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09541APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY BUILDING PROJECT IDENTIFICATION APPLICATION & PERMIT BUILDING - ELECTRICAL- PLUMBING -MECHANICAL PERMIT NUMBER 00541 BUILDING ADDRESS n W E'a NAE y�S � PHDNE QTY. ELECTRIC PERMIT FEE PLAN CH ECK VALI DATION NAMpRAC7o S' OUTLETS -SWITCHES-RECEP 10.00/1.00 LIGHTING FIXTURES 10.00/1.00 ND, ADDRESSTORS APPLIANCES - RESIDENTIAL 4.00 PANELS 10.00 PHONE / DATE OF APPLICATION OR E ENGINEER LIC. No, PANELS (OVER 200 AMP) 20.00 PLAN CHECK FEE P.c, No. SIGNS TRANS. 3.00 ARCH.ADDREss ENG. SPECIAL CIRCUIT 5.00 PERMIT. VALIDATION PAID EMP. METER OR POLE INS. 20.00 ZIP AUG 231 APPLICANTS ADDRESS MOTORS SEE FEE SCH. SERVICE CHANGE 20.00 �Q5 City Of Cupertino LICENSLD CONTRACTORS D17CLARATION TEMP. POLE 30.00 I hereby affirm that I am licensed under provisions of Chapter 9 ISSUANCE DATE (commencing with Section 7000) of Division 3 of the Business and BLDG. ELECT. PLG, MECH. 1'rofessiuns Code and y license is in full fort and effect. License Class - Lic. Number ��_�._ 0 El ❑ Hale - Contractor BUILDING P RMIT OWNER -BUILDER DECLARATION MISC. - REFER TO ORD License I hereby collo that 1 an, exempt from the ContrBusiness INFORM TION PERMIT ISSUANCE 10.00 VALUATION Pr Law forthe followingmason.(Sec.703 uiresa,ermit tocnstruct. alte.ons and Code: Any city or county which requirese permit to construct• alter. ELEC. DONTR. LIC. NO. ELEC. improve, demolish, or repair any structure, prior its issuance, also req the applicant litr such revisit to ❑Ic a signed smtemeN that n TOTAL P RMIT TO is licensed he is licensed pursuant to the provisions of the)ofDivisContractor's License D ivision3of the Law (Chapter 9 (commencing with Section is exempt Business and Professions Codes or that he is exempt therefrom and QTY. PLUMBING PERMIT FEE 1 the basis for the alleged exemption. Any violation of Secl ion 703 L$ 6 E& T E CONSTR. by any applicant fora permit Subjects the applicant to a civil penalty of not more than five hundred dollars (5500).): ALTER -DRAIN & VENT -WATER (EA.) 5.00 ❑ 1, as owner of Ore property, or my employees with wages as their sole compensation, will do the work, amt the structure is not BACK FLOW PROTECT. DEVICE 4.00 DCC. GROUP RES. UNITS DRAINS -FLOOR, ROOF, AREA, COND. 5.00 intended or offered for sale (Sec. 7044, Business and Professions Code: The Contractor's License Law does not apply to an owner of FIXTURES -PER TRAP 5.00 property who builds or improves thereon, and who does such work SQ FT. FLOOR AREA TOTALACREAGE himself or through his own employees, provided that such improve mems are not intended or offered l' or sale. It, however, the building GAS - EA. SYSTEM -1 INC.4 OUTLETS 6.00 or improvement is sold within one year of completion, the owner- builder will have the burden of proving that he did not build or im- GAS - EA. SYSTEM - OVER 4 (EA.) 2.00 BUILDING USE prove for purpose of (lie.1. t ❑ as owner of she exclusively contracting with INDUSTRIAL WASTE INTER. 30.00 RE INO CON PB Oilier ❑ ❑ ❑ ❑ LAWN SPRINKLERS - 1 INC 5 V.B. 6.00 d construct licensed contractors to construct ter project (Sec. 7044, Business he Atixe"VHS PARCEL NO. and Professions Code: The Contractor's License Law does not apply to anowner of property who builds or improves thereon, and who LAWN SPRINKLE RS -OVER 5 (EA.) 1.00 contracts for such projects' with u cantraemrl uu s/ licensed pursns to Contractor's the Cactor's Licenu Law. SEWER -SANITARY -STORM EA. 200ft/10.00 /0 TRACT NO. PARCEL NO. ❑ 1 am exempt under Sec.-, B &P,C, for do, reason WATER HEATER W/VENT 6.00 _ QQ Owner _ Date WATER SYSTEM 5.00 ACC.OATE ACO. FILE NO. WORK I:RS'CO.NPENSATION DECLARATION WATER TREATING EQUIP. 5.00 1 hereby affirm that I have a certificate of consent to self -insure, or a certificate of Workers' Compensation Insurance, or a certified ZONING ENG. SITE NO. copy thereof(Sec. 3800, Lab.C.). Policy No. Company ❑ Certified copy is hereby furnished. FIRE SPRINK ENERGY T-24 Certified c py is lilryed� with he city inspection division. A psi ant_1 119- '���- y ❑ N❑ y ❑ N❑ MISC. - REFER TO ORD. CERTIFICATE OF FXEMP'IION FROM WORK CRS' PERMIT ISSUANCE 10.00 14 dU FLOOD ZONE A. L. U.C. CONPI!N'SATION INSURANCE PLC. CONTE. LIC. NO. PLG. /Ny�� CIhis section need not be completed if the permit is for one TOTAL W v ❑ . N ❑ y ❑ N❑ hundred dollars (8100) or less.) I certify that in the performance of the work for which this per- mit is issued. 1 shall not employ any person in any manner so as to QTY. MECHANICAL PERMIT FEE FEE SUMMARY become 'subject to the Workers Compensation Laws of California. ALTER OR ADD TO MECH. 5.00 Date Applicant BUILDING NOl'ICE '10 APPLICANT': If, after making this Ccrsificate of E - APPLIANCE 5.00 PLAN CHECK emption, you should become subject to the Workers'Cumpensation provisions of he Labor Code, you muss forthwith comply with such provisions or this permit shall be deemed revoked. AIR HANDLING UNIT (TO 1Q000QF.M.) 4.00 FEE AIR HANDLING UNIT(OVER 10=C.F.M.) 6.00 SEISMIC FEE CONSTRUCTION LENDING AGENCY I hereby affirm that there is a construction lending agency for the perl'onnanee of the work for which this permit is issued (Sec. 3097, Civ.CJ. EXHAUST HOOD (WITH DUCT) 5.00 MICROFILM HEATING UNIT (TO 100,000 B.T.U.) 8.00 Lender's Name Lender's Address HEATING UNIT (OVER 100,000 B.T.U.)9.50 ELECTRIC VENTILATION FAN (SINGLE) 4.00 I certify that I have read this application and state Our the above r1 information is correct. I agree to comply with all city and county ordinances and state laws relating to building construction, and PLUMBING QU BOILER H.P. or 100,000 B.T.U.) 6.00 BOILER -COMP (Over 100,000 BTU) SEE FEE SCH. MECHANICAL hereby authorize representatives of this city INenter upon the abovclnentioned properly for inspection purposes. (We) agree to save, indemnify and keep harmless the City of Cupertino against liabilities, judgments, costs and expenses which may in any ay accrue against said City in consequence of the MISC. - REFER TO ORD. PERMIT ISSUANCE 10.00 CONST. TAX ger tfµ oft permil.� i _7r_Yr' MECH, CONT. LIC. NO. MECH. TOTAL " TOTAL ' na )S Ran��fi a at INSPECTOR COPY O Z Z N W91!J _ f1 Z Uo Z V OUJ to U APeLICANT TO FILL IN INFORMATION WITHIN RED LINES -- USE BA -MMINT PEN ONLY BUILDING PROJECT IDENTIFICATION APPLICATION & PERMIT: 275 BUILDING - ELECTRICAL- PLUMBING - MECHANICAL PERMIT NUMBER n 4A u s q.51RE . OWNER'S f `/-(^ NA E PHONE QT'Y. ELECTRIC PERMIT FEE PLAN CHECK VALIDATION CONTRACTOR'S NAME UTLETS-SWITCHES -RECEP 10.0011.00 a NO.C2SM DATE OF APPLICATION LIGHTING FIXTURES 10.00/1.00 ADDReAs Rs PHONE. 7J PPLIANCES- RESIDENTIAL 4.00 PANELS '• 10.00 ARL ITEcrPANELSORENGINEER LIC. NO- OVER 200 AMP) 20,00 PLAN CHECK FEE P.C. NO. SIGNS TRANS_ 3.00 ARCH. ENG. ADDRESS SPECIAL CIRCUIT 5,00 FERMI ON TEMP. METER OR POLE INS, 20.00ZIP QoC AUG 2 3 1985APPLICANT'S ADDRESS MOTORS SEE FEE SCH, SERVICE CHANGE. 20.00 LIt1nt of CupertIflo 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 Cod and icense is in full fore f ec License Class Lic. Number ISSUANCE DATE BLDG. 0 ELECT. L MECH, Dale Contractor OWNER -BUILDER DECLARATION 1 hereby affirm that I am exempt from the Contractor's License Law for the following reason. (Sec, 7031,5,13usinessandProfesdons 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 io file a signed statement that he u licensed pursuant to the provisions of the Contractor's License BUILDING RMIT INFORM TION MISC. - REFER TO ORD VALUATION SIFT. PERMIT ISSUANCE 10.00 ELEC. CONTR. LIC. NO. ELEC. TOTAL RMIT TO. QTY. PLUMBING PERMIT FEE Law (Chapter 9 (commencing with Section 7000) of Division 3 of the Business and Professions Code) or that he is exempt therefrom and the basis for the alleged exemption. Any violation of Sect ion 7031.5 IES T PE CONSTR. by any applicant fora hundred dollars $ 500). he licanttoacivilpenalty of not more than five hundred dollars (SS00).): ALTER -DRAIN BI VENT -WATER (EA.) 5,00 1, as owner of the property, or my employees with wages as their sole compensation, will do the work, and the structure is not BACK FLOW PROTECT. 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 SQ FT. FLOOR AREA TOTAL ACREAGE GAS- EA, SYSTEM -1 INC.4 OUTLETS 6.00 or improvement is sold within one year of completion, the owner- builder will have the burden of proving that he did not build or im- for purpose of sale.). 13 1. as owner of the property, am exclusively contracting with GAS - EA. SYSTEM - OVER 4 (EA,} 2.00 BUILDING USE q IND CON PB Oencr El1. 1:1 11INDUSTRIALWASTEINTER. 30.00 LAWN SPRINKLERS - 1 INC 5 V.B. 6,00licensedcontractorstocorkstrucLtheproject (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 11 ASSESSORS PARCEL NO. LAWN SPRINKLERS -OVER 5 (EA,) 1,00 contracts forsuch projects with a contractor(s) licensed pursuant to the Contractor's License Law. SEWER SANITARYSTDRM EA. 200ftl10.D0 0 TRACT NO. PARCEL NO. lam exempt under Sec. B.&P.C. for this WATER HEATER W/VENT 6.00 reason Owner Date WATER SYSTEM 5.00 ACC. DATE. ACC. FILE NO. WATER TREATING EQUIP, 5.00WORKERS'COMPENSATION DECLARATION 1 hereby affirm that I have a certificate of consent to self -insure, or a certificate of Workers' Compensation Insurance. or a certified ZONING ENG, SITE NO. copy thereof (Sec. 3800, Lab -C.). Policy No. Company FIRESPRINK Y E] N ENERGY T-24 Y 0 NQ Certified copy i5 hereby furnished. pliPCertified c¢py is firmedwith eity inspection division. Apant frslr%fir-ice MISC. - REFER TO ORD. CERTIFICATE OF EXEMPTION FROM WORKERS' PERMIT ISSUANCE 10-00160f) FLOOD ZONE A.L.U.C. PLG. CONTR. LIC. NO. PLG. /t!] TOTAL & COMPENSATION INSURANCE This Section need not be completed if the permit is for one Y [] N Y [:] N QTY. MECHANICAL PERMIT FEE FEE SUMMARY hundred dollars (S 100) or less-) I certify that in the performance of the work far which this per mit is issued, I shall not employ any person In any manner so as to BUILDING become subject to the Workers' Compensation Laws of California, Date Applicant NOTICE TO APPLICANT: If, after making this Certificate of Ex- ALTER OR ADD TO MECH, 5.00 APPLIANCE 5.00 PLAN CHECKemption, you should become subject to the Workers' Compensation provisions of the Labor Code, you must forthwith comply with such provisions or this permit shall be deemed revoked. FEEAIRHANDLINGUNIT (TO 10)000C,F.M.I 4.00 AIR HANDLING UNIT (OVER 10PWC.F,M.) 6.00 SEISMIC FEECONSTRUCTIONLENDINGAGENCY I hereby affirm that there is a construction lending agency for EXHAUST HOOD (WITH DUCT) 5.00 The performance of the work for which this permit is issued (Sec. 3097,Civ.C.). MICROFILM HEATING UNIT (TO 100,000 B.T.U.) 8.00 HEATING UNIT (OVER 100,000 B.T.U.)9.50 ELECTRIC Lender's Name Lender's Address I certify that I have read this application and state that the above information is correct, l agree to comply with all city and county ordinances and state laws relating to building construction, and VENTILATION FAN (SINGLE) 4.00 PLUMBING IQv BOILER COMP (3 H.P. or 100,000 B,T.U.I 6.00 BOILER -COMP (Over 100,000 BTU) SEE FEE SCH. MECHANICALherebyauthorizerepresentativesofthiscity -to enter upon the 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 ay accrue against said City in consequcncc of the gra I of permit. CONST. TAXPERMITISSUANCE10.00 MECH. CONT. LIG. NO, MECH, TOTAL TOTAL gnat re f ppircant Contract nate OFFICE COPY O Z Z N W91!J _ f1 Z Uo Z V OUJ to U APeLICANT TO FILL IN INFORMATION WITHIN RED LINES -- USE BA -MMINT PEN ONLY BUILDING PROJECT IDENTIFICATION APPLICATION & PERMIT: 275 BUILDING - ELECTRICAL- PLUMBING - MECHANICAL PERMIT NUMBER n 4A u s q.51RE . OWNER'S f `/-(^ NA E PHONE QT'Y. ELECTRIC PERMIT FEE PLAN CHECK VALIDATION CONTRACTOR'S NAME UTLETS-SWITCHES -RECEP 10.0011.00 a NO.C2SM DATE OF APPLICATION LIGHTING FIXTURES 10.00/1.00 ADDReAs Rs PHONE. 7J PPLIANCES- RESIDENTIAL 4.00 PANELS '• 10.00 ARL ITEcrPANELSORENGINEER LIC. NO- OVER 200 AMP) 20,00 PLAN CHECK FEE P.C. NO. SIGNS TRANS_ 3.00 ARCH. ENG. ADDRESS SPECIAL CIRCUIT 5,00 FERMI ON TEMP. METER OR POLE INS, 20.00ZIP QoC AUG 2 3 1985APPLICANT'S ADDRESS MOTORS SEE FEE SCH, SERVICE CHANGE. 20.00 LIt1nt of CupertIflo 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 Cod and icense is in full fore f ec License Class Lic. Number ISSUANCE DATE BLDG. 0 ELECT. L MECH, Dale Contractor OWNER -BUILDER DECLARATION 1 hereby affirm that I am exempt from the Contractor's License Law for the following reason. (Sec, 7031,5,13usinessandProfesdons 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 io file a signed statement that he u licensed pursuant to the provisions of the Contractor's License BUILDING RMIT INFORM TION MISC. - REFER TO ORD VALUATION SIFT. PERMIT ISSUANCE 10.00 ELEC. CONTR. LIC. NO. ELEC. TOTAL RMIT TO. QTY. PLUMBING PERMIT FEE Law (Chapter 9 (commencing with Section 7000) of Division 3 of the Business and Professions Code) or that he is exempt therefrom and the basis for the alleged exemption. Any violation of Sect ion 7031.5 IES T PE CONSTR. by any applicant fora hundred dollars $ 500). he licanttoacivilpenalty of not more than five hundred dollars (SS00).): ALTER -DRAIN BI VENT -WATER (EA.) 5,00 1, as owner of the property, or my employees with wages as their sole compensation, will do the work, and the structure is not BACK FLOW PROTECT. 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 SQ FT. FLOOR AREA TOTAL ACREAGE GAS- EA, SYSTEM -1 INC.4 OUTLETS 6.00 or improvement is sold within one year of completion, the owner- builder will have the burden of proving that he did not build or im- for purpose of sale.). 13 1. as owner of the property, am exclusively contracting with GAS - EA. SYSTEM - OVER 4 (EA,} 2.00 BUILDING USE q IND CON PB Oencr El1. 1:1 11INDUSTRIALWASTEINTER. 30.00 LAWN SPRINKLERS - 1 INC 5 V.B. 6,00licensedcontractorstocorkstrucLtheproject (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 11 ASSESSORS PARCEL NO. LAWN SPRINKLERS -OVER 5 (EA,) 1,00 contracts forsuch projects with a contractor(s) licensed pursuant to the Contractor's License Law. SEWER SANITARYSTDRM EA. 200ftl10.D0 0 TRACT NO. PARCEL NO. lam exempt under Sec. B.&P.C. for this WATER HEATER W/VENT 6.00 reason Owner Date WATER SYSTEM 5.00 ACC. DATE. ACC. FILE NO. WATER TREATING EQUIP, 5.00WORKERS'COMPENSATION DECLARATION 1 hereby affirm that I have a certificate of consent to self -insure, or a certificate of Workers' Compensation Insurance. or a certified ZONING ENG, SITE NO. copy thereof (Sec. 3800, Lab -C.). Policy No. Company FIRESPRINK Y E] N ENERGY T-24 Y 0 NQ Certified copy i5 hereby furnished. pliPCertified c¢py is firmedwith eity inspection division. Apant frslr%fir-ice MISC. - REFER TO ORD. CERTIFICATE OF EXEMPTION FROM WORKERS' PERMIT ISSUANCE 10-00160f) FLOOD ZONE A.L.U.C. PLG. CONTR. LIC. NO. PLG. /t!] TOTAL & COMPENSATION INSURANCE This Section need not be completed if the permit is for one Y [] N Y [:] N QTY. MECHANICAL PERMIT FEE FEE SUMMARY hundred dollars (S 100) or less-) I certify that in the performance of the work far which this per mit is issued, I shall not employ any person In any manner so as to BUILDING become subject to the Workers' Compensation Laws of California, Date Applicant NOTICE TO APPLICANT: If, after making this Certificate of Ex- ALTER OR ADD TO MECH, 5.00 APPLIANCE 5.00 PLAN CHECKemption, you should become subject to the Workers' Compensation provisions of the Labor Code, you must forthwith comply with such provisions or this permit shall be deemed revoked. FEEAIRHANDLINGUNIT (TO 10)000C,F.M.I 4.00 AIR HANDLING UNIT (OVER 10PWC.F,M.) 6.00 SEISMIC FEECONSTRUCTIONLENDINGAGENCY I hereby affirm that there is a construction lending agency for EXHAUST HOOD (WITH DUCT) 5.00 The performance of the work for which this permit is issued (Sec. 3097,Civ.C.). MICROFILM HEATING UNIT (TO 100,000 B.T.U.) 8.00 HEATING UNIT (OVER 100,000 B.T.U.)9.50 ELECTRIC Lender's Name Lender's Address I certify that I have read this application and state that the above information is correct, l agree to comply with all city and county ordinances and state laws relating to building construction, and VENTILATION FAN (SINGLE) 4.00 PLUMBING IQv BOILER COMP (3 H.P. or 100,000 B,T.U.I 6.00 BOILER -COMP (Over 100,000 BTU) SEE FEE SCH. MECHANICALherebyauthorizerepresentativesofthiscity -to enter upon the 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 ay accrue against said City in consequcncc of the gra I of permit. CONST. TAXPERMITISSUANCE10.00 MECH. CONT. LIG. NO, MECH, TOTAL TOTAL gnat re f ppircant Contract nate OFFICE COPY