The URL can be used to link to this page

11992 APPLICANT TO FILL IN INFORMATIONXITHIN RED LINES - USE BALL POINT PEN ONLY BUILDING PROJECT I DENTIFICATION - _ PERMITNUMBER RUILOING APPLICATION & PERMIT �� " 1 ADDRESS BUILDING-ELECTRICAL-PLUMBING-MECHANICAL Zo62 wE_.57 OWNER'S _1r�-- PLAN CHECK VALIDATION NAME q /Z�ST/jhwA/J OTY. ELECTRIC PERMIT FEE t nV PRONE GDNTRacroRsUTLETS-SWITCHES-RECEP 10.00/1.00 NAME 4• Nuc:No. LIGHTING FIXTURES 10.00/1.00 CONTRACTOR'S 4AN00 At/ APPLIANCES-RESIDENTIAL 4.00 oDREss �� vR0-rIE�`�3� y PANELS ` 10.00 DATE OF APPLICATION ARCHITECT PANELS (OVER 200 AMP) 2000 - PLAN CHECK FEE P.C.NO. OR ENGINEER LIC.No. - SIGNS TRANS. 3.00 ADDRESS ARCH. ENG. , . SPECIALCIRCUIT - 5.00 PERMIT VALIDATION . ZIP TEMP.METER OR POLE INS. 20.00 APPLICANTS � MLG+Lu�e MOTORS SEE FEE SCH. ADDRESS J026 54 10 4��(. 014jeoofd SERVICE CHANGE 20.00 woo LICENSEDCONTRACTORS DECLARATION /oLA a v I hereby ul'finn that I um licensed under provisions of Chapter 9 A'! �. ISSUANCE DATE w a y (commencing with Section 70007 of Division 3 of the Nosiness and - 16%1- 1 .. BLDG. ELECT. PLG. MECH. r o z Professions Cade,and my II'C��si is in fullll fnrflif.�A/ce and effec�! ❑ z o - License Class n 14- Lia Number 7 i KI ❑ ❑ O m F w Date Cut, r , a x �o=2a�ff�- f `- ity'of Cupertino BUILDING PERMIT ¢ ¢ w¢ OWNf:R-BUIL)ER ECLARA'TIO . oar' MISC.- REFER TO ORD INFORMATION K 3 LL N 1 hereby affirm that I am exempt from the Contractor's License g Business and Professions VALUATION $/FT. r u.0 J Lew for the followin reason.(Sec.703 L5; PERMIT ISSUANCE 10.00, Code:Any city or county which requires a permit to construct,alter, v_ S Q improve,demolish,or repair any structure,prior to its issuance,also ELEC.CONTR. LIC.NO. ELEC. to -y O ¢. requires the applicant for such permit to file a signed statement that TOTAL PERMIT TO w $ he is licensed pursuant to the provisions of the Contractor's License ' r z i Law(Chapter 9(commencing with Section 7000)of Division 3 ofthe 1 ¢ Business and Professions Coded exemption.Any or that he is exempt therefrom and DTV. PLUMBING PERMIT FEE �Z�L ¢ $ the basis for the aIle g e yc clon of$ection 7031.$ I •STORIES TYPE CONSTR. by any applicant for a permit subjects the applicant o a civil penalty q'LTER-DRAIN -WATER (EA.) 5.00 of not more than five hundred dollars($500).): ' ❑ 1,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 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 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 - 5.00 SO.FT.FLOOR AREA TOTAL ACREAGE (' himself or through his own employees,provided that such improve- '`+ .Cuts are not intended or offered for sale,if,however,the budding GAS-GAS -11NC.40UTLETS 6.00 t1 or improvement is sold within one year of completion,the owner- GAS-EA.SYSTEM-OVER 4 IEA.) 2.00 +,1 builder will have the burden of proving that he did not build or im- BUILDING USE prove for purpose of sale.). - INDUSTRIAL WASTE INTER. 3000 RES IND CON PB Omer \ ❑ 1,as owner of the property,am exclusively contracting with . ❑ ❑ O ❑ ❑ licensed contractors m Construct the project(Sec. 7044,Business LAWN SPRINKLERS-1 INC 5 V.B. 6.00 ASSESSORS PARCEL NO. and Professions Cade.The Contractor's License Law does not apply to an owner of property who buildsorimproves thereon.and who LAWN SPRINKLERS-OVER 5(EA.) 1.00 contracts for such projects with a conlractons)licensed pursuant to the Contractor's License Law. SEWER-SANITARY-STORM EA.200ft/10.00 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 ' ACO.DATE ACC.FILE NO, WORKERS'COMPENSATION DECLARATION WATER TREATING EQUIP. 5.00 I hereby affirm that I have a certificate of consent to self-insure, - ZONING ENG.SITE NO. or a certificate of Workers'Compensation Insurance;or a certified copy thereof(Sec.3800,LahC.). �Q✓�4 �NL14�¢/� Policy No.' Company - 0 ❑ Cenified copy is he, fuinihe .pr (• L.� (/ FIRE SPRINK ENERGY T-24 Z Z nifie vp y led ul, the cRY do c o QI ISIon. p pplicant < (lYl� ��w MISC.- REFER TO ORD. Y ❑ N❑ Y . N❑ Hy PERMIT ISSUANCE 10.00 FLOOD ZONE- CERTIFICATE F EXEMPTION FROM WORKERS' A.L.U.C. COh1PENSATI(1N INSURANCE PLG.CONTR. ,. LIC.NO. PLG, CL 0 (This Section need not be completed if the permit is for one _ TOTAL Y❑ N❑ Y❑ N❑ Z) Z hundred dollars IS 100)or less.) U O . 1 certify that in the performance of the work for which tills per- OTY. MECHANICAL PERMIT FEE FEE SUMMARY LL I- mit is issued,I shall not employ any person in any:manner so as to O Ubecome subject to the Workers'Compensation Laws of California BUILDING C. Date Applicant -- ALTER OR ADD TO MECH. 5.00 - �. W NOTICE TO APPLICANT: If,after making this Certificate of Ex- _ H 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 10=11F,M.) 4.00 _ CONSTRUCTION LENDING AGENCY AIRHANDLING UNIT(OVER 10=C.F.M.) 6.00 SEISMIC FEE 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. MICROFILM 3097,Civ.C.). ` HEATING UNIT(TO 100,000 B.T.U.) 8.00 Lender's Name Lender's Address HEATING UNIT(OVER 100,000 B.T.U.19.50 ELECTRIC (U 1 certify that I have read this application and state that the above VENTILATION FAN (SINGLE) 4.00 II � information is correct. I agree to comply with all city andcounty PLUMBING . ordinances and state laws relating to building,connructi c', and BOILER-COMP(3 H.P.0000,000B.T.U.) 6.00 hereby authorize representatives of this city to enter upon the BOILER-COMP (Ovm 100,000 BTU)SEE FEE SCH. 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 CONST.TAX may in any w' 'come against said City in consequence of the PERMIT ISSUANCE 10.00 granting thi rlit. MECH.CONT. LIC.NO. MECH. • �ff� %�'Dat TOTAL TOTAL 'ignatureo App /Con�mctor Dale - OFFICE COPY -