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APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
BUILDING PROJECT IDENTIFICATION
1/
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APPLICATION & PERMIT
.
BUILDING — ELECTRICAL—PLUMBING —MECHANICAL
PERMIT NUMBER
, PAID 716 5
F CI1ECK y( %TION
r LD !/kl II '��
BOiLpiNG
ADOREss
i
NAME 9 -
NAME
_ _ _ _ _ _
QTY. ELECTRIC PERMIT FEE
r^
S PHDNE _ W
Citj of Cupslfi�o.
e°x RAaT09s /L.-'Zs� -
UTLETS-SWITCHES-RECEP 5.00/1.00
LIGHTING FIXTURES .5.00/1.00
(s& /
LIc.No•
L.�•x
ADDRESS on ' 111 pIfGS
PPLIANCES -RESIDENTIAL 4.00'
(1
v.°NEQ (p - Ip
DATE OF APPLICATION
PANELS 5.00
ARCHITECTS,IQNS,
°R
ENGINEER
- uc. NO,
b•
PLAN CHECK FEE P.C. NO.
'
-
SIGNS TRANS. 3.00
neo Ess OR ENa.
•ZIP
SPECIAL CIRCUIT '5.DO
EMP'METER OR POLE INS. 15.00
JIT.VALIDATION
ArsDDRESS
MOTORS .SEE FEE SCH.SERVICE
CHANGE 10.00%LICENSED
CONTRACTORS DECLARATION
/
Ir hereby aff ml thxl I amI cerwd under provisions of Chapter 9'
( mmervang with Section 7000) of Uivi�ion 3 of the tlusinus and
Icsions Coyyy111c, ane my II�e.1�a is in full (orP�eanJ c1fcc1.t
LiccnuCll1a�J_''22_/Ul_Lic Number Sp_�(_
Uate�Ls,C//.
OWNER-BUILDIiR DECLARATION
s Licon
1 hereby affirm that 1 am exempt from the Contrinru
emae
Law for the following reason. (Sec.703L S. Businessandtrct, alt ns
Code: Any city or Countypair any requistoctes aum permit construct, alter.
°'
UANCE GATE
"' O
BL ELECT,
PLG. MECH.
BUILORM PERMIT
INFORMATION
= ." - - TO
MISC. REFER O D
PERMIT ISSUANCE, 6.00
� -
Vy%LUATION S/FT.
U
ELEC. CONTR. LIC. NO.
ELEC: I
TOTALifPERM
o its
impmve. demolish, or repay any stmmure, prior hs its issuance, a1w
requires the applicant for sucti permit to file a Signed zUdemrH; that
he n licensed pursuant to the provisions of the Contractor's License
HOD
QTY. PLUMBING PERMIT FEE
Law (Chapter 9 (commencing with See ion 70001 of Division 3 of the
Business and Professions Code) or that he is exempt Therefrom and
STURIES
Tyr CONSTR.
the Qix for the alleged exemption. Any violation of Seclion7031.5
byany applicant for apermit subjects theapplicant tuacivil (ienalty
of an mom than five hundred dollen the
a :
ALTER -DRAIN & VENT -WATER (EA.)4.00
❑ I, as owner of the properly, or my employees with wages as
their sole compensation, will do the work, and the strecture u not
BACK FLOW PROTECT. DEVICE 2.00
- OCC. GROUP
RES. UNITS
DRAINS -FLOOR, ROOF, AREA, COND. .4.00
intended or offered for sale (Sec. 7044, Business and Professions
"
Code The Contractor's Licence law docs not apply to an owner of
-'
FIXTURES - PER TRAP 4.00
SO, FT. FLOOR AREA
-
TOTAL ACREAGE
property who builds or improves thereon, and who docs such work
himself or Ibrough. his own employees, provided that such improve
ments am Dot intended or offered for sale. If, however, the building
GAS-EA.SYSTEM-11NC.40UTLETS 4.00
r improvement is sold within one year of completion, the owner'
builder will have the burden of proving that he did not build.or on-
prove for porlov, of role.). ' .-
❑ I, as owner of the properly, am exclusively contracting with
GAS ; EA. SYSTEM -OVER 4 (EA.) 1.00
-
TOUSE
E IND CON PB Ouse.
❑ ❑ ❑ ❑
INDUSTRIAL WASTE INTER. 20.00
luenrad contractors to construct the project (Sec. 7044, Business
and Profesaions Code: l'he Comractor's License Law dues not apply
roves therein and who
to an owner of pruperty.w'ho builds or imyo
_ LAWN SPRINKLERS - 1 INC 5 V.B. 5.00
LAWN SPRINKLERS - OVER 5 (EA.) 1.00
ASSESSORS PARCEL NO.
commas forsmchprnjwimacammctoRs)licensed Pursuant to .
file Contractor's License e LLaw.
SEWER -SANITARY -STORM EA: 200ft/8.00
TRACT NO.
PARCEL NO.
-
❑ 1 an, exempt under Sec. ,B.&P.C. for this
mason
-
-
WATER HEATER W/VENT 4,00
owner Date
WATER SYSTEM 4.00
ACC. DATE
ACC. FILE NO.
WORK[:RS'COMPENSATION DECLARATION
WATER TREATING EQUIP. - 4.00
1 hereby affirm that 1 haxi• a criiticateufconsent loself-insure,
or u certificate of Workcrs Compensation Insurance, or a cerl ified
ZONING
ENG. SITE NO.
copy thereof (Sec. 3800, Lab .C.I .
Policy No. Company T
❑ Certifed copy is Immbyfurnished.
�9, CrHir copy A IiICJ vilIt the city inspection division.
Appica I'Yibl�t Bj^
'
FIRE SPRINK
v ❑. N ❑
ENERGY T-24
I v ❑ N❑
MISC. - REFER TO ORD,
CERTIFICATE OFEXGNIPTION PROM WORKERS.
'PERMIT ISSUANCE. 6.00
FLOOD ZONE
A.L.U.C.
• C(IMPENSAT ION INSURANCE
(This section• need not be completed if the permit is for one
PLG. CONTH: LIC. NO.
PL
TOTAL
v❑ N❑
v❑ N❑
bumbed dollars (S 1 W) fir Icsx.)
- -
1 certify that in the performance of the work for which this per-
mit is issued, I shall not employ any persnn in any manner so as to-
QTY. MECHANICAL PERMIT FEE
FEE SUMMARY
BUILDING
v -x /
U
Iwcmoc subject to the Werkers''Compcnsntinn Laws of Califamiu.
'Date Applicant
NOTICE TO APPLICANT: If, after making INS Certificate of F-x-
ALTER OR ADD TO MECH. 4,00
APPLIANCE 4.00
'PLAN CHECK
elnpllon, you should become subject to file Workers' Compensation
provisions of the labor Code you must forthwith comply with
such previsions or this permit shall be deemed revoked.
AIR HANDLING UNIT (TO 10=C.F.M-) 3.00
FEE
AIR HANDLING UNIT (OVER 10000 C. F.M.) 5.00
SEISMIC FEE
CONSTRUCTION LENDING AGENCY
1 bcrchy affirm thud there is a construction lending agency for
EXHAUST HOOD (WITH DUCT) 2.00
the performance of the work for which this permit is issued (Sec
3097, Civ.C.).
MICROFILM
HEATING UNIT (TO 100,000 B.T,U.) 4.00
6enderl N,uiAdd
Lender's Address
HEATING UNIT (OVER 100,000 B.T.U.)7.50
ELECTRIC
I certify that l have read this application and state that the above
VENTILATION FAN (SINGLE) 3.00
informationais Cores laws re t c to complywithand county
information n mnccL I agree to comply with construction,
construction, and
PLUMBING
BOILER - COMP (3 H.P. Or 100,0008.T.U.) 4.00
BOILER -COMP (Over 100,000 BTU) SEE FEE SCH.
MECHANICAL
hereby authorize rcpreuntatives of this city to enter upon the
alwve-mentioned prope,ty for inspection purposas.
(We) agree -to ave, indemnify and keep harmless the City of
Cupertino against liabilities, judgments, coats and expenses which
may in any way aceme' against said City in consequence of the
MISC. - REFER TO ORD.
CONST. TAX
PERMIT ISSUANCE 3.00
ng of this pcnniL
a1 -p-'35
MECH.CONT. LIC. NO.
-
TOCH
TAL
-
TOTAL
Signature of Applicant/Contractor Date
OFFICE COPY
APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
BUILDING PROJECT lDENTIFICATION
APPLICATION & PERMIT
BUILDING - ELECTRICAL- PLUMBING - MECHANICAL
PERMIT NUMBER
7165
ADDRESS OORE55
P hI r C
lqvyc�sjciOWN
IR S
"AME
OTY. ELECTRIC PERMIT FEE
PLAN CHECK VALIDATION
1 � PHONE
l
CONTRACTOR
NF E VIel 00�
LIc.N 1. G
wADDRESSrOH
UTLETS- SWITCHES -RECEP 5.00/1.00
LIGHTING FIXTURES 5.00/1.00
I�i flt(1�
PPLIANCES- RESIDENTIAL 4.00
I•)
PANELS 5.00
DATE OF APPLICATION
on nCmTECT
O
ENGINEER
LIC, NO.
SIGNS 6.00
PLAN CHECK FEE P.C. N0,
SIGNS TRANS. 3.00
ADDRESS ENL'
SPECIAL CIRCUIT 5.00
PER IT Vquogr oN
TEMP. METER OR POLE INS. 15.00
ZIP
A
DRESS Ess
AeDon
MOTORS SEE FEE SCH.
SERVICE CHANGE 10.00
I
LICENSED CONI 'RAC'rORS DECLARATION
'
hereby aff inn that I am licensed under provisions of Chapter 4
( inmencing with Section 7000) of Division 3 of the Business DO
rulcvlons Cu an Iny he sc Is m full fu 'e and effect.
License Ch Lie. Number :[Ot.17! .
ISSUANCE DATE
B1.14G.
ELECT,
❑
PLG. MECH.
❑ ❑
Dutcc Contractor
OWNER -BUILDER DECLARATION
I hereby affirm that I tom exempt from the Contractor's License
Law for the following reason. (Sec. 7031.5, Businessand Professions
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 to lite a signed statement that
he is licensed pursuant to tile provisions of the Contractors License
BUILDING PERMIT
INFORMATION
MISC. - REFER TO ORD
V LUATIOry
W� %%�1
(/�J Z ter,
$/FT.
PERMIT ISSUANCE 6.00
ELEC. CONTR. LIC. NO,
ELEC.
TOTAL
PERM(
OTY. PLUMBING PERMIT FEE
Law (Chapter 9 (commencing with Section 7000) of Division 3 of the
Business and Professions Code) or that Ile is exempt therefrom and
JIHOVIV
S RIES
TVP CONSTR.
the basis for the alleged exemption. Any violation of Section 7031.5
by any applicant for a permit subjects the applicant ma civil penalty
of not Clore than five hundred dollars
ALTER-DRAIN&VENT-WATER'(EA.) 4.00
❑ I, as owner of the property, or my employees with wages as
their sole compensation, will do the work, and the structure is not
BACK F LOW PROTECT. DEVICE 2.00
OCC. GROUP
RES. UNITS
DRAINS -FLOOR, ROOF, AREA, COND. 4.00
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 4.00
SO, FT. FLOOR AREA
TOTAL ACREAGE
properly who builds or improves thereon, and who does such work
himself or through his own employees, provided that such improve-
mentsarenotintendedorofferedforsale. l Lhowever.thebuilding
GAS -EAS -EA q,00
or inhprovemmll is sold within one year of completion, the owner-
builder will have the burden of proving that he did not build or im-
proveforpurposeofsale.LINDUSTRIAL
❑ I, as owner of the property, am exclusively contracting with
GAS - EA. SYSTEM -OVER 4 (EA.) 1.00
BUILDING USE
Es IND CON p0 Ome,
❑ ❑ ❑ ❑
WASTE INTER. 20.00
licensed contractors to construct the project (Sec. 7044. Business
and Protessions Code: The Contractor's License Law does not apply
to an owner of property who builds or improves thereon. and who
LAWN SPRINKLERS - 1 INC 5 V.B. 5.00
LAWN SPRINKLERS - OVER 5 (EA.) 1.00
ASSESSORS PARCEL NO.
theconrun for such pence is wish n cantmdarts) licc.wd pursuant to
the tract, for is License Law.
SEWER -SANITARY -STORM EA. 200ft/8.00
TRACT NO.
PARCEL NO.
❑ tarn exempt under Sec. ,B.&P.C. for this
reason
WATER HEATER W/VENT 4.00
Owner Date
WATER SYSTEM 4.00
Acc. DATE
ACC. FILE NO,
WATER TREATING EQUIP. 4.00
WORK 1: RS'('OMPEIN'SA'IION DECLARATION
1 Ilcreby Afinm that I have a certific:le n(conwot to sell-insum-
or a certificate of Workers' Compensation Insurance, or a certified
ZONING
ENG. SITE NO.
copy thereof (Sec. 3800, Luh C..).
Policy No. Cool pant
❑ CcrilicA c'uPY.rs hereby famished.
�FyCuDif d copy i filed with the city inspection division.
,\pplic�'lr �
FIRESPRINK
y❑ NE]
ENERGY T24
v❑ N[]CERTIFICA
MISC. - REFER TO ORD.
PERMIT ISSUANCE 6.00
PLOOOZONE
A.L.U.c.
rC Liz EXENIIII ION FROM WORKERS'
PLG. CONTH. LIC. N0.
PLG.
TOTAL
COMPENSA'pION INSURANCE
CI III, sectiov need not be completed if the permit is for one
Y E] N ❑
Y 13 N ❑
hundred dollars IS I OUR, less I
I certify that in the performance of the work for which (his per-
mit is issued, I shall not employ any person in any manner SO as to
GTY MECHANICAL PERMIT FEE
FEE SUMMARY
BUILDING
''^ /
U
become subject to the Workers' Compensation Laws of California.
Date Applicant
ALTER OR ADD TO MECH. 4.00
NOTICE "r0 APPLICANT: If, aI'Ier making this Certificate of Ex -
APPLIANCE 4.00
PLAN CHECK
emption, you should become subject to the Worker' Compensation
provisions of the Labor Code, you most forthwith comply with
such provisions or mss permit shall be deenmd revoked
FEE
AIR HANDLING UNIT (TO 10SMC.F.M.) 3.00
AIR HANDLING UNIT (OVER IOPMC.F.111.15.00
SEISMIC FEE
CONSTRUcrION LENDING AGENCY
I hereby afflrhn that Ihcn., is a construction lending agency for
EXHAUST HOOD (WITH DUCT) 2.00
the perlononanee of the work for which (his permit is issued (Sec.
3097, CIV.C.),
MICROFILM
HEATING UNIT (TO 100,000 B.T.U.) 4.00
HEATING UNIT (OVER 100,000 B.T.U.)7.50
ELECTRIC
(.endo', Name
Lender; Address
I certify that I have read this application andslate (hal the above
VENTILATION FAN (SINGLE) 3.00
.formation is correct I agree (U comply with all city and county
rdinances and slate laws relating to building construction, and
PLUMBING
BOILER- COIVP(3H.P.or100,000B.T.U.) 4.00
BOILER -COMP (Over 100,000 BTU) SEE FEE SCH:
MECHANICAL
!slcreby authorize representatives of this city 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 in any way accrue against said City in consequence of the
CONST. TAX
PERMIT ISSUANCE 3.00
g tingofthispermiL
-1fimTDnlyx)�1 a 3 SrJ
MECH. CONT. LIC. NO.
MECH.
TOTAL
TOTAL
Signature o(Applicant/Contractor Date
INSPECTOR COPY