WATER HEATER W/VENT 4.00 -
reason - . . -
Owner • Date WATER SYSTEM 4.00 . ACC.DATE ACC_,FILE NO.
WORKERS'COMPENSATION DECLARATION WATER TREATING.EQUIP. 4.00.
I.hereby affirm that I'have acertilicate of consent to self-insure,
or a certificate of Workers'Compensation Insurance.or a certified - ZONING_ - '
• p �� ENG.SITE NO.
Popy thereof(See.3800.CoLany '/V 94.& -z�
Policy No. Company (T J - -
(]
0 Certified copy is hereby furnished. - _ .FIRE SPRINK ENERGY T-Za
Z Z ❑' Certified'''��`oeeey s �ded with the city inspection division. -
FO Applicant•S�e-f�y/ MISC-- • - ' REFER TO'ORD. Y N0 y0 40
CL CO . - CERTIFICATE OF EXEMPTION FROM WORKERS' PERMITISSUANCE•
6:00 FLOOD ZONE
W . COMPENSATION INSURANCE PLG.CONTR. LIC.NO. PLO
a O 0
(This section need not be completed-if'the permit is.for one• . TOTAL ' V p Np 'V O! ry
'V ZO hundred dollars($100)or less.)
I certify that in the:performan a of thework for which this per- Q•'Y MECHANICAL PERMIT FEE FEE'SUMMARY
ly, U mit s issued L.shall not employ any person in any manner so as to
f..W become subject to the Workers'Compensation Laws of California. ,
d •Date Applicant ALTER OR ADD TO.MECH. BUILDING •
)—o, NOTICE TO APPLICANT: If,after making this Certificate of Es- ' .4.00 ..
1—.Z emption„you shouid'become subject.to the Workers'Compensation APPLIANCE. 4.00 PLAN!CHECK
.provisions of the'Labor Code, you,must forthwith comply with
U such provisions or this permit shall be deemed-revoked. AIR HANDLING UNIT ITO 10,000C.F,MI': ,3.00 ' FEE
• - CONSTRUCTION'-ENDING AGENCY _ . - AIR HANDLING UNIT(OVER 1 )300C.FM) 5.00 ' SEISMIC FEE
hereby I hehy.affirm that there is a-construction lending agency for EXHAUST HOOD(WITH DU-CT I'. 2.00. '
- the performance of.the for which this permit is issued(Sec. . -
3097;Civ.C.). HEATINO,UNIT(TO 100,000 B.T:U.) 4.00
Name
- MICROFILM
Lender's Nae •
' Lender's Address _ • - HEATING UNIT(OVER 100,000B.T.U.17:50 ELECTRIC . ge ,
I certify that I have read this application and state tharthe above VENTILATION FAN'ISINGL'EI- • 3.00 —
•
information is correct.I agree to comply with-all city and county — PLUMBING -
ordinances and slate laws relating to•building construction,and BOILER,,-COMP(3 H.P.or 100,000 B.T:U.) 4.00 -
•
hereby authorize representatives of this city to enter upon the .
above-mentioned property for inspection,purpoNx, BOILER-COMP'IOser/110,WOBTUI SEE PEESCH. .MECHANICAL
•
(We) agree to save, indemnify and.keep-harmless the City of. MISC.- ' REFER,TO ORD.
• Cupertino against liabilities,judgments,vests and expenses which - CONST:TAX
may in-anyway•accrue 'nst said City in consequence of the' PERMIT-ISSUANCE 3.00 •
ting Of ilio permit.
MECH.CONT. LIC.-NO., MECH.
. . bf2G `t(' �i4'—Date ITorAL TOTAL sa
azure of Applicant/Contractor Contractor -
_
- . OFFICE COPY
- . 'APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY-
BUILDINGPROJECTIDENTIFICATION PERMIT NUMBER
BUILDING APPLICATION & PERMIT • -
ADDRESS ff� • 1
Z('Lf�c�O (..�1..��-1/4-,{ G4C+r �, BUIL'DING.-ELECTRICAL-PLUMBING-MECHANICAL 557 1
OWNER'S . _ --- PLAN CHECK VALIDATION
�rN'�AME `j '�I-/IIOTY. .ELECTRIC PERMIT FEE. .
. WNT an
Z/A _ �rO� PHONE. �c��
RACTOWS 1 IJ �p/AID
NAME' el Cud 131 OUTLETS.-SWITCHES-RECEP .5.00/1 00 '�„ L'AlV -
72,.0q4 2- ,-,--4-)Ire,,J LIC.NO. LIGHTING FIXTURES 5.00/1.00 ' ( ' • p '
CONTRACTOR'S - APPLIANCES-RESIDENTIAL . 4.00 AUG /,,, 1984
�A1DDrRE/S•S: }-� •" r7-2CjZ/I_ f^
2 CLIC mc�nlfl,�I s1 PHONE�G / �,CL-- PANELS 2 - 5,00.
/ .. 5.--- PkaEµDgAHTE�OEFrA�PPrL.IrCAATION
ARCHITECT, - • SIGNS - 6.00 . C14J'y1'Vrarre,.IEEO P.C.NO;
'ENGINEER ' •
• LIC.I NO. SIGNS TRANS-. • 3.00 - • '
4AODRE55 ENO. •
:,SPECIAL.CIRCUIT 5.00 PERMIT�VALIOATION.
_ ZIP TEMP.METER'OR-POLE'INS.. .15.00 I dl
.APPLICANT'S / ,VLU//1
ADDRESS r MOTORS lie �. 'SEE FEE SCH: �7 .4 U - ` 11/,a/
�'�� 1 ' rC FiIJl�x ,�1 � cun-J SERVICE CHANGE 10.00. �(
w o0 LICENSED CONTRACTORS DECLARATION . .
•
u w Thereby affirm.that Lam licensed under provisions of Chapter.9 •
2/w (commencing w th Section 7000)of Diviiion 3 of the Business and - • ISSUANCE DATE
a-o Professions Code,and license is in full fort Aqnnd effect.- r BLDG., EL T. PIG. MECH.
z o LiCCBSC lass Lie.Number huts
f 15 / -• - -
o zr.•o Date Contractor
w•a OWNER-BUILDER DECLARATION -. •
B LDING PERMIT
°n oMISC.- REFER''TO ORD > INFORMATION
x:a.is.O. Thereby affirm that I am,exempl from.the Contractor's License - VALUATION S/FT.
H O. La for the following reason..(See.1031.5;Business and Profeisions �� -
-'._ Code:Any - PERMIT ISSUANCE 8.00 -
F i s' mulor-county which srionse permit to issuanee.a (7
a O. I nprove demolish.or repair any structure:prior to its Issuance,also ELEC.CONTR:' LIC.NO. ELEC. '
W°LL regWtt-theapphcanlfor such permit 10'fIhasgned sldlemenithat Br -) G./t` CIOz/_/-ar�,�TOTAL , S� ERMIT TO
m he rs licensed pursuant i0'Ine provisions of Ire Contractor sLmense 5/ /- t-W r ?'
•
th
E -2 a Business-andrProfessions Code)lor that)on he is exempt therefromrand QTY. PLUMBING PERMIT' FEE
•
¢ I1- 0 the-basis for the alleged exemption.Any violation of Section 7031;5' STORIES TYPE CONSTR.
- i ;'m' by any applicant fora permit subjects the applicant to chill penallyI
of not more than five hundred dollars(S500).): ALTER-DRAIN&VENT-WATER(EA.) •
4.00 "
. ' ,El.I,as owner of the property or my employees with.wages as BACK',F LOW PROTECT:DEVICE 2.00 .00C.GROUP • RES.UNITS
their Sole.compens.tion,will do the work,and the structure is not •
intended or offered.for sale(Sec.7044. Business and Professions DRAINS-FLOOR,.ROOF,-AR EA,COND. 4.00 '
Code:The-Contractor's License Law does nofapply to an owner,of. - -
property who builds or improves thereon.and who doer;itch work - FIXTURES n-PER TRAP - ' 4:00 50.FT.FLOOR AREA -TOTAL ACREAGE
himself orlhrough Asir own employees provided that such improve-
mentsarenotintendedoroffend for sale.If;however,the building GAS-EA.SYSTEM-1 INC.4 OUTLETS 4.00
_. or improvement is sold within one yearrof.complehon.the owner- GAS-EA.'SVSTEM-OVER 4(EA.) 1,00 •
builder will Mahe the burden of proving afhe did hat build or im- • BUILDING USE
• prove for purpose of sale.). - _ INDUSTRIAL WASTE INTER. IND CON- ''PB - 9ther
❑ I,as owner of the property,ant exclusively contraclingwith. "20.00 O EI O. ❑
• 1¢cnctd contractors to•constru t the project(Ste 7044,Business LAWN SPRINKLERS.-1 INC 5 V.B- 5.00 ' ASSESSORS PARCEL Na
and Professions Code:The Contractors LicenseLaw 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 contmctorts)licensed punnane to
th Contractor's License-Law. SEWER-SANITARY-STORM EA.'200ft/8.00 TRACT NO. PARCEDNO.
• ' ❑ ..I.am exempt under Sec. ,B.&P.C.for this. 4.00
reason WATER HEATER W/VENT
Owner - Date WATER SYSTEM 4.00 ACC:DATE ACC.FILE NO.
WORKERS'.COMPENSATION DECLARATION • WATER TREATING EQUIP. 4.00 , ' .
1 hereby affirm that I have a certificate of consent to sell-insure, -_
or o certificate of Workers'Compensation Ins nee or a certified ZONING' . •.ENG.SITE NO. 'I
copy thereof.Sec 3800,Lab.C.1 I=Y- (� J 1�'},•Z
'Policy No. (_olnpany /a ✓ - • .
O D. Certified copy is hereby furnished. '
Z z ❑ Certife o is•filed with the city inspection division. FIRE SPRINK- ENERGY T-24
'.F O Applicant /- Pyr//J MISC.- - -REFER TO ORD. v D .N D y ND
CC - CERTIFICATE OF EXEMPTION FROM WORKERS'us
PERMIT ISSUANCE 6.00 FLOOD ZONE A.L.U.C.
'W•> COMPENSATION INSURANCE PLG.CONTR. LIC.No. PLG. " _.
1 O (This section need not be completedrif the-permit is for-one I TOTAL •Y❑ N❑ Y O. N❑
U O hundrd'dollars(S 100)or Iasi- - - -
I certify that an the performance of the work fur which,this per. QTV MECHANICAL PERMIT FEE SUMMARY
LL P nut ns Issued.1 shall not employ any person in any mariner so as to FEE
O w become subject to the Workers:Compensationluws of California. ,
O. Date' Applicant _ ALTER OR ADOTO,MECH. 4.00 •. BUILDING
,>-'m NOTICE TO APPLICANT: If;after-making this Certificate-of Ex' .
I-.Z emotion,you should become subject to the Workers'Compensation • APPLIANCE. •
4.00 '
provisions of the Labor Code, you!must forthwith comply with. - PLAN CHECK'
U such provisions or this permit shall be deemed revoked. : AIR HANDLING UNIT(TO 10,000CF.M) .3.00 FEE' - '
' CONSTRUCTION LENDING AGENCY AIR HANDLING UNIT(OVER 10/0O0C.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(Sec.' - . -
3097,Civ.C.). - HEATING UNIT(T0'100,000 B.T.U.)- 4:00 . •
MICROFILM'
Le'nder's Name - A
Lender's Address _ HEATING UNIT(OVER 100,000 B.T.U.)7.50 ELECTRIC g 0
Move(certify that Move read this application and statedhal the above VENTILATION FAN (SINGLE) 3.00 V
40 information is correct.I agree to comply with ull,city and county: BOILER-CONT - PLUMBING ,
ordinances and state laws relating to building conslruction.,hnd I3 H.P.Or 100,000 B.T:U.) 4,00 -
hereby authorize representatives of this city to enter upon the
above-mentioned property forinspection purposes BOILER-COMP(Over'100,000 BTU/SEE FEE H. MECHANICAL
(We)Tftgree to save. Indemnify and keep harmless the City of MISC.- REFER TO-ORD. ' r
Cupertino.against liabilities,judgments, costs and expenses which -
' mays in any way accrue against said City in con equence ofthe PERMIT ISSUANCE • 3.00 CONST.TAX
ails ling of this permit.- • MECH.CONT. LIC.NO.
e
MECH:(
.( •oA_ . RIS, i. --- - Lt. '. TOTAL TOTAL 82
m
09
aruoffApplicant/Contractor Date
- .• OFFICE COPY . - • . . ,
;r. •
APPLICANT TO ALL IN INFORMATION WITHIN RED LINES —USE BALL POINT PEN ONLY'
BUILDING PROJECT'IDENTIFICATION i - PERMIT NUMBER
BUILDING • . APPLICATION & PERMIT -
ADDRESS • ' •
2C={O`� I _ C . e ._!_ ����� 'BUILDING—ELECTRICAL—PLUMBING—MECHANICAL •
OWNER'S -UJA�f 0 . - PLAN.CHECK VALIDATION.
NAMEyII/t •
'CONTRACTOR
,�w PHON��-4X4'4 DTV. ELECTRIC PERMIT • FEE ;
• /CONTRACTOR-s P ' •
NAME CA !>Z(af313 OUTLETS':SWITCHES.-R ECEP '5.00/1:00 447. _�rr
E # S(tell rti—1 LIC:NO. LIGHTINGFIXTURES ' 5.00/1:00 /„'•7) �Al
�
CONTRACTOR'S -7 APPLIANCES—RESIDENTIAL . •' 4'.00
ADDRESS LL r q ry �p��
'Ly 5( m Lcl)O 5T FHOrvNE /'2PHU PANELS 5.00 �� i�OgAZLIlv7f16t
ARCHITECT .. SIGNS • 6-� PLAN CHECK FEE
� }, .P,C.NO.
-.ENGINEER `Iair Cbl BI
- uc:No. " SIGNS TRANS. 3:00 I eY P inm
ADDRESS
END. • '_SPECIAL CIRCUIT _ 5.00PERMIT VALIDATION
_•
ZIP EMP:METER'OR POLE-INS. 15.00 -
APPnCANT'S MOTORS ��� ,D .'SEE FEE SCH. 3 5 •
ADDRESS
•Z-L(Sf /he-!.L'Yo Vt'a/ ,,yf _� 4,:,:-5 SERVICE CHANGE 10.00 } (41:-/" T
w 0 0 LICENSED CONTRARORS DECLARATION ( /
• .,, . I hereby affirm that-I.am licensed under provisions of Chapter 9 - -
a n (commencing with Section 7000)of Division 3 of the Business and , . ISSUANCE DATE
H 01 Professions Coddyy and any license is m,full force and°fleet.
BLDG. ELEC PLG, MECH.
a O e. License ass C- 1f - Lie.Number 2—L4 13' 1 3 ' • 0 �. ; -0
0'2r. in H'w Date '-7 —. 9-Contractor- -
¢ ¢W cc ,OWNER BUII:UER DECLARATION -
- - BU DING PERMIT
•MISC.— • REFER,TO ORD 'INFORMATION
x-;'m I hereby affirm that I am exempt from9be Contractor's License -
FNoa Law for.the following reason(Sc7031.5.BpsinessandProfessions PERMIT'ISSUANCE 600' , VALUATION. ,S/FT.
Code:Any city or county which requlresa permit toconstruct alter., -
¢-¢g. improve,demolish,or repair any structure,:prior to its issuance,also ELEC.CONTR. LIC.NO: ECSC
O u requires Ihoappbcnne for such pumrt to file n.signed smtemcnl that en' $q' / /3-x SII nn e-n
N m he u(Chapter
9pursuant to the prongons of the Conlmelor's License '"' /[�f CIO V�}I TOT a PERMIT.rO
F'i Law(Chapter 9(commencing with Section is f Division 3 of the
5,i n.. Business and Professions Code)or,that he is exempt m'znd QTY, PLUMBING PERMIT FEE '
¢H m the.basrs for the alleged exemption.Any violation of Section 703E5 STORIES TYPE CONSTR.
a'E � by any applicantfoe apermiesubjeetsthc applicant to a civil penalty. ALTER:DRAIN&VENT-WATER'-(EA.) 4.00 ' •
Of fmore than five hundred'dollars(5500),):
no ,
❑ I,as owner of the property,or my employees-wilh'.wages as 'BACK FLOW PROTECT,DEVICE' 2.00 DCC,GROUP 'RES,UNITS
their sole compensation;will Bothe work,and the structureisnot
intended or offered.for sale(Sec. 7044, Business and Professions DRAINS-FLOOR,ROOF,AREA,COND. 41)0 -
' 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 .4.00 SC FT,FLOOR AREA TOTAL ACREAGE
• himself or through his awn employees.provided that such improve-
ntents:arenotintended or offered for.sale.If,however,the building GAS-EA.SVSTEM-1 INCA OUTLETS 4.00
or improvement issold within one year of completion,the owner-
buddcr'will have;Elle burden of Proving that he did not build or im- GAS-EA.SYSTEM-OV ER.4(EA.). , '1:00 BUILOINGUSE
prove for purpose of sale,), INDUSTRIAL.WASTE'INTER. .40,00 RES IND CON Pa Omer
❑ I. as owner of the property am exclusively contracting with - ❑ ❑ ❑ ' 0
licensed contractors(to construct the project(S e.7044.Business' LAWN SPRINKLERS-1•INC 5 V.B.. 5.00. 71 ASSESSORS PARCEL NO.
' and Professions Code:The Contractors I icenSelaw does not apply,
to an owner of property who builds or improves thereon.and'who LAWN SPRINKLERS,-OVERS(EA.) .1.00 - •
contracts for such projectswith a'contractons)Iicensedpursuant to' - •
theContructo?sLicenseLaw. SEWER-SANITARY-STORM EA.200ft/8.00 • TRACT NO. PARCEL NO.
0,:1 am exempt under Sec. ,B:&P.C'for this
reason - WATER HEATER W/VENT - 4M0 • -
• Owifer - Date WATER SYSTEM 4,00 ACC:DATE ACC:FILE NO.'
'WORKERS'COMPENSATION DECLARATION WATER TR EATING.EQUIP. ' 4:00 -
• I hereby at irm that I'hava a certificate of consent to cel(-insure.
or a'certificate of Workers Compensationilnsurance.ora certified .. - - . ZONING ' ENG:SITE NO.
copy thereof(See.3800:.Lah.0:).y1 /I -
PolicyNo. Company /iI �Lte ( F3 ' -
O' ❑ Cerldied'copy'is hereby furnished. '
2 Z '❑ Cerlific��yi copy is filed with the city inspection division. • FIRE SPRINK ENERGY T-24
- p Applicant _ - MISC.- REFER TO.ORD. yip N 0 r'D ND
ccT CERTIFI/1C__ATE__OF EXEMPTION FROM-WORKERS' • PERMIT ISSUANCE , 6.00 FLOOD ZONE A,LU,C.
W > COMPENSATION INSURANCE PLG.CONTR. . LIC.Na PLG.
1 O (This section need not.be completed if The permit is for'one ,. -TOTAL Y❑ ND' Y El . ND
QU O hundred dollars 15100)of less.) , ,, - _ - -
Icertifythai'inthe.performance of the workfor whichthis per- GTY FEE.SUMMARY '
LL f mit 'tissued.I shall not employ any person'nnany manner so as to MECHANICAL PERMIT FEE
0 W becomesubject to the Workers'Compensation Laws of California.' ,
n Dale Applicant ALTER OR ADD TO MECH. , 4.00 BUILDING
} en NOTICE TO APPLICANT: 1(,•after making:this Certificate of Ex- •Z emission you should beconie subject to the Workers'Compensation APPLIANCE - 4-00 '
provisions of"thu Labor Code, you must forthwith complyiwiln '' ' PLANCHECK
C.T such provisions orehis permit shall be deemed revoked. . AIR,HANDLING UNIT(TO 10 FEE
p00CF.M) 3.00 ,
CONSTRUCTION LENDING•AGENCY AIR HANDLING UNIT(OVER.10,AOOCF.M:) 5.00 SEISMIC FEE
•
• I hereby,affirm thatithen- is a construction lending agency•for EXHAUST HOOD(WITH DUCT) 2,00 • '
the performance of,the work for which this permit is ssucd(sec. .
3097.Civ. . - HEATING UNIT(70'.100,000 B.T.U.) 4.00 MICROFILM
Lender's Name ' y
Lender's Address - 'HEATING UNIT(OVER 100,0008.T.U.)7.50 • ELECTRIC :Aso
•I certify that I have read this application and state that the above VENTILATION FAN (SINGLE) 3.•
00 '
•• information.is correct.1 agree to comply,wieh all city.and county PLUMBING. -
ordinances -- (3 H.P.and state laws relating to building construction, and BOILER-COMPor'100,000B.'T.U.) 4-00
hereby authorize representatives of this city to enter upon,the BOILER-COMP
above mentioned property for inspection purposes. (Owry100,000 BTUI SEE P,EE SCH. 'MECHANICAL
(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 "consequence of the PERMIT ISSUANCE 3.00 •
/6{aMin /off this germ't/ /'{r' // +Sf ,,_ MECH.CONT, -LIC,No. MECH.
NW W( Ora.3—' 7. TOTAL
ignature of Applicant/Contractor Dale ,TOTAL � �
• OFFICE:COPY. - v
,v .
APPLICANT TO•FILL IN INFORMATION WITHIN RED LINES - USE BALLPOINT PEN ONLY • .
•
• ' BUILDING PROJECT IDENTIFICATION PERMIT NUMBER
• BUILDING, APPLICATION & PERMIT /�
ADDRESS •
2. C'Cp /Z Gf l..e f e t l r el
- BUILDING--ELECTRICAL-PLUMBING-MECHANICAL•
5.573
TI J
OWNER'S PLAN CHECK.VALIDATION
NAME - r
• /�''�) I^� •
�`,v''3 7Zf-49-94 QTY: ELECTRIC'PERMIT . • FEE .
V� ^117�� i ,,,p PHONE.
CONTRACTORS r ', 'I
NAME OUTLETS,SWITCHES-RECEP 5.00/100 to
y� 1 5 CIyv. I co Z.�1313� • LIGHTING FIXTURES' 5.00/1.00 6,/
'4C�"rlL /. I-G�'\“IrNILIC.NO. 1,7 �r r
` CO TRACTOR'S - 7-20 _JAPPLIANCES-RESIDENTIAL 4:00 o
ADDRESSO,ry
• 2-tf-05 Man V S} PHONE PANELS 5.00 /1',{;J SApE OF TION
ARRCHITECT SIGNS •
"6� PLAN CHECK ,F�J y�{II P.C.Na •
-
ENGINEER rCity
rtjnol
• LIG,NO. GN
. SIS TRANS. 3.00 of Cit Y
be
• . ADDRESS:ARCH.OR ENG. • SPECIAL CIRCUIT - .5.00 - PERMIT-VALIDATION
- TEMP.METER OR POLE INS. 15.00 •
zip•
APPLICANT'S
�j(�
ADDRESS �
•
Z��(j • MOTORS HNSEE FE �j,S-(J
MGFUC7L/�j•-�• } SERVICE CHAANGEE • 10 10.000
w
0 LICENSED CON�fRACTORS DECLARATION
'r i w I,hereby affirm that l-am licensed under,provisions of Chapter 9 • , • - IS
y,a u- (commencing with Section 7000)of Division 3-of the Business andELECT.
DATE
BLDG. • ELECT. PLG. MECH.
en is LiceISC Professions Cs L- a license ii in fullNumber”
of ••r.•1, r D y� ❑ O •
i O'-- LicenseQ Class (�\V (Luc:Numberri (� I "�I - J/IlI�/11
y.F w,' Dale 6 Z3— ,gconlmctor ' •
N -`C J.
¢ ¢,w a OWNER-BUILDER DECLARATION - B ICDING PERMIT.
D • INFORMATION
w;°r N I hereby affirm that-I am exempt from the Contractors License MISC.- -REFER-TO ORD •
of Law for the following reason.(See.70315,Business and Professions VALUATION SIFT,
t7 -.,n • PERMIT:ISSUANCE' 6.00 -
Cute.Any city or county which regwr sa permit to construct,alter,also - �O.
2 Q',¢0 Imp rove,demolish,or repair any strudure,.prior to its¢sonnei,also •ELECT CONTR. LIC.NO. ELEC.
.. (� ,` '
-DLL requires the applicant foe such permit to file a signed statement that {;{'T,� s 3Il TOTALS 2 `Jv
K S h•is licensed pursuant to the provisio s of the Contractor's License 4Ct ( /<c �,��4��r-'1 PERMIT TO
-
F-- E• Law(Chapter 9(emnmencing with Section 7000)of Division 3 of the -
13- ,l,
Business and Professions Code)or that he is exempt therefrom andr OTY. !PLUMBING'PERMIT FEE- 7
¢r1-S the basis for the alleged ezcmplwn.Any violation of Section 7031.5 . S RI S• TYPE CONSTR.
i"3_ by anYaPPlicani for a permitsubjects the applicant to a civil penalty,
of not more than-five hundred dollars(8500).);, ' ALTER-DflA1N&.VENT-WATER (EA.)"4:00 -
❑'I,'as owner of the property,*my employers with wages'as BACK FLOW.PROTECT..DEVICE
- their sole compensation,will do the work,-and the structure is nor - 2.00 _.OCC:GROUP RES.UNIT$
.intended or offered for sale(Sec. 7044, Business.and Professions , DRAINS-FLOOR,ROOF,AREA,COND. 4,00 •
Code:The Contractor's license Law does not apply.to son owner of
40
property who builds or improves thereon;and'who does such work '' FIXTURES-PER TRAP • 4.00 SO.FT.FLOOR AREA TOTAL ACREAGE
•
himself or through his own employees provided that such improve-
ni•nts are nor intended or offered for sale.If
.however,the buildingGAS-EA.SYSTEM-1INC:4 OUTLETS '4-00
or Improvement is wed within one year of completion,the owner- GAS-EA.$YSTEM-OVER 4(EA.). "
builder will have the burden of proving That he did not build or im- 1.00 BUILDING USE •
•
, prov•'for •purpose of sale.). - INDUSTRIAL WASTE INTER. 20.00 , IND r.CON Pe •Other
❑ I,as owner of the property,ani exclusively contracting with O_; ,.
hecnsed+contractors to constnier the projecl.ISec 7044.Business LAWN SPRINKLERS-.1 INC,6V.B, 5.00 ASSESSORS PARCEL NO.
• and Professions Code'The ContractorsLicense Lawdoesnot apply
to an owner ofpropertywho builds or improves thereon.and who LAWN SPRINKLERS-OVER 5(EA.) '1.00 ••
contracts for such'projects with a conlractortsl licensed pursuant to' - -
• theCmnractor'sLicenseLaW,' SEWER.SANITARYSTORM EA.200ft/8.00 " TRACT NO. PARCEL NO.
❑ Lmn exempt under Sec. ,B,&P.C.for.this . WATER HEATER W/VENT - '
reason - ,4.00 '
' Owner Date WATER SYSTEM - 4.00 Ace:DATE r ACC.FILE NO,
WORKERS'COMPENSATION DECLARATION' WATER'TREATING EQUIP,. 4;00
I hereby.affirm that I have a:cerlificute of consent to sellainsure: - -
ora certificate of Workers'.Compensation Inauranceeora'cenified' ' • - ' 'ZONING ENG.-SITE NO.. -
copythermf(Sec.3800.1ab.C.)./1 i A- .1I L. ju . '
Polley,Nis NCompany re (R L/
.0 Certified copy is hereby furnished: - r
Z 2 'O Certifiedopy is glee with the city inspection division. 41RE SPRINK ENERGY T24
FO', Applicant /y-C-f1� MISC.- REFER TO ORD. '
PERMIT ISSUANCE �� NE v �• N�
� N CERTIFICATE OF EXEMPTION FROM WORKERS' 6.00 'FLOOD ZONE .-AL.UC.
W COMPENSATION INSURANCE • PLG:CONTR. LIC.NO: PLG.
CL 13' - (Thus�sedion need not he'com'completed if the e - -
p permit is lar one LTOTAL „ ,Y❑ N Y ❑ N0
U
Z.
hundred dollars IS 1001(Weiss.(
I certify that in the performance of the work for which This per- Qyy MECHANICAL PERMIT ' FEE SUMMARY
"ly it, mitis issued,1 shall not employ any person in any mannei so as to. FEE
O W 'beemnesubjed.ro the Workers Compensation Laws of California. - ,.' ;
y Dale Appli`ant ALTER OR ADD TO MECH, ' 4,00 ' BUILDING - '
• } m NOTICE TO APPLICANT: If.'after making this Certificate of Ex- - -
.1''F-- z - emption,,you'should become subject to,the Workers'Compensation APPLIANCE .4.00 . PLAN CHECK':-
io
provisns of,the Labor Code, you must forthwith comply with•
.'U i such provisions or this permit shall be deemed revoked. AIR HANDLING UNIT(TO 10,000 CF: .) 3.00 -
FEE
•
•
CONSTRUCTION LENDING AGENCY - AIR HANDLINGUNIT(OVER 10,OODCEM-):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(Sec. MICROFILM
3097,Civ.C.). . HEATING'UNIT'(TO 100,000 B.T.U.) 4.00'
L nder's Name' - ��
Lender'sAddress - HEATING-UNIT(OVER 700,000 B.T.U./7.50 ELECTRIC 5U
I certify that 1 have read this application and state that-the above VENTILATION FAN (SINGLE) 3.00.
. 'information.is correc(rl agree.to comply:with all ity:and county i PLUMBING
ordinances and slute'laws relating to building construction,and BOILER-COMP(3 RP.or 100,000 B.T.U.) 4:00 •
hereby authorize representatives of-this city to enter upon ilio BOILER-COMP(Oxer'I00,000 BTU)SEE FEE SEH.
ebov mentioned properly.for inspection purposes. _ MECHANICAL
(We) agree to.save ;indemnify and.keep.harmless the•Clly'of MISC:- REFER TO ORD.
Cupertino against liabilities,.judgments,costs and expenses'which _
may in any way seen,- against:said City in consequence of the - PERMIT ISSUANCE 3.00 • ' CONST.TAX
ntmg'of this permit: •. r • _ MECH.CONT. LIC.NO. MECH. •- /p�
/ /L �J.�.( ) -$N• -TOTAL• TOTAL • 2�1JP'
bgne ore of Applicant/Contractor Date `)
OFFICE COPY - •
•
.. ' APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY . .
BUILDING PROJECT
IDENTIFICATION „ PERMIT NUMBER -
amtoilvc APPLICATION & PERMIT • ��n a
ADDRESS• r (�
Lacs
.q3 (� L (sr,-1•.„,e
BUILDING -ELECTRICAL-•
PLUMBING.=MECHANICAL •
ac PLAN CHECK VALIDATION
NAME .
^� � //�x � DTY. ELECTRIC PERMIT FEE- •
• D.„4 lr/.' lir°p 'PHONc 7 UIY�
COTRACTOR'SFF ` - /n -
NAME f OUTLETS-SWITCHES-RECEP 5.00/1.00 '/
.gt 4 SI.ec#tir�I' LIG.'No,GIO.(i(3i? LIGHTING FIXTURES ,. 5.00/1.00. /3 .
.,..4.-t-
. NTRACTOR3` `' ' APPLIANCES-RESIDENTIAL . 4.00' ./
7� { , ipy S� PHONE2 7`ZD Lit ,.PANELS _ 5.00 r� .DATE OF•APP4CATION
•ARCHITECT l r'`—J,l . d PLAN CHECK FEE P.C.NO.
OR SIGNS • 6.00
-ENGINEER '
LIC.NO. SIGNS TRANS.' 300
' ADDRESS ENG., . SPECIAL CIRCUIT -5,00 PERMIT VALIDATION
s ZIP TEMP.METER OR POLE INS. 15.00 /'
'APPLICANT'S
. MOTORS r `Iji Ht - SEE FEE BCH: �, ct2 DD,/ / " ' •
ADDRESS
't'-t'tf �Yl`�(3p\/ j-$ ., .5'�,�-CO3' 'SERVICE:CHANGE ,10.00 ,�/
m opo 'LICENSED •
CONTRACTORS'DECLARATION - - t
<ow w I hereby affirm that I am licensed tinder provisions of Chapter 9 . 'ISSUA i DATE
f< A (commencing with Section 7000)of Division 3 of the Business and BLDG. 'E PLG.' MECH.
•
r o-2 , Professions Code,an licenseis m full force and effect. ,
o 2 a.: r License Clan tic:Numtier 7 /,.._r 3/ 3 . 0 M 0 0
w H Date j¢-1- Contractor • -
•
`a M s :' - BUILDING PERMIT
- is w o .OWNER-BUILDER DECLARATION'
M ISC.. •
REFER?O ORD INFORMATION
'x ;u N • thereby alfsrm,that I am exempt from the Contractor's License VALUATION, .S/FT.
w _o4 Law for the following reason.(Sec 70315,Business and Professions PERMIT'ISSUANCE
fr"'^> . Code Any city or county which requiresa permit toconstruct:aller. 6'� 1.1 i
0 ie ¢.0 improve,demolish-,or repair any structure,prior to its issuance,'also. ELEC.CONTR{A ,LIC.NO; ECECI c '
A •
•
m a te requires the applicant for.such permit to a signed statement that 4I ' 4 A//^l2 fee TOTAL p Li D.� /P IT TO
• heir licensed.pursuant to the provisions of the Contractor's License' V / 1 Y
f'i o Bus essandrProfesso s�Co e)w�or Olatth the ion s exempt therefrom'and DTV., PLUMBING PERMIT' FEE', , �� •
the basis for.the alleged exemption Any violation of Section 7031 5 "- STORIES TYPE CONSTR. •
e 3._. by any applicant fora permit subjects the applicant to civil penalty
of not more than five hundred dollars(5500).): ALTER,DRAIN&.VENT-WATER MAJ.4,00,
O I,as owner of the propertyor my employees with wages as BACKFLOW PROTECT.DEVICE 2.00 oCD.GROUP RES.UNITS
their sole compensation,will do the work,and the structure is not, . ..
intended or offered for sale(Sec. 7044. Business and-Professions DRAINS-FLOOR,ROOF,AREA,COND.-4,00 . •
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 J 4.00 ' so.FT.FLOOR AREA TOTAL ACREAGE
• himself or through•his own employees,provided that such improve- - TOTAL
mems air not intended or offered for sale.df,however,the building GAS-EA.SYSTEM-1 INC.4 OUTLETS 4-00
o improvement is within one y,,.of completion.the owner- GAS-EA.SYSTEM-,OVER 4 (EA:) .1,00 BUILDING USE
.builder will have the burden of proving that he-did not build or im-
, provcfor:purpose of Sale.). INDUSTRIAL WASTE INTER:. RES IND 'CON PB ..;Odic,
❑ I,as owner of'theproperly.am exclusive) - - . '20.00 ❑ - ❑' '0 .❑ ❑
Y.eonlracOng with - -
licensedcontractors;to'construct.the.project(S 7044.Business i LAWN SPRINKLERS-1'INC 5.V.B. .. PARCEL No
5.00 ASSESSORS P .
and Professions Cod The Contractor's License Law does not apply -
to styowner of property wbo•huilds or improves'lhereon.and who LAWN.SPRINKLERS-OVER'5 IEA:) -1.00 '
contracts.for such projectswillia contractor(s)licensed'pursuunl to
the Contractor's License,Law: SEWER-SANITARY-STORM EA.200ft/8.00 . . TRACT NO. PARCEL'NO.
❑ f ant exempt under Sec: ;B.ARC:for this
' reason WATER'HEATER W/VENT:, 4:00
• Owner - - Dale WATER SYSTEM - • " 4:00 ACC.DATE 'ACC.FILE NO.
WORK ERS'COMPENSATION 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(Sec.3800,Lab.C.p.,n 61 �L /f' -
Policy No.- I�
Company/
,0 Certified copy I'.hereby furnished: FIRE SPRINK ENERGY T.
Z 2 ❑' Certified copy is filed with the city inspection division. 24
Applicam - MISC."- ' REFER TO ORD. • y0 N0 y'0 No
_DS, - PERMIT ISSUANCE,
W CERTIFICATE OF EXEMPTINSURAM WORKERS' - 6:00 'FLOOD ZONE A.L LLC:
W D 'COMPENSATION INSURANCE PLG.CONTR. LIC.NO: PLO. -
n' O (This section need not•be completed if the permit is,for one •• '' ' I TOTAL ' ' V 0 N❑ Y 0 NO
,
•
0ZO ,hundred dollars IS 100)or less.) . - .. .
I certifygfiat m the performance ufJhework for which this per- Q.nr MECHANICAL PERMIT ' • 'FEE FEE,SUMMARY
LL •
I mit is.issued,I'shall not employ any person in any manner so asto
O become subject to the Worker Compensation Laws of California.
a 'Dat` Applicant ALTER OR ADD TO MECH. q.00 BUILDING
).;vco. NOTICE TO APPLICANT:'If,after'rriaking this Certificate of Ex.,
F 2 emotion.you should become subject to the Workers'Compensation APPLIANCE • 4,00 AN'CHECK
provisions of the Labor Code, you must'forthwith comply with •
PL.FEE-.
U. .such provisions or this permit shall be deemed revoke 'AIR HANDLING UNIT(TO'10,000C.F.M) 3,00 '
CONSTRUCTION LENDING AGENCY AIR HANDLING UNR(OVER 10000CF.M)'5.00 SEISMIC-PEE
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(Sea MICROFIL
• '3097,Civ.C.). MHEATING;UNIT�(TO 100,000 B.T.U.) 4:00
Lenders Name
Lenders Address HEATING UNIT(OVER 100,000 B.T.U.17:50 ELECTRIC
•I certify that I have read this application and slate that the above VENTILATION FAN(SINGLE). 3.00.
• iiaformation'is correct I agree to Cumply.with.all city and'county - PLUMBING
'hereh'ordinances and state laws relating to building construction,and �L� COMP 13 H.P.or 100,0008 BTU) 4.00
hereby authorize representativesfoof.thiscity to enter upon the'
abovcmentioned property for inspection purposes. BOILER-COMP(Over too,000 BTU/SEE FEE SCH. MECHANICAL
• (We) agree lo'save,.indemnify ond'keep'harmless the City of MISC:- - - REFER TO ORD. .
Cupertino against'liabilities,'judgments,casts-and expenses which CONST.'TAX
may m any way•accrue against said City in consequence of the -PERMIT ISSUANCE 3.00
•• ming of this permit. MECH.CONT. .LIC.NO. MECH. y�
Applicant COI/ —Z f f TOTAL TOTAL , Z Jj
ignnlure ofA bean!Conlrador• Pare• —
OFFICE COPY '
• APPLICANT TO FILL IN INFORMATION WITHIN REDLINES — USE BALL.POINT PEN ONLY
PERMIT NUMBER
•
BUILDING PROJECT IDENTIFICATION APPLICATIONEI REKNIT
WILDING _ 5575
ADDRESS •
�� ��� 1 C�r7• '�`
BUILDING, ELECTRICAL-
xER SIG T -PLAN CNECK VTgpB
NPb1/EJ/r1 7 1R-
OTT- a. ELECTRIC PERMIT . .FEE- ryF� •
-i• Wrlfn Cn ITS bP 'PHaNE /275-4L'INLY ' _ - AUG
NAME a ro s ff
OUTLETS:SWITCHES-RECEP 5.00/1.00 �`7 '' /� G ,a�r'7
Re4i- 5L.Prt-c- (ctI Liz,40:a t)Lar 13i• : : LIGHTINGFI)(TURES ' 5.00/1.00, ) 7 I/.' ryeQ •
•
ADDRESS •} APPLIANCES-RESIDENTIAL AAO - '�ar7dll�Tr^4MI
• /��� m` UOI/ �'� PHONEZt7.'�pyq PANELS 5.0M0 5 DATE OF APPLICATION
ARRCHITECT T - SIGNS - ) • 6 W - ' PLAN CHECK FEE - P.C.NO:
ENGINEER
' Llama: - . SIGNSTRANS, 3.00 -
nooe E55 ENO. - •
•SPECIAL CIRCUIT •'S 00 PERMIT VALIDATION
ZIP , TEMP.METER OR POLE INS. 15.00 '
'V APPLICANT'S' - /
, ADDRESS• / MOTORS i1.1•=f-f I I7. SEE'FEE$CH: I SU
• 2Lt l5 (`!'�� GOnI/ •��-� yssx SC,fvd SERVICE CHANGE. 10.00 6 /
• o o LICENSED CONTRACTORS DECLARATION C. //
Q u's~a i;hereby affirmihat I am-licensed-under provisions of Chapter 9 - � ' -
SSU N E DATE
Ito-Q,'u Pro ssionang•with Section 90001 of full force of'the Business and
H w Professions C a d license r in full forte nod etfajll�. - e DG. E T. PLG. MECH:
•G i m.- Llccns�Cl_ss LH Number'? 7 Til
•m f Date4,- Contractor
•
¢:Q m a OWNER-BUILDER DECLARATION - • SUI'INFORMATION
..i
at"o A-0 : , INFORMATION
w:;w N I hereby allirM (hal 1 um exempt from ihpContraclor's License
MISC.- .REFER?O ORD
LL O.a Law for thefollowing reason.(Sec.7031.5,Business and Professions G•
L VALUATION VET.
v - wgPERMIT ISSUANCE 6 W -
Code:Any city or county which requires a permit to construct.alter,¢ rtap improve.demolish,or repair any structure,prior to its issuance,also ELEC.CONTR. • LIC. O. ELEC, • - '
W 0'a requires the applicant for such permll to file a signed statement that 7�--L',`/T C j ' C "-2 '3n' TOTALT7. �'4 p MIT TO
•$ he Is Law(Chapter
pursuant to the provisions of the )ofDivlor's Licen rl(l7- "-- /
f.Z > Business andrProfessions Coodde)Ith Section or that he is exempll therefromision 3 (and QTY. - PLUMBING PERMIT FEE (�a
a
F' the basis(or the alleged exemption,Any violation of Section 7031,5 • , . S RIES TYPE CONSTR.
i;',- by any applicant fora permit subjects theapplicanl lou civil penally' -
ofnofmorethanfrehundreddollars(5500).): ALTER-DRAIN (EA./ 4,00'
❑ 1,as owner of the property,or my employees wilA.wages as , BACK.FLOW PROTECT.DEVICE
their sole compensation,will'do the.work,•and.the structure is not 2-� OCC.GROUP pES.UNITS
' -intended or offered for sale(Sec. 7044,Business and Professions DRAINS-FLOOR..ROOF,AREA.COND. 4:00 ' r
'Code:The.Contractor's License Law does not apply to an owner Of -
property who builds or improves thereon,and who don such workFIXTURES-PER TRAP '4.00 ' SO.FT.FLOOR AREA' TOTAL ACREAGE,
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- GAS-EA.SYSTEM-OVER 4(EA.) .1.00 BUILDING USE
'prove for purpose of sale.). INDUSTRIALWASTE INTER: AES IND CON PB. Other
❑,Las owner of the property,am exclusively contracting wits p-� • ❑ ❑ ❑ O O
licensed contractors to construct the project(Sec,7044,Business LAWN SPRINKLERS-1'INC 5 V.B. 5.00 ,ASSESSORS PARCEL NO:
and Professions Code:The Contractors License Law does not apply ,
to an-Owner of property who-builds or-improves thereon:and who LAWN SPRINKLERS-OVERS(EA.) 1.00
• es
contracts:for such-projects with a contractors)Iicensed.puuant to _ _
the Contractor'sLicense Law. SEWERSANITARYSTORM EA.'200ft/8.00 TRACT NO. PARCEL'NO.
❑ I'am exempt under Sec. • ,B.6.P.C-for this.
reason - - WATER HEATER W/VENT q,00
Owner - •
Date WATER SYSTEM 4:00 ACC.DATE .ACCT FILE NO.
WORKERS'C'OMPENSATIONDECLARATION WATER TREATING EQUIP:- 4.00
•
•
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 therenf(Sea 38IXL Lab.C.).Ai fG 4 /4 .
Policy No, CompanyIT
0'
0 Certified copy is hereby furnished. • FIRE SPA ENERGY T-24
Z 2 ❑. Certified lop .I's filed:with the city inspection division. '
F O Applicant&f.. O MISC..- REFER TO ORD. v ND y❑ ND
cc H CERTIFICATE OF EXEMPTION FROM WORKERS' PERMIT ISSUANCE 6.00 FLOOD ZONE A,LU.C-
W COMPENSATION INSURANCE • PLG.CONTR.- .. LIC.NO. PLG.
'
CL O (This section need'not be 'completed if the permit is for one- (TOTAL Y 0 N� 'Y0 ND
-
D 2 hundred dollars($100)or less.) - _ -
U O I certify that h the not
of the work for which this per O ,' ' :•MECHANICAL •PERMIT. . FEE ,FEE SUSJMARV I
IL F. mit is'issubjec shall nal any„person in any manner so as to y -
in W become subject tri the Workers'Compensation Laws'of California, - - ,
a - Dam Applicant ALTER:OR ADD TO MECH. 4.00 - BUILDING
} ye NOTICE'.TO APPLICANT'::If,after making this Certificate of Ex
1_.2 emption,you should become subject to the Workers'Compensation APPLIANCE 4:00P,LAN'CHECK '
`provisions of the Labor.Coda:you mush forthwith.comply-with -
0' such provisions or this permit shall be deemed revoked: AIR HANDLING UNIT(TO 10{OOGF,M.) 3.00 FEE
ti
CONSTRUCTION'.LENDING AGENCY AIR HANDLINGUNIT(OVER lO000GEM) 5.00 • - SEISMIC FEE
I hereby.affirm that there-is a construction lending agency for EXHAUSP.HOOD(WITH DUCT) 200 .
' the performance of the work for which this-pennit is Sued(Sec.
- - MICROFILM
3097.Civ.0-). - HEATING UNIT(TO100,OW B-T,U.) 4.00
Lender's Name -
• Lender's Address HEATING UNIT(OVER 100,0008-T:U-)7,50 - ELECTRIC '
I cerlify that I have read this application and slate that the above VENTILATION FAN.(SINGLE) 3.00
•
information.is correct.I agree to comply with•all city and county PLUMBING i
ordinances and state lawsesentaelabng to building construction,and BOILER lX3AT(3 H.P.or 100,000 B.T.U.) 4.00
hereby authorize representatives for ins of laic city to.cover upon the
above-mentioned property for inspection purposes.
BOILER-COMP tOO,OeO BTU)SEE FEE SCh. MECHANICAL '
(We).wee 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-aceme against said City in consequence of the PERMIT ISSUANCE • 3.00
d): •rating of this perm'. MECH.CONT. LIC.NO. • MECH.
f //J .. a✓ • -i - - ✓' TOTAL TOTA - 5Z3
ignature of Applicant/Contractor Date . -
• - OFFICE COPY
APPLICANT TO FILL IN,INFORMATION'WITHIN REDLINES - USE BALL POINT'PEN ONLY ..
BUI LDIWG PROJECT.I DENTIFICATION PERMIT NUMBER
BUILDING APPLICATION & PERMIT
ADDRESS' u •
15 1
�CP�is GL�r /f Circ.
/- 18UIL'DING-ELECTRICAL-PLUMBING;-MECHANICAL 5 Vn
OWNER'S 5Y� a'[' , . , "c '- PLAN CHECK VALIDATION
^•
N]A�ME- '///�� //��" - �-'F.. )! )/,,UTY. ELECTRIC PERMIT ,' F•EE: +
CONTRACTOR5
'NAME • 6)(-2Z /3)3 JUTLETS-SWITCHES-'RECEP 5.00/100 .tibz'
/J-r/rif r../ LIC.NO. LIGHTING"FIXTURES " 5.00/1 00 � ,-�
ADDRESSTORS PPLIANCES-RESIDENTIAL •' •• 400 ,.,R - • -
Z q- l-nt-t✓Dy 3; �? Za lav 5
.PHONE . PANELS S.00 .DATE OF APPLICATION )
ARCHITECT SIGNS - _'.5•pp PLANCHECK FEE , PC.NO.
OR .
ENGINEEflI . '
• LIC.No. SIGNS TRANS- '3.00 ,
- ..ARCH:OR ENG: - .PERMIT�VALIDATION
.ADDRESS'. SPECIAL1CIRCUIT 5.00 ,
�$ ki 1 ,S- os� . - 0
• ADDRESS,T:s '3, S0 'I
•
RS
•
!P1- A Il
7^'` n • ��� Cf p U
Z mLcUo J SERVMOTOICE CHANGE' SEE FEE'SOCpH
ZIPTEMP. i 5
',o ii o. LICENSED CONTRACTORS DECLARATION •
.- •
424 z;w' I hereby'affirm that!am licensed under,provisions of Chapter 9 s ,- I ISSUANCE DATE
rz B.
0 (commencing with wy.ln cense)i i fusion the Business�Jand l- - 'ELECT: PLG. MECH.
5t a Professions Cody.,an cttio license Ism full fo d(e( ,. BL G- +
2 0'" License lass 'LIC Number - - ❑ I ,
0 F . Date Z3 Contractor' ,
< M - • �BUILDING'PERMIT
¢ ¢ ¢a OWNER-BUILDER DECLARATION _
• INFORMATION
x•;u r I hereby riffirmlthal'1 am exempt from the on rat or License REFER TO'ORD -
w 0 j •Law for the following Eason.(Sec 7031.5.Business and Professions VALUATION $/FT,
PERMITISSUANCE • 5-pp G
improve,demolish or repair any structures prior to its Issuance,also EWT13. LIC NO: •
ELEC. /•�
x m•LL requires iLic vie dp ursual for the promul tons file a Cont actor's Li enatse / S/� �. C/O�/-` /y' TOTAL ;S(/ /L-iLlf T TO .
w w r ihes u es th ea pursuant r the prermit to of the Coed state statement
that ( / C--v- "Y
Fir ILaw(Chapter 9(commencing with Section 7000)0(Divvision 3 of the - ,
• 4 c Business:andProfessions Code)or that'he is exempt therefrom and QTY: ..PLUMBING PERMIT FEE I /'
¢'I-`c0. the basis for the alleged exemption Any violation of Section7031.5 - ,� STORIES T TYPE CONSTR.
_.'. by any applicant for a permit subjects the applicant to a civil penalty ALTER-DRAIN&VENT-WATER (EA7),4.00 'r. '
Of not morclhan five hundred dollars(8500)D: r `
'❑;I,as owner of theproyerty,or my.:employees withwages as
r • their sole compensation,will do the wurk,'and Ihu•structure is not BACK FLOW PROTECT. DEVICE .2:00 Dee:GROUP RES UNITS
untended;or,offered for,sale(Sec. 7044„Business and Professions DRAINS-FLOOR,ROOF,AREA,COND. 4.00, '
Code:The Contractor's.License Law does not apply to an owner of - -
r propertylwho bends or improves thereon,and'who does such work FIXTURES.-PER TRAP' ., , • ' ''4A0
••;` himself or through his own employees,provided that such improve- - - 50.FT:FLOOR AREA TO' ACREAGE
menta are',not intended or offered for`sale.Ifrhuwever.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 ice -GAS-.EA.SYSTEM-OVER 4)(E4.) 1.00 ' BUILDING USE
prove for purpose of sale). - INDUSTRIAL WASTE INTER '. - • IN ON PB O❑r
❑ I,as owner of the property am exclusively contracting with 20.00 , El
hcensed'contractors to construct theprojecl;(Sec 7044.Business - LAWN SPRINKLERS- 1 INC 5 V:B. ' .5.00 , ASSESSORS PARCEL NO
and Professions Cod 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 forsuch projects with a'contraction)licensed pursuant to
the Contractor's License Law,. ' - • SEWER SANITARY-STORM EA-200ft/8:00 TRACTNO PARCEL No.
El am exempt under Sec. ,B.&P.C.for.this
WATER HEATER W/VENT 4:00 a • reason
OwnerPate WATER SYSTEM; 4,00 ' ACC.DATE, ACC FILE NO.
•
WORKERS'COMPENSATION DECLARATION WATER TREATING EQUIP:' 4:00 •
+ 'I hereby;alfirm"that:l have a certificate of consent to self-insure. - - - - ..
or a,cerlifioatSec Workers h.C.l ensation Insura/n_ce of a Certified ZONING ENG:SITE NO:
copy thereof(Sec'3800.Lab.C:)� r4 a I, /i. .7 • '' .
r ..
Policy No. Company(!(/,( - 'Y
•
❑ Certified copy Is hereby, urnished.. -
Z.z ❑ CertipYcity p division. - " FIRE$PRINK ENERGY T-P4.
yed o is filed with the inspection
F'O Applicant 0.-701i MISC.- • REFER TO • v0.' ND' ,v ❑ F❑'
'CC42 : CERTIFICATE OF EXEMPTION FROM WORKERS' PERMITISSUANCE .6.00 FLOOD ZONE
COMPENSATION INSURANCE - PLG.CONTR. 'LIC.NO. - - '
1 0 (This.section need not'be,-completed if the permit is for'one I PLO,; ,TOTAL tO NO -Y'.❑I NO
2. hundred dollars(S 100)or less.)- - '
U O. I certify Ilial in the performance of the work forwhich this ver. QTe. 'MECHANICALPERMIT - IEEE FEE SUMMARY
LL'f., mit is-issued.I shall not rkers .any person in any manner so as to ,
a W'; become subject,to the Workers Compensation Laws of Califoroia. '
. .. s. . Date ' Applicant - AlTEROR:ADD�TO MECH. a ;4.00 ; BUILDING'
}'m' NOTICE TO'APPLICANT: If.after making this Certificate;of Ex- ..,
„FZ emotion,you should become subject to the Workers'Compensation. APPLIANCE •
'4.00 .PLAN CHECK'
sue provisions,ofthe Laboriee Cit shill
ll deemed re orth comply with- FEE'
U''- such provisions or this permit shall be deemed revoked. AIR HANDLING UNIT(TO 10,000OF.M) ,-'3.00 '
�_'. CONSTRUCTION LENDING AGENCY AIR HANDLING UNIT(OVER�10p00C.F-M.)'5.00 SEISMIC FEE.
0.
I
performance ofat there is thework for wfi chrth s permiuction t isgi agency
(Sec. EXHAUST'HOOD(WITH DUCT) 2.00 •'
• me (Sec. MICROFILM,
3097,Civ.C.). HEATING UNIT(TO 100,000 B.T:U.)• 4.00 - • •
Lenders Ad -
Lcnde sAtldrdr ess " HEATING UNIT(OVER'100• ,000 B.T!lll)7:50 ELECTRIC-
_ I certify that I ha a read the application'and state that the above VENTILATION FAN(SINGLE) ' ' 3.00 _ a
• information is correct I agree'to comply with all city and•county PLUMBING
• .ordinances and slate Taws relating to building Construction.
BOILER-COMM(3 H-P-or 100000 B:TU
ion..and , .) 4:00
,h reby authorise representatives of this city. to enter upon the
, above mentioned property for inspection purposes. " BOI L•ER-COMP(Oyer 100,000 BTU)SEE FEE$CH. MECHANICAL
(We) agree to save indemnify and keep.hannkssi We:City of MISC.- - REFER'TO ORD' -
Cupertino against liabilities,judgments,vests and`expenses which CONST:'TAX1
• 'may many'way accrue against said City in.consequence;Ofthe PERMIT ISSUANCE ..3:00
sling o(this perms ',1 � MECH.CONT 11C.NO. MECH.
LCL � ate - ITOrAL • TOT; / 7�zS'.
gnatureof Applicant/Contmc[or Data
- - OFFICE-COPY '. - .t •
•
,..APPLICANT TO FILL IN INFORMATION WITHIN RED LINES'- USE•BALL POINT PEN•ONLY
BUILDING PROJECT I DENTI FICATION PERMIT NUMBER
BUILDING. APPLICATION &PERMIT
ADDRESS
• 7t 1& C��-<,S-ILj �(�!'C I{ - BUILDING—ELECTRICAL—PLUMBING—MECHANICAL 557-7
OwxERS, I, • - - • -� — — -- PLAN CHECK VALIDATION
NAME 72`—(1.9 Y9
• rJ '17 QTY• ELECTRICPERMIT - FEE
••/./- ifA-7.4 9e2p -PHONE
CONTRACTOR'S II -SWITCHES-RECEP 5.00/1.00
NAME tf _ do7IP 1,313 A.
P,4 C letrf1)t'/t) LIG NO LIGHTING FIXTURES 5.00/1.00 `7j i
ADDRESS ADDRESS /^ C/ 21c7--2044
�7_� PPUANCES-RESIDENTIAL• `
-' (�[17U off J/ ,PHONE �� PANELS. $:OO ,�jDATE OFAPPLICATION
ARCHITECT - - - PLAN CHECK FEE P.C.NO. -
on SIGNS - 6.00
IENGINEER
't LIC.ND. •SIGNS;TRANS, 3.00
ARCH OR ENG,' PERMIT.VALIDATION "
ADDRESS,' .SPECIAL CIRCUIT '5;00
ZIP EMP.METER OR'POLE'INS- 15.00
I.
APPLICANT'$
ADDRESS ' C ' MOTORS J �s{.,it, 1J. SEE FEEISCH, .TO ' i (
t{ 4 �1LOLuo- ST,•
Srb.cs ,{Ki• SERVICE CHANGE ' •10.00 �/ /
w oa
LICENSED CONTRCTORS DECLARATION - /.
a •
tl.,H • I hereby affirm:that I am licensed under.provisions of Chapter 9, . ' • 1
� J Z r. Prof mons Codecotimencing lh Sectionlicense is F Divi full force and effect.
Business and' 8LDj' ELE T.• - PLG. MECH.
Z i in apt W License Clap Lie.Number 'D (p f 3 (� _ ■ . .0 .0
'Dale -'° ontmclor _ •
G yf J. _ n�� _
¢ ¢ m.a OWNER-BUILDER DECLARATION • - --BUILDINOPERMIT
D A - ' iNFQM4TION. ,,
,°<- g LL;- I hereby affirm that I am exempt from the Contractor's License MISC-- REFER TO ORD ' - -
LL al Law for the following reason(Sec.7031.5.Businessand Professions VALUATION
L - PERMIT ISSUANCE
4 w c,.2, Code:Any city or county which requiresa permit toceinstmct,alter, - 6•� �t , -
¢¢ a0 Improve,demolish;or repair any structure,prior to Is issuance,.also: EL CO TR. •
LIC,NO, ELEC.
O u requires the applicant for such permit Io file YsigneJ statement that '3 TOTALQ
raw$ hes licensed pursuant to the with lions of the Contmelon's-license' /-�� C/v �-, t+ Z E'SQ /�ERMIT TO
Hi> law(Chapter 9(commencing with Section is f Division 3'Of the ill u'
f x.o else bass and ProfessionslegCode)or•that he is exempt therefrom 1 5• QM ''P,LUMBING PERMIT, - . `• FEE. -
'¢1-,(. the basis for tM alleged exemption Any violation of Section 7031,5 - -
u; by any applicant fora permit subjects the applicant to civilpenail STORIES TYPE CONSTR..
y' ALTER-DRAIN&VENT-WATER' 4:00 '`
rof not more than fivehundred dollars(5500).): '., - ,'
❑ I.as owner of lhe property,or my employees with wages as • BACK-FLOW PROTECT-, DEVICE
their sole compensation,will do the work;and the sWoture is not, 2.00 • - OCG.GROUP RES.UNITS
intended Or 0Deold forlsale-(Sec, 7044:;Business and Professions. DRAINS-FLOOR,ROOF;AREA;COND-"4:00
. Code:The Contractor%License Law does not apply to an owner of r;
property who builds or improves thereon.and who does such work FIXTURES,-PERTRAP 4.00 - Sa FT.FLOOR AREA TOTACACREAGE
� himself.or through hs own employees,provided That such improve
-_ ;meats are notintended or offered for sale..IF however th buildmg; . GAS-EA,SYSTEM-1 INC:4 OUTLETS' 4.00
or improvement is sold within one year of completion.the owner- GAS'-EA.SYSTEM-OV ER.4(EA.) 1'.00
builder will-have the burden of proving that he did not build oven.' GAS.- USE
prove for purpbsp of sale.). ''` INDUSTRIAL WASTE INTER - 20-p0 E IND CON PB orb.
CL 1,as owner_of the property am delusively contracting with IkkMQQQttyyy(((���,,BBB///SSS��' El ❑ • ❑ ❑
licensed contractors10 construct the project(Sec.7044,Business LAWN SPRINKLERS-,1 (NGS V.B. 5.00 'ASSESSORS PARCEL NO.
and Professions Code.The Contractors License Law does nut apply
toanowner.ofproperty'who builds or improves thereon,and who LAWN SPRINKLERS-'OVER'I5(EA.) 1.00
`(
•
contracts for such projects with a contractosl licensed pursuant to - •
the Contractors License Law. SEWER-SANITARY-STORM EA.200ft/8.00 . .TRACT NO. PARCEL NO.
❑ I am exempt under Sec. -,RAPE.for this.
reason ' '' WATER HEATER WNENT 4,00 _
Owner - Date - WATERSYSTEM - 4.00 , ACC.DATE ACC.FILE NO.
WORKERS'COMPENSATION 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'Insuance.or a certified ' .. - ZONING ENG.SITE NO. • -
'copY,thereof(Sec.J800, piny ).,,s i jr 4, f ��7
Policy No. Company V
Q.. 0 Certified copy is hereby furnished:. -. . - ' •
Z.z ❑ Certifiedecopy is filed with the city inspection.division. FIRE SPNINK' ENERGY T72.4
.j r1Q ,- MISC:- - REFER TO ORD: F�,
Q Applicant' •
Y N V ND
• scH CERTIFICATE OE EXEMPTION FROM WORKERS• :PERMITtISSUANCE . • ' 6,00 '
COMPENSATION INSURANCE PLG CONTR. - FLOOD ZONE Aa:U.C.
.. O . LIC:NO. PLG. t
n rs dollars rased not se comPkted if the permit it for one s•. (TOTAL Y 'N� YO ry�
Z hundred dollars 1E 100)or less.) -
U'O,- ThrUfy that in the`performance of the work for which per-
QTY. ' MECHANICAL PERMIT. FEE - :FEE•SUMMARYf -
IL f .mit Is Issued,1 shall not employ any.person in any manner so as ro . '!�^
U w become subject to the Workers'Compensation Laws of California.'
y Date Applicant - ALTER OR ADD TO MECH. - q,p0 BUILDING
} Os NOTICE TO APPLICANT: If.after making this Ccrtifiata'ofEx-
1— Z emption,you should become subject to the Workers.Compensation - ' , APPLIANCE •
-
•
provisions.of the labor Code,:you must forthwith comply.with - 4.00 PLAN CHECK
U - such provisions or this pernlit'shall be deemed revoked. - ' ' AIR HANDLING UNIT(TO 10p00GF.M) 3.00 FEE -
.
•
• CONSTRUCTIONLENDING'AGENCY • r AIRHANDUNG UNIT:OVER 1opDOC.F.M) 5.00 • SEISMIC FEE
I. •hereby'affirm that there is a construction lending agene).foe - EXHAUST HOOD(WITH DUCT) 2.00
performance the of•the-.work for which this permit is issued(Sec.
•
3097,Civ.C.). - - HEATING UNIT(TO 100,000.B,T-U,) 4.00 ' MICROFILM
Lender's Name • r
Lenlfer'sAddress - ' _HEATING UNIT 100,000B:T:U.)7.50 ELECTRIC if� ,�
I certify that I have read this application and state that Use above VENTILATION FAN(SINGLE) • • 3.00 '
information is correct. Ipgree to comply with all city;and'county:
ordinances ands state laws relating to building.construction. BOILffl-COIl�13 H.P.or 100,000 B.T.U.) 4.00 PLUMBING ,ti.
hereby authorize repreN:nlatives of this.city to enter upon the.
above-mentioned property for inspection purposes. • BOILER-COMP(Overt00,000 OTUISEE FEE SCH. MECHANICAL
(We)-agree to save, indemnify and keep harmless-the City of • MISC.-' ; ' REFER TO.ORD:
Cupertino against liabilities,judgments, costs and expenses which _
may in any way accrue against said.City in consequence of the 'PERMIT ISSUANCE -I3.00 CONST,TAX
ranting
gf tthiiss permit// /'y /-�/J/1 MECH,CONT LIC NO MECH. •
1 /.fAW`; 1HNsus �� TOTAL 2u
ignature of Applicant/Contractor Date • TOTAL • y//JL/51)
. OFFICE COPY -