12895 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
BU I LDING PROJECT I DENTIFICATI ON PERMIT NUMBER
\, EDILOING APPLICATION & PERMIT
T• ADDRESS 11363 D(- )�7-C R- BUILDING - ELECTRICAL-PLUMBING-MECHANICAL 12895
OWNER'S PLAN CHECK VALIDATION
NA1E1J L) CITY. ELECTRIC PERMIT FEE
�1 PRONE -
NOME AcroR's , OUTLETS-SWITCHES-RECEP 10.00/1.00
COPlUmBN6J 1C}[T/Ik LIC.N0 7q0 LIGHTING FIXTURES 10.00/1.00
cONTHACTORs APPLIANCES-RESIDENTIAL 4.00
ADDRESS (� 1 LJ(�
3 -ONE PINE LkAg
INE PHONE -S PANELS 10.00 DATE OF APPLICATION
OARCHITECTPANELS (OVER 200 AMP) 20.00 PLAN CHECK FEE P.C.NO.
ENGINEER
LIC.No. SIGNS TRANS. 3.00
ADDRESS ENc. SPECIAL CIRCUIT 5.00 PERMIT VALIDATION
ZIP TEMP. METER OR POLE INS. 20.00
APPLICANTS MOTORS SEE FEE SCH.
ADDRESS
SERVICE CHANGE 20.00
o o LICENSED CONTRACTORS DECLARATION p
a u I hereby affirm that I am licensed under provisions of Chapter 9 ISSUANCE DATE
vi Q h (Commencing with Section 7000)of Division 3 of the Business and BLDG. ELECT. PLG. MECH.
F N z Professions Codchand my t�ic�Ase is in full fof0iol effect. ❑ ❑ ❑
z out - Lice C s GG C,y6.Lia Nwnber 1`LS
o y-'D Dat Contractor
r -
a xBUILDING PERMIT
¢ o a OWNER-BU
DECLA0.ATIOA INFORMATION
w ;w w I hereby affirm that I am exempt from the Contractor's License MISC.- REFER TO ORD
LL o a Law for the following reason.(Sea 7031.5,Businessand professions PERMIT ISSUANCE 10.00 VALUATION S/FT.
� - 0 Code:Any city or county which requires a permit to construct,alter,
ELEC.CONTR. LIC.NO.
¢¢ a Q improve,demolish,or repair any structure,prior to its issuances also ELEC.
¢ requires the applicant for Such permit to file a Signed statement that TOTAL PERMIT TO
u w m" he is licensed pursuant to the provisions of the Contractor's License
iii La..(Chapter 9(commencing with Section 7000)ofDi,isi,,n 3 of the
a Business and Professions Code)or that he is exempt therefrom and OTY. PLUMBING PERMIT FEE
¢ o the basis for the alleged exemption.Any violation of Section 7031.5 STORIES TYPE CONSTR.
Lu s2
by any applicant for a perm it subjects the applicant to a civil penalty ALTER-DRAIN -WATER (EA.) 5.00
of not more than five hundred dollars($500).):
❑ I,as owner of the property,or or,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 Licerse Law does not apply to an owner of
property who builds or improves thereon;and who do,isuch work FIXTURES-PER TRAP 5.00 SO,FT.FLOOR AREA TOTAL ACREAGE
himself or through his own employees,provided that such improve-
ments arcnot intended or o0cred]or sale.11,however,the building GAS-EA.SYSTEM-1 INC.4 OUTLETS 6.00
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 ins- BUILDING USE
prove for purpose of sale.). INDUSTRIAL WASTE INTER. 3000 RES IND CON PB Omer
❑ I,as owner of the property,am exclusi .
vely contracting with ❑ ❑ ❑ ❑ ❑
licensed contractors to construct the pmjem/Sec.]044,Business LAWN SPRINKLERS-1 INC 5 V.B. 6.00 ASSESSORS PARCEL NO.
and Professions Code- rhe Contractor's License Law does not apply
to an owner of properly who builds of improves/hereon.and who LAWN SPR IN KLERS-OVER 5 (EA.) '1.00
contracts for such projecia with a colorations)licensed pursuant to SEWER-SANITARY-STORM EA.2001t/10.00
the Contractor,License Law. TRACT N0, PARCEL NO.
❑ I am exempt under Sec. ,0.&I'.C.lin Ih's WATER HEATER W/VENT 6.00
reason
Owner Date WATER SYSTEM 5.00 ACC.OATE ACC,FILE NO.
WORKERS'COMPFNSATION DECLARATION WATER TREATING EQUIP. 5.00
I hereby affirm that I have a certificate of consent to self insure' ZONING
or a certificate of Workers'Compensation Insurance,or a certified ENG.SITE NO.
copy thercof(Set.3800,Lah.CA
Policy No. Company
0 ❑ Certified copy is hereby furnished. FIRE SPRINK ENERGY T 24
Z Z ❑ Certified copy is filed with the city inspection division.
O) Applicant MISC.- - REFER TO ORD. Y❑ N❑ I Y ❑ N❑
CC CIi R'I'IFICATI:OF-EXEMI'1'ION PROM WORKERS' PERMIT ISSUANCE 10.00 FLOODZONE A.L.u.C.
W > COMPENSATION INSURANCE PLG.CONTR. LIC.NO. PLG,
Z (Phis section need not be completed if the permit is for one TOTAL Y❑ N❑ Y ❑ N
hundred dollars IS 100)or less,)
U O 1 certify that in the pe conn Ace of the work for which this per G MECHANICAL PERMIT FEE FEE SUMMARY
LL t- mit is issued,I shall not employ any person in any throne so as to
0 U become subject to the Workers'C�om�p}•m��o�tion 1.' s of C Air.
Date Applicant crz4rlLe ALTER OR ADD TO MEC 5.00 BUILDING
} NOTICE TO APPLICANT.. th
T.. If,after making Is Certificate of lix-
2 emptier,you should benmc subjcci m e or ken'Conlpcnsnfion APPLIANCE 0 PLAN CHECK
provisions of the Labor Code, you must forthwith comply with FEE
U such provisions or this permit shall be deemed(evoked. AIR HANDLING UNIT(TO 10,000 0
CONSTRUCTION L17NDING AGENCY AIR HANDLING UNIT IO C.F.M.) ,0 SEISMIC FEE
I hereby affirm that mere is a construction lending agency for EXHAUST HOOD(WITH D CT
the performance of the work for which this permit is issued(Sec. MICROFILM
3097,CN.C.), HEATING UNIT(TO 100, .U.) 8.00
Lender's Name
Lender's Address HEATING UNIT(OVER 100,000 B.T.U.)9.50 •-? ELECTRIC
Y I certify that I have read this application and state that the aboveVENTILATION FAN (SINGLE) 4.00 1
information is correct. 1 agree to comply with all city and county PLUMBING
ordinances and state laws relating to building construction, and BOILER-CDMP(3 H.P.or 100,000 B.T.U.) 6.00
hereby authorise representatives forms inspection
this city to enter upon the BOILER-COMP/Over 100,000 BTU)SEE'F,EESCH. MECHANICALSZ
above-mentioned property forinsp ofth i puity to _
(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 way accrue against said City in consequence of the PERMIT ISSUANCE 10.00
granting of this permit. ' MECH.CONT. LIC.NO. MECH.
/ f'r�j 2-Z? �?7 TOTAL / G S� TOTAL
\ / Signature of Applica /Contractor Date
X OFFICE COPY
APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
BU I LDING PROJECT I DENTIFICATI ON PERMIT NUMBER
\, EDILOING APPLICATION & PERMIT
T• ADDRESS 11363 D(- )�7-C R- BUILDING - ELECTRICAL-PLUMBING-MECHANICAL 12895
OWNER'S PLAN CHECK VALIDATION
NA1E1J L) CITY. ELECTRIC PERMIT FEE
�1 PRONE -
NOME AcroR's , OUTLETS-SWITCHES-RECEP 10.00/1.00
COPlUmBN6J 1C}[T/Ik LIC.N0 7q0 LIGHTING FIXTURES 10.00/1.00
cONTHACTORs APPLIANCES-RESIDENTIAL 4.00
ADDRESS (� 1 LJ(�
3 -ONE PINE LkAg
INE PHONE -S PANELS 10.00 DATE OF APPLICATION
OARCHITECTPANELS (OVER 200 AMP) 20.00 PLAN CHECK FEE P.C.NO.
ENGINEER
LIC.No. SIGNS TRANS. 3.00
ADDRESS ENc. SPECIAL CIRCUIT 5.00 PERMIT VALIDATION
ZIP TEMP. METER OR POLE INS. 20.00
APPLICANTS MOTORS SEE FEE SCH.
ADDRESS
SERVICE CHANGE 20.00
o o LICENSED CONTRACTORS DECLARATION p
a u I hereby affirm that I am licensed under provisions of Chapter 9 ISSUANCE DATE
vi Q h (Commencing with Section 7000)of Division 3 of the Business and BLDG. ELECT. PLG. MECH.
F N z Professions Codchand my t�ic�Ase is in full fof0iol effect. ❑ ❑ ❑
z out - Lice C s GG C,y6.Lia Nwnber 1`LS
o y-'D Dat Contractor
r -
a xBUILDING PERMIT
¢ o a OWNER-BU
DECLA0.ATIOA INFORMATION
w ;w w I hereby affirm that I am exempt from the Contractor's License MISC.- REFER TO ORD
LL o a Law for the following reason.(Sea 7031.5,Businessand professions PERMIT ISSUANCE 10.00 VALUATION S/FT.
� - 0 Code:Any city or county which requires a permit to construct,alter,
ELEC.CONTR. LIC.NO.
¢¢ a Q improve,demolish,or repair any structure,prior to its issuances also ELEC.
¢ requires the applicant for Such permit to file a Signed statement that TOTAL PERMIT TO
u w m" he is licensed pursuant to the provisions of the Contractor's License
iii La..(Chapter 9(commencing with Section 7000)ofDi,isi,,n 3 of the
a Business and Professions Code)or that he is exempt therefrom and OTY. PLUMBING PERMIT FEE
¢ o the basis for the alleged exemption.Any violation of Section 7031.5 STORIES TYPE CONSTR.
Lu s2
by any applicant for a perm it subjects the applicant to a civil penalty ALTER-DRAIN -WATER (EA.) 5.00
of not more than five hundred dollars($500).):
❑ I,as owner of the property,or or,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 Licerse Law does not apply to an owner of
property who builds or improves thereon;and who do,isuch work FIXTURES-PER TRAP 5.00 SO,FT.FLOOR AREA TOTAL ACREAGE
himself or through his own employees,provided that such improve-
ments arcnot intended or o0cred]or sale.11,however,the building GAS-EA.SYSTEM-1 INC.4 OUTLETS 6.00
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 ins- BUILDING USE
prove for purpose of sale.). INDUSTRIAL WASTE INTER. 3000 RES IND CON PB Omer
❑ I,as owner of the property,am exclusi .
vely contracting with ❑ ❑ ❑ ❑ ❑
licensed contractors to construct the pmjem/Sec.]044,Business LAWN SPRINKLERS-1 INC 5 V.B. 6.00 ASSESSORS PARCEL NO.
and Professions Code- rhe Contractor's License Law does not apply
to an owner of properly who builds of improves/hereon.and who LAWN SPR IN KLERS-OVER 5 (EA.) '1.00
contracts for such projecia with a colorations)licensed pursuant to SEWER-SANITARY-STORM EA.2001t/10.00
the Contractor,License Law. TRACT N0, PARCEL NO.
❑ I am exempt under Sec. ,0.&I'.C.lin Ih's WATER HEATER W/VENT 6.00
reason
Owner Date WATER SYSTEM 5.00 ACC.OATE ACC,FILE NO.
WORKERS'COMPFNSATION DECLARATION WATER TREATING EQUIP. 5.00
I hereby affirm that I have a certificate of consent to self insure' ZONING
or a certificate of Workers'Compensation Insurance,or a certified ENG.SITE NO.
copy thercof(Set.3800,Lah.CA
Policy No. Company
0 ❑ Certified copy is hereby furnished. FIRE SPRINK ENERGY T 24
Z Z ❑ Certified copy is filed with the city inspection division.
O) Applicant MISC.- - REFER TO ORD. Y❑ N❑ I Y ❑ N❑
CC CIi R'I'IFICATI:OF-EXEMI'1'ION PROM WORKERS' PERMIT ISSUANCE 10.00 FLOODZONE A.L.u.C.
W > COMPENSATION INSURANCE PLG.CONTR. LIC.NO. PLG,
Z (Phis section need not be completed if the permit is for one TOTAL Y❑ N❑ Y ❑ N
hundred dollars IS 100)or less,)
U O 1 certify that in the pe conn Ace of the work for which this per G MECHANICAL PERMIT FEE FEE SUMMARY
LL t- mit is issued,I shall not employ any person in any throne so as to
0 U become subject to the Workers'C�om�p}•m��o�tion 1.' s of C Air.
Date Applicant crz4rlLe ALTER OR ADD TO MEC 5.00 BUILDING
} NOTICE TO APPLICANT.. th
T.. If,after making Is Certificate of lix-
2 emptier,you should benmc subjcci m e or ken'Conlpcnsnfion APPLIANCE 0 PLAN CHECK
provisions of the Labor Code, you must forthwith comply with FEE
U such provisions or this permit shall be deemed(evoked. AIR HANDLING UNIT(TO 10,000 0
CONSTRUCTION L17NDING AGENCY AIR HANDLING UNIT IO C.F.M.) ,0 SEISMIC FEE
I hereby affirm that mere is a construction lending agency for EXHAUST HOOD(WITH D CT
the performance of the work for which this permit is issued(Sec. MICROFILM
3097,CN.C.), HEATING UNIT(TO 100, .U.) 8.00
Lender's Name
Lender's Address HEATING UNIT(OVER 100,000 B.T.U.)9.50 •-? ELECTRIC
Y I certify that I have read this application and state that the aboveVENTILATION FAN (SINGLE) 4.00 1
information is correct. 1 agree to comply with all city and county PLUMBING
ordinances and state laws relating to building construction, and BOILER-CDMP(3 H.P.or 100,000 B.T.U.) 6.00
hereby authorise representatives forms inspection
this city to enter upon the BOILER-COMP/Over 100,000 BTU)SEE'F,EESCH. MECHANICALSZ
above-mentioned property forinsp ofth i puity to _
(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 way accrue against said City in consequence of the PERMIT ISSUANCE 10.00
granting of this permit. ' MECH.CONT. LIC.NO. MECH.
/ f'r�j 2-Z? �?7 TOTAL / G S� TOTAL
\ / Signature of Applica /Contractor Date
X OFFICE COPY