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096070Ofz W 0 O 2aw' hw H = z0y 0 y H W Q Y Y J rC 2 W Ua '0 rl 7K LL y F LL 0jen W i M W ¢ O 0 d X O LL W N ccxa ccxI-o w so U APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY BUI LDI NG PROJECT 1 DENTI FICATION APPLICATION & PERMIT BUILDING - ELECTRICAL- PLUMBING -MECHANICAL PERMIT NUMBER n OuGUILDIVUADDRESS P83 fy dJ OWNER'S NAME QTY: ELECTRIC PERMIT FEE PLAN CHECK VALIDATION. NNrRwcroRs NAME OUTLETS -SWITCHES- RECEP 10.0011.00 LIGHTING FIXTURES 10.0011.00Aneo CONTRACTOR'S ADDRESS RESIDENTIAL 4.00 PANELS 10.007 * A PH N tf jy DATE OF APPLICATION ARCHITECT iF-7n0-yJ ORENGINEER LIC. ND, PANELS iOVER200AMP) 2O,Q0 PLAN CHECK FEE P.C. NO. SIGNS TRANS. 3.00 ARCH, oR ENG. ADDRLSS SPECIAL CIRCUIT 5.00 PER Aq[jfFj 1TION 1"7 Loi EMP, METER OR POLE INS, 20.00zip SEP Q 19 City at Cupertino APPLICANT'S ADDRESS 37-v A Q MOTORS SEE FEE SCH, SERVICE CHANGE 20.00 LICENSED CONTRACTORS DECLARATION TEMP. POLE 30:00 I hereby affirm that I am licensed under provisions of Chapter 9 commencing with Section 7000) of Division 3 of the Business and Professions Code. and m 'license is in full force sa eat. 15" License Class Lie. Number -A . Date contractor ISSUANCE DATE BLDG. ELECT. PLG, E BUILDING PERMIT INFORMRMATIQNOWNER -BUILDER DECLARATION I hereby affirm that [ am exempt from the Contractor's License Law for the following reason. (Sec. 703 1.5, Business and Professions Code. Any city or county which requires a permit to construct, alter, improve, demolish, or repair any structure, prior to its issuance, also requires the applicant for such permit to file a signed statement that he is licensed pursuant to the provisions of the Contractor's License Law (Chapter 9 (commencing with Section 7000) ofDivision 3 of the Business and Professions Code) or that he IS exempt therefrom and MISC. - REFER TO ORD VALUATION fFT, PERMIT ISSUANCE 10.00 ELEC. CONTR. LIC. NO. ELEC. TOTAL PERMIT TO UPIQTY. PLUMBING PERMIT FEE STORIES TYPE CONSTR. the basis for the alleged exemption. Any violation afsection 7031.5 by any applicant for a permit subjects the applicant to a_ civil penalty of not more than five hundred dollars (S500).): ALTER DRAIN & VENT -WATER (EA.) 5,00 1, as owner of the property, or my employees with wages as their sale compensation, will do the work, and the structure is not BACK FLOW PROTECT. DEVICE 4.00 OCC. GROUP RES. UNITS DRAINS -FLOOR, ROOF, AREA,COND. 5.00intendedorofferedforsale (Sec. 7044, Business and Professions Code: The Contractor's License Law does not apply to an owner of property who builds or improves thereon, and who does such work himself or through his own employees, provided that such Improve- ments are not intended or offered for sale. if, however, the building FIXTURES - PER TRAP 5.00 SO. FT. FLOOR AREA TOTAL ACREAGE GAS-EA.SYSTEM-11NC.40UTLETS 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 ofsale.). 1, 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 licensed contractors' to construct the project (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 LAWN SPRINKLERS - 1 INC 5 V.H. 6.00 ASSESSORS PARCEL NO. LAWN SPRINKLERS - OVER 5 (EA.) 1.00 contracts forsuch'projects with a conlractor(s) licensed pursuant to the Contractor's License Law. SEWER -SANITARY -STORM EA. 200ftI10.00 T IACT NO. PARCEL NO. 0 I am exempt under Sec. BAP.C. for this WATER HEATER WIVENT 6.00 reason Owner Dale WATERSYSTEM 5.00 ACC. PATE ACC - FILE NO. WATER TREATING EQUIP, 5.00WORKERS' COMPENSATION DECLARATION I hereby affirm that I have a certificate of consent to self -insure, or a certificate of Workers' Compensation Insyrancc, ora certified copy there oLi ec. 3800, Lab.C.)__722 7 / Polic o. i ompany -dui (/ Certified copy iS hereby furnished. Certified copy is filed with the city inspection division. Applicant ZONING ENG. SITE NO. FIRE SPRINK Y N ENERGY T-24 Y N MISC. - REFER 70 ORD. CERTIFICATE 01= EXEMPTION FROM WORKERS' PERMIT ISSUANCE 10.00 FLOOD ZONE AA_U.C. PLG. CONTR. LIC. NO. PLG. TOTAL COMPENSATION INSURANCE This section need not be completed if the permit is for one Y N I Y N 0 QTY. MECHANICAL PERMIT FEE FEE SUMMARY hundred dollars (S 100) or less.) 1 certify [hat 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: If, after making this Certificate of Ex- ALTER OR ADD TO MECH. 5.00 APPLIANCE 5.00 PLAN CHECK FEE emption, you should became subject to the Workers Compensation provisions of the Labor Code, you must forthwith comply with such provisions or this permit shall be deemed revoked. AIR HANDLING UNIT (TO 10.0MC.F.M.) 4.00 AIRHANDLINGUNIT(OVER IO,COOCF.M,) 6.00 SEISMIC FEECONSTRUCTIONLENDINGAGENCY I hereby affirm that there is a construction lending agency for the performance of the work for which this ermit is issued (Sec. 3097,Civ, C.). EXHAUST HOOD (WITH DUCT) 5,00 . d0 MICROFILM HEATING UNIT (TO 100,000 B.T.U.) 8.00 8 .prJ HEATING UNIT (OVER 100,000 B.T,U.)9.50 ELECTRIC Lender's Name dLender's Addres I certify that 1 have read th s4pn ltcat(on and state that the above V EN71 CATION FAN [SINGLE) 4.00 r•00 information n correct. 1 agree to comply with, all city and county ordinances and stale laws relating to building construction, and PLUMBING BOILER -COMP (3 H.P. or 100,000 B.T,U.) 6.00 BOILER -COMP (Over 100,000 BTU) SEE FEE SCH. MECHANICALherebyauthorizerepresentativesofthiscitytoenteruponthe above-mentioned property for inspection purposes. MISC. - REFER TO ORD. We) agree to save, indemnify and keep harmless the City of Cupertino against liabilities, judgments. costs and expenses which may m any way accrue against said City in consequence of the CONST. TAX PERMl71SSUANCE 10.00 p,pv MECH. CONT. LIC. NO. MECH%. grantin of this permit. TOTAL 00 TOTAL Signa of pplicantJContractor Date - OFFICE COPY 0Ofz W 0 O 2aw' hw H = z0y 0 y H W Q Y Y J rC 2 W Ua '0 rl 7K LL y F LL 0jen W i M W ¢ O 0 d X O LL W N ccxa ccxI-o w so U APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY BUI LDI NG PROJECT 1 DENTI FICATION APPLICATION & PERMIT BUILDING - ELECTRICAL- PLUMBING -MECHANICAL PERMIT NUMBER n OuGUILDIVUADDRESS P83 fy dJ OWNER'S NAME QTY: ELECTRIC PERMIT FEE PLAN CHECK VALIDATION. NNrRwcroRs NAME OUTLETS -SWITCHES- RECEP 10.0011.00 LIGHTING FIXTURES 10.0011.00Aneo CONTRACTOR'S ADDRESS RESIDENTIAL 4.00 PANELS 10.007 * A PH N tf jy DATE OF APPLICATION ARCHITECT iF-7n0-yJ ORENGINEER LIC. ND, PANELS iOVER200AMP) 2O,Q0 PLAN CHECK FEE P.C. NO. SIGNS TRANS. 3.00 ARCH, oR ENG. ADDRLSS SPECIAL CIRCUIT 5.00 PER Aq[jfFj 1TION 1"7 Loi EMP, METER OR POLE INS, 20.00zip SEP Q 19 City at Cupertino APPLICANT'S ADDRESS 37-v A Q MOTORS SEE FEE SCH, SERVICE CHANGE 20.00 LICENSED CONTRACTORS DECLARATION TEMP. POLE 30:00 I hereby affirm that I am licensed under provisions of Chapter 9 commencing with Section 7000) of Division 3 of the Business and Professions Code. and m 'license is in full force sa eat. 15" License Class Lie. Number -A . Date contractor ISSUANCE DATE BLDG. ELECT. PLG, E BUILDING PERMIT INFORMRMATIQNOWNER -BUILDER DECLARATION I hereby affirm that [ am exempt from the Contractor's License Law for the following reason. (Sec. 703 1.5, Business and Professions Code. Any city or county which requires a permit to construct, alter, improve, demolish, or repair any structure, prior to its issuance, also requires the applicant for such permit to file a signed statement that he is licensed pursuant to the provisions of the Contractor's License Law (Chapter 9 (commencing with Section 7000) ofDivision 3 of the Business and Professions Code) or that he IS exempt therefrom and MISC. - REFER TO ORD VALUATION fFT, PERMIT ISSUANCE 10.00 ELEC. CONTR. LIC. NO. ELEC. TOTAL PERMIT TO UPIQTY. PLUMBING PERMIT FEE STORIES TYPE CONSTR. the basis for the alleged exemption. Any violation afsection 7031.5 by any applicant for a permit subjects the applicant to a_ civil penalty of not more than five hundred dollars (S500).): ALTER DRAIN & VENT -WATER (EA.) 5,00 1, as owner of the property, or my employees with wages as their sale compensation, will do the work, and the structure is not BACK FLOW PROTECT. DEVICE 4.00 OCC. GROUP RES. UNITS DRAINS -FLOOR, ROOF, AREA,COND. 5.00intendedorofferedforsale (Sec. 7044, Business and Professions Code: The Contractor's License Law does not apply to an owner of property who builds or improves thereon, and who does such work himself or through his own employees, provided that such Improve- ments are not intended or offered for sale. if, however, the building FIXTURES - PER TRAP 5.00 SO. FT. FLOOR AREA TOTAL ACREAGE GAS-EA.SYSTEM-11NC.40UTLETS 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 ofsale.). 1, 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 licensed contractors' to construct the project (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 LAWN SPRINKLERS - 1 INC 5 V.H. 6.00 ASSESSORS PARCEL NO. LAWN SPRINKLERS - OVER 5 (EA.) 1.00 contracts forsuch'projects with a conlractor(s) licensed pursuant to the Contractor's License Law. SEWER -SANITARY -STORM EA. 200ftI10.00 T IACT NO. PARCEL NO. 0 I am exempt under Sec. BAP.C. for this WATER HEATER WIVENT 6.00 reason Owner Dale WATERSYSTEM 5.00 ACC. PATE ACC - FILE NO. WATER TREATING EQUIP, 5.00WORKERS' COMPENSATION DECLARATION I hereby affirm that I have a certificate of consent to self -insure, or a certificate of Workers' Compensation Insyrancc, ora certified copy there oLi ec. 3800, Lab.C.)__722 7 / Polic o. i ompany -dui (/ Certified copy iS hereby furnished. Certified copy is filed with the city inspection division. Applicant ZONING ENG. SITE NO. FIRE SPRINK Y N ENERGY T-24 Y N MISC. - REFER 70 ORD. CERTIFICATE 01= EXEMPTION FROM WORKERS' PERMIT ISSUANCE 10.00 FLOOD ZONE AA_U.C. PLG. CONTR. LIC. NO. PLG. TOTAL COMPENSATION INSURANCE This section need not be completed if the permit is for one Y N I Y N 0 QTY. MECHANICAL PERMIT FEE FEE SUMMARY hundred dollars (S 100) or less.) 1 certify [hat 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: If, after making this Certificate of Ex- ALTER OR ADD TO MECH. 5.00 APPLIANCE 5.00 PLAN CHECK FEE emption, you should became subject to the Workers Compensation provisions of the Labor Code, you must forthwith comply with such provisions or this permit shall be deemed revoked. AIR HANDLING UNIT (TO 10.0MC.F.M.) 4.00 AIRHANDLINGUNIT(OVER IO,COOCF.M,) 6.00 SEISMIC FEECONSTRUCTIONLENDINGAGENCY I hereby affirm that there is a construction lending agency for the performance of the work for which this ermit is issued (Sec. 3097,Civ, C.). EXHAUST HOOD (WITH DUCT) 5,00 . d0 MICROFILM HEATING UNIT (TO 100,000 B.T.U.) 8.00 8 .prJ HEATING UNIT (OVER 100,000 B.T,U.)9.50 ELECTRIC Lender's Name dLender's Addres I certify that 1 have read th s4pn ltcat(on and state that the above V EN71 CATION FAN [SINGLE) 4.00 r•00 information n correct. 1 agree to comply with, all city and county ordinances and stale laws relating to building construction, and PLUMBING BOILER -COMP (3 H.P. or 100,000 B.T,U.) 6.00 BOILER -COMP (Over 100,000 BTU) SEE FEE SCH. MECHANICALherebyauthorizerepresentativesofthiscitytoenteruponthe above-mentioned property for inspection purposes. MISC. - REFER TO ORD. We) agree to save, indemnify and keep harmless the City of Cupertino against liabilities, judgments. costs and expenses which may m any way accrue against said City in consequence of the CONST. TAX PERMl71SSUANCE 10.00 p,pv MECH. CONT. LIC. NO. MECH%. grantin of this permit. TOTAL 00 TOTAL Signa of pplicantJContractor Date - OFFICE COPY APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY BU LDI NG PROJECT 1 DENTI FICATI ON PERMIT NUMBER ADDRESSILDIN APPLICATION & PERMIT ^ U BUILDING - ELECTRICAL-PLUMBING-MECHANICAL u 9607 OWNER'S PLAN CHECK VALIDATION NAME /J QTY. ELECTRIC PERMIT FEE O ,n .(_A PRONE CONNAAME ACTORS OUTLETS-SWITCHES-RECEP 10.00/1.00 /a LIC.ND. 4 LIGHTING FIXTURES 10.00/1.00 ADDRESS TORS APPLIANCES-RESIDENTIAL 4.00 � p l vH NE q PANELS 10.00 I DATE OF APPLICATION ARCHITECTV - YtP��F (� !� Sid/ PANELS 200 AMP) 20.00 AN CH OR ECK FEE P.C.NO. ENGINEER ' uc.No. SIGNS TRANS. 3.00 ADDRESS Rea SPECIAL CIRCUIT 5.00 PERMIT VALIDATION ZIP TEMP.METER OR POLE INS. 20.00 nA'D, APPLICANT ADDRESS MOTORS SEE FEE SCH. r A ,n t ,, a- 7t SERVICE CHANGE 20.00 SEP 0 41985 00 LICENSED CONTRACTORS DECLARATION TEMP.POLE 30.00 I av w I herby affirm that I am licensed under provisions of Chapter 9 y a N (commencing with Section 7000)of Division 3 of the Business and BILD&I E EC F N z Professions Code,and my license is in full force and effect 1. z O m - License Clasy�. -Lic.Number 'j -'c/a(+ S ❑ ❑ ❑ O v, O Date 3 /sG O• i• //�. .'1/ r L e1 -3 > 'Contracmr 7-9-T_'7 OWNER-BUILDER DECLARATION BUILDING PERMIT o a U INFORMATION wI hereby affirm the 1 and exempt from the Contractor's License MISC.- REFER TO ORD r LL O J Law for the following reason.(Sec.7031.5,business and Profesxions PERMIT ISSUANCE 10.00 VALUATION $/FT. 0f Code:Any city or county which requiresa permit to construct,alter, ar Q ¢ 0 Improve,demolish,or repair any structure,prior to Its Issuance,alio ELEC.CONTR. LIC.NO. ELEC. Q ¢ requires the applicant for such permit to file a signed statement that TOTAL PERMIT TO d w es m he is licensed pursuant to the provisions of the Contractor's Littnse FT Law(Chaple,9(commencing with Section 7000)of Division 3 of the E 4 ¢o Business and Professions Code)or that he is exempt therefrom and QTY. PLUMBING PERMIT FEE L e F o the basis for the alleged exemption.Any violation O(Section 7031.5 $TORTE N E CONSTR. a ;°1 by any applicant for a permit subjects lire applicant to a civil penally ALTER-DRAIN&VENT-WATER (EA.) 5.00 -+ of not more than five hundreJ Aollurs I SS00).1: ❑ I,as owner of the property,or my employees with wages as BACK F LOW PROTECT.DEVICE 4.00 OCG GROUP RES.UNITS their sole compensation,will do the work,and the structure is not intended or offered for sale (Sec. 7044, Business and Professions DRAINS-FLOOR,ROOF,AREA,COND. 5.00 Code:The Contractors License Law docs not apply to an owner of properly who builds or Improves thereon,and who docs such work FIXTURES-PER TRAP 5.00 SQ FT.FLOOR AREA TOTAL ACREAGE himself or through his own employees,provided that such improve- ments are not intended or offered for sale.If,however,the building GAS-EA.SYSTEM-1 INC.4 OUTLETS 6.00 or improvernent-is sold within one year of completion,the owner- GAS-EA.SYSTEM-OVER 4(EA.) 2.00 builder will have Iheburden of proving that he did not build or ire- BUILDING USE prove for purpose of sale.). RE IND CON PB Other ❑ I,as owner of the property',am exclusively contracting with INDUSTRIAL WASTE INTER. 30.00 ❑ ❑ ❑ ❑ licensed contract.,, to construct the project(Sec 7044, Business LAWN SPRINKLERS- 1 INC 5 V.B. 6.00 ASSESSORS PARCEL NO. anti Professions Code:The Contractors License Law does not apply to an owner of property who builds or improves thereon.and who LAWN SPRINKLERS-OVER 5 (EA.) 1.00 contracts for such projects with a contractorfs)licensed pursuant to SEWER-SANITARY-STORM EA.200ft/10.00 the Contractor's License Law. TRACT NO. PARCEL NO. ❑ 1 um exempt under Sri,-,B&P.C.for this WATER HEATER W/VENT 6.00 rca$oll Owner Date WATER SYSTEM 5.00 ACC.OATE ACC.FILE NO. WORK ERS'COMPENSATION DECLARATION WATER TREATING EQUIP. 5.00 1 hereby affirm Ihut I have n certificate of consent to,elf- insure. or a certificate of Workers Compensation Insurance,or a ccrtl'ied ZONING ENG.SITE NO. copy thereoffSee.3800,Lab.C.).�n'. Poll No.�,j[(,pv'`Cnm pan Y Poll copy is hereby famished.. 01 ' FIRE SPRINK ENERGYT-24 Z Z ❑ Certified copy is fled with the city mspecfion division. MISC.- REFER TO ORD. F O Applicant _ Y ❑ N❑ Y ❑ N❑ w CERTI FICA I F OP EXE M PTION I7ROM WORKE RSPERMIT ISSUANCE 10.00 FLOOD ZONE A.L.U.C. W > COM PIiNSA'I'ION INSURANCE PLG.CONTR. I - LIC.rvo. PLG. d O (This section need not be completed if the Penni[ is for one TOTAL y❑ N❑ y ❑ N❑ Z hundred dollars(S 100)or Iess.1 U O 1 certify that in the performance of the work for which this per- QTY. MECHANICAL PERMIT FEE FEE SUMMARY LL U mit is issued, I shall not employ any peon in any manner so us to Ow become subject to the Workers Compensation Laws of California. 0. Date Applicant BUILDING } to NOTICE TO APPLICANT: If,after making this Certificate of Ex- ALTER OR ADD TO MECH. 5.00 Z emption,you should become subject to the Workers'Compensation APPLIANCE 5.00 PLAN CHECK provisions of the Labor Code, you must forthwilh comply with FEE U such pro visions or this permit shall be deemed revoked. AIR HANDLING UNIT(TO 10=C.F.M.) 4.00 CONSTRUCTION LENDING AGENCY AIR HANDLING UNIT(OVER IO,000GEM.) 6.00 SEISMIC FEE I hereby affirm tint there is a construction lending agency for EXHAUST HOOD(WITH DUCT) 5.00 A-� �i the performance Of the work for which this permit is issued(Sec. MICROFILM 3097.0,C.). HEATING UNIT(TO 100,000 B.T.U.) 8.00 Lender's Name ELECTRIC Lenderi Name / -g - finr ' �y- 0- ate_ 1111t,AIIINISLINII IOVER100,000B.T.U.)9.50I certify that179*t-ad2h-YseppiRrion and state that the aboveVENTILATION F.AN (SINGLE) 4.00dninformation is correct. I agree to comply with all city and county PLUMBING ordinances and stale laws relating to building construction, andBOILER-COMP(3HP.orlOO.000B.T.U.) 6.00hereby authorize representatives of this city to enter upon thegOILE1i0MP (Over 100,000 BTU)SEE FEE SCH. MECHANICAL abovemmrtioned property for inspection purposes,(We) agree to save, indemnify and keep harmless the City ofMISC.- REFER TO ORD. Cupertino against liabilities,judgments, costs and expenses which PERMIT ISSUANCE 10.00 CONST.TAX may in any way accrue against said City in consequence of the grantin of this permit MECH.CONT.[/CoLIC.NO. MECH. _ TOTAL 3100 TOTAL Ignature of Appticanntractor U:ve INSPECTOR COPY