6862 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
BUI LDI NG PROJECT IDENTIFICATION PERMIT NUMBER
BUILDING /J APPLICATION & PERMIT
ADDRESS� 1)14 N 6862
C BUILDING -ELECTRICAL-PLUMBING-MECHANICAL
OWNER'S PLAN CHECK V LIDATION
`A NAME �rn TY. ELECTRIC PERMIT FEE s2
S• CW. PHONE !-i�� f /b a�7 -
CONTRACTOR s SI(NUTLETS-SWITCHES-RECEP 5.00/1.00 �,C�
N �i
NAMEME 'gyp
,p Sj A2aC l.4021;r,No. 417-30% LIGHTING FIXTURES 5.00/1.00
s �.CONTRACTORz /.7^ APPLIANCES-RESIDENT IAL 4.00
JV Reif PIEON,7K-6-1QD0 PANELS 5.00 DATE OF APPLICATION
ARCHITECT SIGNS 6.00 PLAN CHECK FEE P.C.NO.
OR
ENGMEER�y yA
LIC.ND, SIGNS TRANS. 3.00
ARCH.OR END' SPECIAL CIRCUIT. 5.00 PERMIT VALIDATION
ADOREss
ZIP frEMP.METER OR POLE INS. 15.00 n
APVLICANT'$ ri
ADDRESS MOTORS SEE FEE SCR, q
SERVICE CHANGE 10.00 fl/o o LICENSED CON"TRACTORS DECLARATION JAH 1 C: ID.J
nE F.
R v b I hereby affirm that I am licensed tinder provisions of Chapter 9 ISSUANCE DATE
w R u (commencing with Section 7000)of Division 3 of the Busiron anJ BLDG. ELECT. PLG. MECH.
H w i Professions Codc, d rqy license is in full force ylJcffe' t" y (f •�7e tir� ❑
0 o m- icenw las ('7��L�!_i ,Lie Number. �-F 1
O r w Dalc-z�Z� ontra or f�
s rvx.a..f.. I,AS/'�NRVI 2.ES BUILDINGFPE RMIT
M ,,- <' �rvtiR-BuauPR OT:L Rnnory '.'!INFORM_ ATION
m o a G MISC.- REFER TO ORD �"
w LL P- I hereby affirm that 1 am exempt from the Contractor's License vq LUATION E/FT.
FLL0J law for the following reason.(Sec.703 1.5,Businessand Professions PERMIT ISSUANCE 6.00
Code:Any city or county which requires Permit to construct.alter,
a ¢ ¢ p improve,demolish,it repair any slruclure,prior to its issuance,also ELEC.CONTE. UC.NO. ELEC. / ri
in
S, requires the applicant for such Permit to file a signed statement that TOTAL PERMI TO
a w m he is licensed pursuant to the provisions of the Contractor's License qT�l
H z a law(Chapter 9(commencing with Section 7000)of Division 3e,film /\CMO/��L'
E 4 o Business and Professions Code)or that he is exempt therefrom and CITY. PLUMBING PERMIT .FE
¢r_ the basis for the alleged exemption.Any violation if ScClion 70315 STORIES TYPE CONSTR.
by any applicant for a permit Subjects the applicant too civil Penally ALTER-DRAIN&VENT-WATER (EA.) 4.00
of nol mom than five hundred dollars(SSOOL):
❑ 1,as owner of the property,or my employees with wagesas BACK FLOW PROTECT.DEVICE 2.00 OCC.GROUP RES.UNITE
their mile compensation.will do the work,and the slruclure Is not
intended or offered for sale (Sec. 7144, Business and Professions DRAINS-FLOOR,ROOF,AREA,COND. 4.00
Code;The Contractor's License Law does not apply to an owner of
property who builds or improves thereon,and who docs such work FIXTURES-PER TRAP 4.00 SO.FT.FLOOR AREA TOTAL ACREAGE
himself it through his own employees,provided that such improve,
Lrnls arc nut intended.,offered for sale.I L however,the building GAS-EA.SYSTEM-11NC.40UTLETS 4.00
or improvement is sold within one year of completion,the owner- GAS-EA.SYSTEM-OVER 4(EA.) 1.00 BUILDING USE
builder will have the burden of proving that he did not build or im- RES IND CON PB Omer
Prove for Purpose.1'a leJ. INDUSTRIAL WASTE INTER. 20.00
❑ 1,as owner of the property,am exclusively contracting with ❑ ❑ ❑ ❑ ❑
licensed contractors to construct the project(Sec. 7044,Business LAWN SPRINKLERS-1 INC 5 V.B. 5.00 ASSESSORS PARCEL NO.
and Professions Code:*The Contractor's License Law does not apply
to aowner of property who builds or improves thereon,and who LAWN SPRINKLERS-OVER 5(EA.) 1.00
aon Onucts for such projects with a contructons)licensed pursuant to
the Contractors License Law. SEWER-SANITARY-STORM EA.200ft/8.00 TRACT NO. PARCEL NO.
❑ lam exempt under Sea ,B.&P.C.lin this WATER HEATER W/VENT 4.00
reason
Owncr Dam WATER SYSTEM 4.00 ACC.DATE ACC.FILE NO.
WORK ERS'COMPENSATION DECLARATION WATER TREATING EQUIP. 4.00
1 hereby affirm that 1 have a certificate of consent t.selfinsure. ZONING ENG.SITE NO,
or a certificate of Workers'Compensation Insurance,or a certi0ed
copy therein'(Sec.3800,1ab.0-)
Policy No. Company MLCS/d� /�fJ�((
O ❑ Certircdcopyishembyh...ishcd.We /d0d'9� FIRESPRINK ENERGY T-24
Z Z >e Cerlif d oP� "s Elc w' (h.. II n cc o division.
O Applmi �!%4_.3 L�;f_ �c f�c} iyY..ZI-� MISC.- REFER TO ORD. y❑ N❑ Y ❑ No
F y � -! PERMIT ISSUANCE 6.00 11oo6 E A.L.U.C.
CC - C11R'fIFICA'Il;OF EXEMPTION FROM WORKERS'
UJ > COMPENSATION INSURANCE PLG.CONTR. LIC,No, PLG.
CL O ('Phis section need not he completed if tine Permit is for one TOTAL V[:] N❑ V ❑ N❑
0 2 Imndred dollars($100)or less.)
U O 1 certify that in the performance of the work for which this FEE SUMMAR V;'
Per- QTY. MECHANICAL PERMIT FEE
0 F mit is issued,I shall not Workers'
any person in any Iof so California..to _
O W become suM1iem to the Workers'Compensation Laws ol'CaliiaBUILDING d"�
Date Applicant ALTER OR AD `TO MECH. 4.00 ��0
} y NO'T'ICE'10 APPLICANT: If,after making this Certificate of Ex-
F.. ? cmption,you should become subject to the Workers'Compensation APPLIANCE 4.00 PLAN CHECK
provisions of the Labor Code, you must n'orthwith comply with FEE
U such provisions or this permit shall be deemed revoked. AIR HANDLING UNIT(TO 10=C.F.NL) 3.00
CONSTRUCTION LENDING AGENCY _ AIR HANDLING UNIT(OVER 10=C.F.M.) 5.00 SEISMIC FEE
I hereby aftirm that 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 HEATING UNIT(TO 100,000 B.T.U.) 4.00 MICROFILM
3097,Cie.C.).
Lender's Name HEATING UNIT(OVER 100,000 B.T.U.17.50 ELECTRIC
Lender's Address
I certiny that l have read this application and state that the above VENTILATION FAN (SINGLE) 3.00
infornmtion is correct.1 agree to comply with all city and county PLUMBING
ordinances and state laws relating to building construction, and BOILER-COMP(3 H.P.or 100,000 B.T.U.) 4.00
hereby authorize representatives of this city to enter upon the BOILER-COMP Over IO0.0008TU)SEE FEE SCH. MECHANICAL
ubova-mentioned property for inspection purposes.
(We) agree to save, indemnify and keep harmless the City of MISC.- REFER TO ORD.
Cupertino against liahilitius,judgmmtts, costs and expenses which PERMIT ISSUANCE 3.00 CONST.TAX
may in any way accrue against said City in consequence of the
granting of perlltQD $T(L✓1C71f2F1' IN ECH.CONT. LIC.NO. MOTAL
/rr'✓ 24 5 TOTAL
Signature of Applicant/Contractor Date
OFFICE COPY
APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
BU LDI NG PROJECT I DENT[FICATI ON PERMIT NUMBER
BDI LDING APPLICATION & PERMIT
AD DREss
zO �2 BUILDING -ELECTRICAL-PLUMBING-MECHANICAL6862
OwNER'S V - PLAN CHECK VALIDATION
NAME �: ` TV. ELECTRIC PERMIT FEE oZ ,� 7--Z
syl do. PHONE b (/
CONTR CTO 'S [ - G
1! NAmE SP/ ^r UTLETS-SWITCHES 5.00/1.00 iyL� i �aG/�fC
/ a STQ(AC11A(WNo. 4i2sQ1 LIGHTING FIXTURES 5.00/1.00
oorvTRAcrors
ADDRESS z4-7q PPLIANCES-RESIDENTIAL 4.00
vL/ PHONE 6-' p PANELS 5.00 DATE OF APPLICATION x
ARCHITECT SIGNS 6.00 PLAN CHECK FEE P.C.NO.
ENGINEER�y LIC,No, SIGNS TRANS. 3.00
ARCH.OR ENG, PERMIT VALIDATION
ADDRESS SPECIAL CIRCUIT 5.00
ZIP FrEMP.METER OR POLE INS. 15.00
APPLICANTS
ADDDRESSDRESSMOTORS SEE FEE SCH.
SERVICE CHANGE CHANGE 10.00 • // %fs
o O LICI?NSP.D CON'I'RACI'ORS DECLARATION /
U v. I hereby affirm that I Am licensed under provisions of Chapter') ISSUANCE DATE
y<vAi Icommenenng with Section 7000)of Division 3 of the Business and BLDG. ELECT. PLG. MECH.
Professions Code,'nJ y liansr is in full force a J effect.
Z o= License Cla Lic.Number -3L1� ❑ ❑ I❑
o N Date�r _�\ Intmclor�Jr�•�2 rt_L(1
r �4ivlll:R-el ILDhR I.E ,Alin i rtNam ee,S 1 BUILDING PERMIT
Ix rc w a INFORMATION
o A ° MISC.- REFER TO ORD
K
3 I H hereby affirm that 1 am exempt from the Contractor's License VALUATION $/FT,
N .. m j Law fur the following reason.(Sec 7031.5,Businessand Professions PERMIT ISSUANCE 6.00
Code:Any city or county which requires a permit In construct.alter,
Qu,Q improve,demolish,Of repair any structure,prior t0 its issuance,also ELEC.CONTR. ELEC.
G¢ requires the applicant for such permit to file a signed statement that TOTAL PERMIT TO
a w mIle is licensed pursuant to the provisions of the Contractor's License
N z a
Law(Chapter 9(commencing with Section 7000)of Division 3 of Die N
Business and I'odr,sim,Code)or that he is exempt therefrom and OTV. PLUMBING PERMIT FEE
it I o the basis for the alleged exemption.Any violation nf5ection 7031.5 STORIES TYPE CONSTR.
A. by any Applicant for a permit subjects the applicant to a civil penally ALTER-DRAIN -WATER (EA.) 4.OD
of not more than five hundred dollars(5500).):
❑ I,as owner of the property.or my employees with wages as BACK FLOW PROTECT. DEVICE 2.00 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 Professionx DRAINS-FLOOR,ROOF,AR EA,COND. 4.00
Code:The Contractor i License Law docs not apply to an owner al ,.
property who builds Or Improves therect,and who docs us
work F IXTURES-PER TRAP 4.00 50.FT.FLOOR AREA TOTAL ACREAGE
himself or through his own employees,provided that such improve. .
ments are not intended or offered for sale.If,however,the building GAS-EA.SYSTEM-1 INC.4 OUTLETS 4.00
or improvement is sold within one year of completion,the owner- GAS-EA.SYSTEM.OVER 4 (EA.) 1.00 BUILDING USE
builder will have the burden of proving that he did not build or im- RES IND CON PB Omer
prove for purpose of sale.). INDUSTRIAL WASTE INTER. 20.00
❑ I,as owner of the property,am exclusively contracting with E] E] ❑ E] ❑
licensed contractors or construct the project(Sec 7044,Business LAWN SPRINKLERS-1 INC 5 V.B. 5.00 ASSESSORS PARCEL NO.
And Professions Code:The Contractor's License Law does not apply
to an owner of property who builds or improves 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/8.00 TRACT NO. PARCEL NO.
❑/l am a xcmpl under Sce. ,B.&P.C.for this WATER HEATER W/VENT 4.00
reason
Ow"cr Date WATER SYSTEM 4.00 ACC.DATE ACC.FILE NO.
WORKERS'COMPENSAI'ION DECLARATION WATER TREATING EQUIP. 4.00
1 hereby atfirn that I have a certificate ofconent to sclflnsum, - ZONING
or a certificate of Workers'Compensation Insurance,or a certified ENG.SITE NO.
copy thercof(Sec.3800,Lab,C I _
Policy No.-Company' M, V, /NJ3
O ❑ Cenilicd copy is hereby furnished.VJ /-aGOd4h<�6 FIRE SPRINK ENERGY T$4
Z
Z 19(Cen Ricd opY is Iiia1�nth the uty ins onion division. MISC.- REFER TO ORD.
Applicant-/?l t-IF xST2LA - Y ❑ N❑ Y ❑ N❑
~ � PERMIT ISSUANCE 6.00 FLOOD ZONE A-L.0 c.
N/ CI'R'I'I I'1�11`I:OP I:XI:M'TION 4 OM WORKERS'
LU � COMPENSATION INSURANCE PLG.CONTR. LIC.NO. PLG.
d O ('Phis section need not be Completed if tire Ye permit is for one TOTAL ❑ N❑ Y. ❑ N❑
Z hundred dollars(S 100)or lcssJ
U O 1 certify that in the performance of the work for which this per- OTY. MECHANICAL PERMIT FEE FEE SUMMARY
LL F- mit is issued, I shall not employ any person in any manner so as to
OV become subject to the Workeri Compensation haws of California.
w BUILDING
a Doc X Applicant ALTER OR ADD TO MECH. 4.00
} w
NOTICE T'0 APPLICANT': IC after making this Ccrlifmpe o(Ex-
F Z emption,yourshould become subject m the Workers'Compensation APPLIANCE 4.00 PLAN CHECK
provisions of tire Labor Codc, you must forthwith comply with FEE
O such provisions of this permit shall be deemed revoked. AIR HANDLING UNIT(TO 10XMC.F.Ivl) 3.00
CONSTRUCT ION LENDING AGENCY AIR HANDLING UNIT(OVER 10SMC.F.M.) 5.00 SEISMIC FEE dl�a
I hereby affirm that there is a construction lending agency for EXHAUST HOOD(WITH DUCT) 2.00
the performance of lire work for which this pennil is issued(Sec. MICROFILM
3097,Civ.C.). HEATING UNIT(TO 700,000 B.7.U.) 4.00
Lender's Name
Lender's NamAddre HEATING UN IT(OVER100,000B.T.U.)7.50 ELECTRIC
ss
I certify that I have read this application and stat,that the above VENTILATION FAN (SINGLE) 3.00
•
ordinances and stale laws relating to building construction, and BOILER-00iormation is correct. I agree to comply with all city and county PLUMBING
MP(3 H.P.or 100,000 B.T.U) 4.00
hereby mrhorize representatives of this city to enter upon the BOILER-COMP (Over 10g000BTUISEE FEESCH. MECHANICAL
Above-min ioned properly for inspection purposes. -
(We) agree to save, indemnify and keep harmless the City o1MISC.- REFER TO ORD.
Cupertino against liabilities,judgments, costs and expenses which CONST.TAX
may in any way accrue against said City in Conscyuence of the PERMIT ISSUANCE 3.00
granting of this PcrmiL/�Jlq QV Sr12NC 11Q t-j I N ECH.CONT. LIC.NO. MECH.
M - TOTAL TOTAL y�
\' �/. LY S S
x Signature of Applicant/Contractor I ate
/ \ INSPECTOR COPY