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09606 Y APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY BUILDING PROJECT lDENTIFICATION PERMIT NUMBER, ADLLAPPLICATION & PERMIT ADDREESSSS Ju 6 .....OJ BUILDING -ELECTRICAL-PLUMBING-MECHANICAL 0^606 OwNEP'S PLAN CHECK VALIDATION NAME QTY. ELECTRIC PERMIT FEE all PHONE:C,),/ NemERgcrons UTLEL-SWITCHES-RECEP 10.00/1.00 LIC.NO. - LIGHTING FIXTURES 10.00/1.00 'COADDRESS AD o,ri 17 ns PPLIANCES-RESIDENTIAL 4.00 PDDRE55 ARCHITECP ONF� , PANELS 10,00 DATE OF APPLICATION OR r1M63� PANELS (OVER 200 AMP) 20.00 PLAN CHECK FEE P.C.N0. ENGINEER LIC,NO SIGNS TRANS. 3.00 AARCH.OR DDRESS ENG.' SPECIALCIRCUIT 5.0Q PERMIT VALIDATION ZIP TEMP.METER OR POLE INS. 20.00 PAID APPLICANTS MOTORS SEE FEE SCH. ADDRESS ��� AA i _ y SERVICECHANGE 20.00 985 ° 0 .Hoo LICENSED CON'T'RACTORS DECLARATION TEMP.POLE 30.00 /�y� . F z w 1 hereby affirm that I am licensed under provisions of Chapter 9 bIEJ qg� (commencing with Section 7000)of Division 3 of the Business and BLDG. ELECT- PLG. MECI, r 7 i Professions Code,and my license is in full force and effect. zo= - . •Cicense ClSs� -+ - __R9 �., Lie.Number - ? o .'�w Date_"'_meq-+`5.8-ss•J+gonlructor a m -•��3 BUILDING PERMIT a OWNER-BUILDER DECLARATION w u - INFORMATION w `;LL I- I hereby a(frm that I am exempt from the Contractor's License MISC.- " \ (x REFER TO ORD LL o Law for the following reason.(Sec 7031.5,Businessand Professions -PERMIT ISSUANCE -T-O0-0- < VALUAnON S/FT. - Code:An cit or count Any y countywhichany struture permit issuance.also r EE improve.improve,demolish,or repair troy structure,prior to its issuance.also ELEC.CONTR. LIC.NO. ELEC. •d' ' D LL reQnlres the applicant for such permit to file a signed statement that th \ TOTAL x m m he is lemervJ pursuant to e provisions of the Co ncri,ler's License MIT T rZ > Law(Chapter 9(commencing with Section 7000)ofDivision 3 ofine x o Business and Professions Code)or that he is exempt therefrom and QTY. PLUMBING PERMIT FEE P Iw r m the basis for the allege)exemption.Any violation of Section 7031.5 STo IES V CONSTR. n ; _ by any applicant for a permit subjects the applicant to a civil penalty oI not more than five hundred cellars($500),): ALTER-DRAIN&.VENT-WATER (EA.) 5.00 ❑ I,as owner of the property,or my employees with wages as BACK FLOW PROTECT. DEVICE 4.00 OCC,GROUP RES.UNITS Their sole compensation,will Jo the work,and the structure is not intended or offered for sale (Sec. 7044, Business and Professions DRAINS-FLOOR,ROOF,AREA,COND. 5.00 Code:The Contrac(or's License Law does not apply to an owner of property who builds urimproves thereon,and who docs such work FIXTURES-PER TRAP 5.00 SO.FT.F LOCH AREA TOTAL ACREAGE • himself or through his own employees,provided that such improve- mems are not intended or offered for sale.If,however,the building GAS-EA.SYSTEM-1 INC.4 OUTLETS 6.00 `•x or improvement is sold within one year of completion,the owner. GAS-EA.SYSTEM-OVER 4(EA.) 2.00 builder will have the burden of proving that he did not build or im. BUILDING USE prove for purpose ofsle.)' INDUSTRIAL WASTE INTER. 30.00 IND CON PR CO., ❑ 1,as owner of the property,am exclusively contracting with licensed contractors to construct [[in project(Sec.7044,BusinessLAWN SPRINKLERS-1 INC 5 V.B. 6.00 ASSESSORS PARCEL NO. and Professions Cade:The Contractor's License Law does riot apply to an owner of property who builds or improves thereon,and who LAWN SPRINKLERS-OVER 5(EA.) 1.00 tl contracts for such projects with a coutraemds)licensed pursuant to SEWER V-STORM EA.200ft/10.00 PP the Contractor's License Law. TRACT NO. PARCEL NO. ❑ lam exempt under Sec. ,B.&OC.for this WATER HEATER W/VENT 6.00 - reason Owner Date WATER SYSTEM 5.00 ACC.DATE ACG FILE NO. WORK BRS'COMPENSAI ION DECLARATION WATER TREATING EQUIP. 5.00 1 hereby affrm that I have a certificate ofconsent m sel&insure. ZONING or a certificate of Workers'Compensation Insurance,or a ccr Ifcd ENG.SITE NO. uapy thereof(Sec.3800,Leb.C.L Policy No./, ,z.�C'rnnpuny n'y- �� _ O �c Ilifed copy a hereby funushe . RE$DRINK ENERGY T-24 Z Z Certified copy is filed with the city inspection division. Ni REFER TO ORD. O App icent YEI N Y N ~ w PERMIT ISSUANCE 10.00 LU - CERTIFICA Nihil IATI KION PRN WORKGRS' 'FLOOD ZONE A.L.U.C. 0- need not be completed INSURANCE; PLC.CONTR. LIC.NO. L.G.PV N v� N Z hundred dollars need not be completed i( the permit is for one TOTAL hunercd dollars(b 100)or less U O 1 cerGty that in the pertimmine,of the work for which this per- QTY MECHANICAL PERMIT FEE FEE SUMMARY IL 1- mil is issued,I shall not employ any person in any manner is,as to O Ubecome subject to the Workers'Compenction Laws of California. Do O, Duty APpiica"t ALTER OR ADD TO MECH. 5.00 BUILDING } W NOTICE T'O APPLICANT: If,after making this Certificate of I's. F Z_ emption,you should become subject to the Workers'Compensation APPLIANCE 5.00 PLAN CHECK provisions of the Labor Code, you must forthwith comply with FEE U such provisions or this permit shall be deemed revoked. AIR HANDLING UNIT(TO 10MC.F.M.) 4.00 CONSTRUCDON LENDING AGENCY AIR HANDLING UNIT(OVER 10=C.F.M.) 6.00 SEISMIC FEE I hereby affirin that there is a construction lending agency for EXHAUST HOOD(WITH DUCT) 5.00 the performance of lire work for which this permit is issued(Sec. MICROFILM 3097,Civ.C.L HEATING UNIT(TO 100,000 B.T.U.) 8.00 d Lender's Name / Lender's Addres / w HEATING UNIT(OVER 100;000B.T.U.)9.50 ELECTRIC I certify mat Inwi"re'ad�fiisaPnlieafon wul state Wit the above .O VENTILATION FAN (SINGLE) 4.00 ou S 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 100,0008.T.U.) 6.00 hereby authorize representatives of this city to enter upon Ole BOILER-COMP (Over 100.000BTU)SEE FEESCH. MECHANICAL above-mentioned property for inspection purposes. (We) agree to save, indemnify and keep harmless the City of Misc - REFER TO ORD. Cupertino against liabilities,judgments, costs and expenses which PERMIT ISSUANCE 10.00 CONST.TAX may in any way accrue against said City in consequence of the , granting of this permit. MECH.CONT. LIC.NO. H. TOTAL TOTAL Sgi ahireo Appbcanl/ ontracmr Dalc INSPECTOR COPY APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY O Z z y LU 7 t0_ z U O LL U 0 U BUI LDI NG PROJECT I DENTI FICAT10N APPLICATION & PERMIT BUILDING - ELECTRICAL -PLUMBING -MECHANICAL PERMIT NUMBER 09606BUILDINGADDRESS X .6~ OwNER'S NAME QTY, ELECTRIC PERMIT FEE' PLAN CHECK VALIDATION HON -/ Car•IrRAcrDH's NAME OUTLETS - SW ITCHES - R ECEP 10.00/1.00 LIGHTING FIXTURES 10.0011.00LIC.NO. -R -s7/_449 CONTRACTOR'S ADDRESS PPLIANCES- RESIDENTIAL 4.00 PANELS 10.007N /, 9 DATE OF APPLICATION ARCHITECT i ORENGINEER LIC. No. PANELS (OVER 200 AMP) 20.00 Pt-ANCHECKFEE P.C. NO. SIGNS TRANS. 3.00 AARCH. OilDDRESS ENG SPECIAL CIRCUIT 5,00SERM IOATION EMP. METER OR POLE INS. 20.00ZIP SEP a 1985APPLICANT'S AOORESS MOTORS SEE FEE SCH. SERVICE CHANGE 20.0037A91 Of Cupertino 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 and eff et. Licenst Jac 6 c. Number Q ISSUANCE DATE BLDG, ELECT. I PLG. I PUC Nfi Date ontractar BUILDING PERMIT OWNER -BUILDER DECLARATION I hereby affirm that 1 aexempt from the Contractor's Licensem Law for the following reason. (Sec. 7031.5, Business and Professions Code: Any city or counly which requires permit to Construct, alter, improve, demolish, or repair any structure, prior to its issuance, also requires the applicant for such permit to rile a signed statement that he is licensed pursuant to the provisions of the Contractors License INFORMATION MISC. - REFER TO ORD VALUATION SIFT. PERMIT ISSUANCE 10.00 ELEC. CONTR, LIC. NO, ELEC, TOTAL IT T CITY, 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 Section 7031.5 STORIES TYPE CONSTR. ALTER -DRAIN &VENT WATER IEA.) 5.00byanyapplicantforapermitsubjectstheapplicanttoacivilpenalty of not more than five hundred dollars (S500).): 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 (See. 7044, Business and Professions Code: The Contractor's Licensc 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 F IXTUR ES - PER TRAP 5.00 50, 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- prove for purpose of sale.). as owner of the property, am exclusively contracting with licensed contractors to construct the project (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 GAS EA. SYSTEM -OVER 4 (EA.) 2.00 BUILDING USE INP CON PB Other 3 INDUSTRIAL WASTE INTER. 30.00 LAWN SPRINKLERS - 1 INC 5 V.B. 6.00 ASSESSORS PARCEL NO. LAWN SPR INKLERS - OVER 5 (EA.) 1.00 contracts for such projects with a contractor(s) licensed pursuant to the Contractor's License Law. SEWER SAN ITARYSTORM EA, 200ft/_ 10.00 TRACT ND. PARCEL NO. l am exempt under Sec. BAP.C. for this WATER HEATER WIVENT 6.00 reason Owner Date WATER SYSTEM 5.00 ACC. DATE AGC. F [LE N0. WATER TREATING EQUIP. 5:00WORKERS'COMPENSATIONDECLARATION 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 thereD Sea 3800 Lab -C Polic o.mpany. V'/Certified copy is hereby famished. ertitied copy is fled with the city inspection division. Applicant FIRESPRINK Y N ENERGY T-24 Y N MISC. REFER TO ORD. CERTIFICATE OF EXEMPTION FROM WORKERS' PERMIT ISSUANCE 10.00 FLOOD ZONE A.L.U.C- PLG, CONTR. LIC. NO. PLG. TOTAL COMPENSATION INSURANCE This section need not be completed if the permit is for one Y [-]N Y N MECHANICAL PERMIT FEE FEE SUMMARY hundred dollars (S 100) or less.) 1 certify that in the performance of the work for which this per -QTY. mit is issued, i shall not employ any person in any manner so as to become subject to the Workers Compensation Laws of California. Date Applicant NOTICE TO APPLICANT: if, after making this Certificate of Ex- BUILDING ALTER OR ADD TO MECH. 5.00 APPLIANCE 5.00 PLAN CHECK FEE emplion, you should become subject to [he Workers' Compensation provisions of We Labor Code, you must forthwith comply with such provisions or this permit shall be deemed revoked. AIR HANDLING UNIT (TO 10DWC F.M.) 4.00 AIR HANDLING UNIT (OVER 10PIX)C.F,M.) 6.00 SEISMIC FEECONSTRUCTIONLENDINGAGENCY 1 hereby affirm that there is a construction lending agency for the performance of the work for which this permit is issued (Sec. 3097,Civ.C.). EXHAUST HOOD (WITH DUCT) 5.00 .g oD MICROFILM HEATING UNIT (TO 100,000 B.T.U.) 8.00 pv HEATINGUNIT(OVER100,000H.T.U.)9.50 ELECTRIC Lend"" Name Lender's Add.' , 1 certify that 1 have rc ffi app ILation and state that the above information is correct. 1 agree to comply with all city and county ordinances and state laws relating to building construction, and VENTILATION FAN (SINGLE) 4.00 p-va PLUMBING rBOILER -COMP (3 H.P. or 100,000 e,T.U.) 6.00 BOI LER-COMP (Over 100,000 BTU) SEE FEZ: 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 in any way accrue against said City in consequence of the CONST. TAX PERMIT ISSUANCE 10.00 p.dd granting of this permit. MECH. CONT. LIC. NO. MECH. TOTAL a o TOTAL 13ignbture of ApplicantlContractor Date OFFICE COPY