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09531APPLICANT TO FILL IN INFORMATION WITHIN RED LINES -USE BALL POINT PEN ONLY BUILDING PROJECT lDENTI FICATION APPLICATION & PERMIT - BUILDING - ELECTRICAL -PLUMBING -MECHANICAL PERMIT NUMBER 09531 AD ADDDRESSRESS RF D - NAME -67)LA )?'/ HDNE _ . - QTY. ELECTRIC PERMIT FEE PLAN CHECK VALIDATION No�ERAc s` - OUTLETS -SWITCHES-RECEP 10.00/1.00 LIGHTING FIXTURES 10.00/1.00 c. No. RACTO 's I ADDRESS APPLIANCES - RESIDENTIAL 4.00 PANELS 10.00 FHONE �' r DATE OF APPLICATION oRc c^ ENGINEER uc. No. PANELS (OVER 200 AMP) 20.00 PLAN CHECK PEE P.c. No. SIGNS TRANS. 3.00 ADORESs eruct SPECIAL CIRCUIT 5,00 (DATION EMP. METER OR POLE INS. 20.00 Tlp AUG 2 r3 190' 5 A aoREs UDITr55 MOTORS SEE FEE SCH. SERVICE CHANGE 20.00 city Of Cupertino . LICENSED CONTRACTORS DECLARATION TEMP. POLE 30.00 1 hereby_affirn that 1 am licensed under provisions of Chapter 9 (commencing with Section 7000) of Division 3 of the Business and 11.Olex,ems Code, and my liccuse LS m full force meffect License Class Lie. Number �idS­-670 - ISSUANCE DATE BLDG. ❑ ELECT. ❑ PLG. MECH. ❑ Date �- Contractor T- BUILDING PERMIT INFORMATION OWNER -BUILDER DECLARA'f10N I hereby affirm that I am exempt from the massa d is License Low for following reason. (Sec. 703 t,5, Fairness and Professions Code: Any city or county which requiresa permit to construct, alter, improve, demolish, .,repair any structure, prior to its issuance, also requlres the applicant for such permit to file a Signed statement that he is licensed pursuant to the provisions of the Contractors License MISC. - REFER TO ORD PERMIT ISSUANCE 10.00 VALUATION - _$/FT. ELEC. CONTR. LIC. NO. ELEC. TOTAL QER TO \I - OTY. PLUMBING PERMIT FEE Law (Chapter 9 (commencing with Section 7000) of Division 3 of the Business and Professions Code) or tat he is exempt therefrom and STORI T E CONBTR. the basis for the alleged exemption, Any violation of Section 7031.5 by any applicant fora permit subjects the applicant roacivil penalty of not more than five hundred dollars (my ALTER-DRAIN-WATER(EA.) 5.00 employees ❑ Las owner at the property, or my employees with wages of their sole compensation, will the work, and structures not BACK FLOW PROTECT. DEVICE 4.00 OCC. GROUP ES. UNITS DRAINS -FLOOR, ROOF, AR EA, CONE. 5.00 intended or offered for sale (Sec. Business (S Business and Professions Code: The Contractor's License Law docs not apply o an owner of doe builds or improves emploeereomandwhod such i he y- property lf or through re through his own employers, provided that such improve- Tnotnt is or offered I Chowcveq the FIXTURES - PER TRAP 5.00 SO, FT. FLOOR AREA TOTAL ACREAGE GAS-EA.SYSTEM-1.INC.40UTLETS 6.00 ^� orents improvemethe owner or improvement is sold within one year of completion, the owner- sold builder will have the ideJ. of proving that he did not build or int- prove for purpose of the 0 L as owner of the exclusively contracting with GAS - EA. SYSTEM - OVER 4 (EA.) 2.00 _ BUILDING USE IND 1:1 PR ower ❑ ❑ ❑ ❑ INDUSTRIAL WASTE INTER. 30.00 LAWN SPRINKLERS -I INC 5 V.B. 6.00 it,, licensed contractors to construct the project (Sec. does r Business construct and Professions Code.property to an owner of property who builds or improves thereon, and who ty Contractor's License s Law docs not who Assessors PARCEL No. ' LAWN SPRINKLERS -OVER 5 (EA.) 1.00 contracts for such projects with a contractors) licensed pursuant to the Contmctoi s License Law. - SEWER -SAN ITARY-STORM EA. 200ft/10.00 TRACT NO. PARCEL NO. ❑ l ahih exempt under Sec. ,B.&P_C. for this reason WATER HEATER W/VENT 6.00 _CX Owner Date WATER SYSTEM 5.00 Sr CID ACC. DATE ACG FILE NO. WATER TREATING EQUIP, 5.00 WORKERS'COMPF.NSA'DON DECLARATION 1 hereby affirm that 1 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.T - Policy No. Company F IRE SPRINK V ❑ N❑ EN ERGY TYA V ❑ N❑ ❑Certified copy is hereby f urnished. AA�Certified copy is Bled with eche city inspction division. , cant MISC.- REFER TO ORD, CFRTIFICATEOE EXEMPTION FROM WORKERS' PERMIT ISSUANCE 10.00 OU FLOOD 20RE A.L.0 C. COMPENSATION INSURANCE (This s,,tRm Fred not be completed if the permit is for one PLG. CONTE. un, NO. pLG. V� TOTAL Y ❑ N ❑ V ❑ N❑ hundred dollars IS 100) or less.) I cenify that in the performance of the work for which this per mit is issued, I shall not employ any person in any remove so as to CITY. MECHANICAL PERMIT FEE FEE SUMMARY BUILDING become subject to the Workers' Compensation Laws of Calitomia. Date ApplicantALTER OR ADD TO MECH. 5.00 NOTICE 'f0 APPLICANT'. If, after making this Certificate of Es APPLIANCE 5.00 PLAN CHECK emption, you should 6scome subject to the Workers' Compensation provisions of the Labor Code, you must forthwith comply with such provisions or this permit shelf be deemed revoked. FEE AIR HANDLING UNIT (TO 10=C.F.M.) 4.00 AIR HANDLING UNIT(OVER 10=C.EM.) 6.00 SEISMIC FEE CONSTRUCTION LENDING AGENCY I hereby aD'irin 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 (See. 3097. Civ.C.l. i Lender's Name MICROFILM HEATING UNIT (TO 100,000 B.T.U.) 8.00 HEATING UNIT 100,000 B.T.U.) 9.50 ELECTRIC ' t - Lender's Address I certify that l have read this application and state that the above nfonn:dion is correct. I agree to comply with all city and county ordinances and state laws relating to building construction, and VENTILATION FAN (SINGLE) 4.00 PLUMBING till BOILER-COMP(3 H.P.or 100,000B.T.U.) 6.00 BOILER -COMP (Over t00,0006TU15EE FEE SCH. MECHANICAL hereby authorize representatives of this city toenter, upon the above-mentioned property for inspection purposes. MISC. - REFER TO ORD. CONST. TAX (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 gmehip pf s permit. pERMIT ISSUANCE 10.00 MECH. CONT. LIC. NO. MECH. � , �10 / fI➢,r- TOTAL TOTAL Sh at re o Appleant/CDntractor Date INSPECTOR COPY C Z Z P 0 CC jLU - CL D Z 00 U_ U 0 Lu cn F- Z A AQPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY BUILDING PROJECT IDENTIFICATION APPLICATION &PERMIT BUILDING - ELECTRICAL- PLUMBING - MECHANICAL PERMIT NUMBER O 9531It"TINo' ADDRESs • O E 's f , Yl NAM[; ' 6-W- 6- PHONEv W I QTY. ELECTRIC PERMIT FEE PLAN CHECK VALIDATION NANTRACTn s NAME UTLETS-SWITCHES-RECEP 10.00/1.00 91 N0. LIGHTING FIXTURES 10.00/1.00 CONTRALTO 'S ADORE APPLIANCES - RESIDENTIAL 4.00 PANELS 10.00PHONE DATE OF APPLICATION RC ECT I ORENGINEER LIC. NO. PANELS (OVER 200 AMP) 20,00 PLAN CHECK FEE P.C. NO. SIGNS TRANS, 3.00 AACH. OR ENG. ADDRESS SPECIAL CIRCUIT 5.00 PE1115VLa710N j EMP. METER OR POLE INS. 20.00ZIP AUG 2 '(O®5 APPLICANT'S ADDRESS MOTORS SEE FEE SCH. SERVICE CHANGE 20,00 II JJ city of CupertinoLICENSEDCONTRACTORSDECLARATIONTEMP. POLE 30.00 1 hereby affirm that I am licensed under provisions of Chapter 9 commencing with Section 7000) of Division 3 of the Business and Professions Co , a my license is in full force n _ se I ssLic. Number ISSUANCE DATE BLDG. El ELECT. 13 P G. MECH. ElLicer. Date Contractor BUILDING WRMIT INFORMATIONOWNER -BUILDER DECLARATION 1 hereby affirm that I am exempt from the ContraelorsLice nse Law for the following reason. (Sec. 703 1.5. Business and Professions Code: Any city or county which requires a permit 10 construct, alter, improve, demolish, or repair any structure, prier to Its issuance, also requires the applicant for such permit to -lite a signed statement that he is licensed pursuant to the provisions of the Contractor's License Law (Chapter 9 (commencing with Section 7000) of Division 3 of the Business and Professions Code) or that he is exempt therefrom and MISC. - REFER TO OR VALUATION SIFT. PERMIT ISSUANCE 10.00 ELEC. CONTR. LIC. NO. ELEC. TOTAL R 71 TO OTY. PLUMBING PERMIT FEE the basis for the alleged exemption. Any violation ofSeelion 7031.5 STORI S T CONSTR. by any applicant for a permit subjects the applicant to a civil penaltygLTER-DRAINofnotmorethanfivehundreddollars (5500).): 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 LAES. UNITS DRAINS -FLOOR, ROOF, AREA, COND- 5.00intendedorofferedforsale (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 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 r FIXTURES PER TRAP 5.00 SQ Fl. 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 of sale.). I, as owner of the property, am exclusively contracting with GAS - EA. SYSTEM OVER 4 CEA.} 2.00 BUILDING USE IND CON PB Other INDUSTRIAL WASTE INTER. 30.00 Ellicensedcontractorstoconstructtheproject (See. 7044, Business and Professions Code: The Contractor's License Law does not apply 10 an owner Of property who builds or improves thereon, and who ASSESSORS PARCEL NO. LAWN SPRINKLERS - 1 INC 5 V.B. 6.00 LAWN SPR INKLERS - OV ER 5 (EA.) 1.00 contracts for such projects with a contractor(s) licensed pursuant t0 the Contractor's License Law. SEWER -SANITARY -STORM EA, 200ft/10.00 O TRACT NO. PARCEL NO. 1 am exempt under Sec. B.&P.C. for alis WATER HEATER W/VENT 6.00 reason Owner Date WATER SYSTEM 5.00 t ACC. DATE ACC. FILE NO. WATER TREATING EQUIP. 5.00WORKERS' COMPENSATION DECLARATION 1 hereby affirm that 1 have a certificate of consenl to self -insure. or a certificate of Workers' Compensation Insurance, Or a certified ZONING ENG. SITE NO. copy thereof (See. 3900, Lab,C.). Policy No. Company FIRESPRINK Y [] NO ENERGY r-24 Y NO Certified copy Is hereby furnished, Certified Copyt riled with the city Inspection division. App antf %44tlrar S MISC. - REFER TO ORD. CERTIFICATE OF EXEMPTION FROM WORKERS' PERMIT ISSUANCE 10.00 f/U0 FLOOD ZONE A.L.U.C. PLG. CONTR. LIC. NO. PLG. (j` d 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 for which this per- mit Is issued, 1 shall not employ any person In any manner so as t0 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 CHECKcmption, 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.) 4.00 AIR 14ANDLINGUNIT(OVER10J=C.F.M.) 6.00 SEISMIC FEECONSTRUCTIONLENDINGAGENCY hereby affirm that there is a construction ]ending agency for EXHAUST HOOD (WITH DUCT) 5.00 the performance of the work for which this permit is issued (See. 3097, Civ,CJ. MICROFILM HEATING UNIT (TO 100,000 B.T.U.) 8:00 HEATING UNIT (OVER 100,000B.T.U.)9.50 ELECTRIC Lender's Name Lender's Address I certify that 1 have read this application and state that the above information is correct. I agree 10 comply with all city and countyBOILERordinancesandslatelawsrelatingtobuildingconstruction, and VENTILATION FAN (SINGLE) 4.00 PLUMBING COMP f3 H.P. Dr 100,000 B.T.U.} 6.00 BOI LER-COMP (over 100,000 BTU) SEE FEE SCH, hereby authorize representatives of this city to enter upon the above-mentioned property for inspection purposes. MECHANICAL 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 "d City in conseq}}tlence of the CONST, TAXPERMITISSUANCE10.00 MECH. CONT. LIC. NO. MECH. gra permit. / TOTAL TOTAL Signa urs of Applicant/Contractor Date OFFICE COPY