6277 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
BUILDING PROJECT IDENTIFICATION PERMIT NUMBER
BUILDING APPLICATION & PERMIT n
` ADDRESS BUILDING-ELECTRICAL-PLUMBING-MECHANICAL 2
d O
77
PLAN CHECK VALIDATION
AME OTY,:;, "ELECTRIC PERMIT '4 ys1FEC
I �q� PNONEZljZ .
,CONTRACTORS UTLETS-SWITCHES-RECEP 5,00/1.00
NAME nn /n� ^ �y
61.1 (1-C- F�-r Lt..No.'3)9-rJO�J LIGHTING FIXTURES 5.00/1.00
CONTTBACTORS Fre....4-.�L*- &, \ PPLIANCES-RESIDENTIAL 4.00 '
442:Ll (Dr�wNer F�,1<{rG(�PNDNC61S_t 31 ( PANELS 5.00 DATE OF APPLICATION
..// ARCHITECT
OR SIGNS b6.00PLAN CHECK FEE P.C.NO.
ENGINEER
LIC.rvD. SIGNS TRANS. 3.00
A-CH.08 ENG. SPECIAL CIRCUIT 5.00 PERMIT VALIDATION
ADDRESS
ZIP TEMP.METER OR POLE INS. 15.00 /
APPLICANT MOTORS SEE FEE SCH. 10
/1 qj�tk
SERVICE CHANGE 10.00
w O a LICENSED CONTRACTORS DECLARATION Q'
a v D I bumby a,inn 11,31 1:.in licensed under provisions of Chapter 1) _ �_ ISSUANCE DATE
m ZQ
a N (commencing will,Section 7000)of Division 3 of the Business and libluli. ELECT. I PLG. MECH.
H w z profession,Code n license is in full for 4offe� ❑ ❑
O imp License C�d Q_I- r
Lie Number - ❑
Date_ _f$.rA;4_CoIdmcta
a x < '`eBl'JIL"OINGE,RMIT
w¢ OWNIi R-BUILDER DECLARATION � INFORIYIATiIUN
REFER TO ORD
w 3 LL y I hereby affirm Thal 1 am exempt from the Contractor's License MISC.- -VALUATION f/FT.
,. o J Law for the followingmuson.(Sec.7031.5,Business and Professions PERMIT ISSUANCE 6.00
� - Code:Any eityoreounty which requires a permit to construct,alter,
/
QaImprove,demolish,or repair any structure.prior to its issuance.also ELEC.CONTR. LIC.NO, ELEO.
O¢ requires the applicant for such permit to file a signed statement that TOTAL ERMIT TO
u w m w he is licensed pursuant to the provisions of the Contractor's License
Fzr
Law(Chapter 9(commencing with Section 700()of Division 3 oflhe
- a 1lusmess and professions Code)ar that he is exempt theuefnm,and OTY. PLUMBING PERMIT FEE
¢ r o the basis for the alleged exemption.Any violation of Section 7031.5 - STORIESTYPE CONSTR.
by any applicant for a permit subjects the applicant toa civil penally ALTER-DRAIN& VENT-WATER (EA.) 4.00
.Fuel more than five hundred dollars(5500).1:
❑ I,as owner of the property,or my employees with wages as BACK FLOW PROTECT.DEVICE 2.00 OCC.GROUP RES.UNITS
their sole cmn pensation,will do the work,and the etmcture is not
immoded or offered far sale (Sec. 7044, Business and I'mieseioos 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 does such work F IXTUR ES-PER TRAP 4.00 SO.IT.FLOOR AREA TOTAL ACREAGE
himself or through his own employees,provided that such improve-
mentsarenotinteadedorofferedl'ot sale.If,however,the building GAS-EA.SYSTEM-I 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 int' R IND CON PO Omer
prove for purpose of sale.). INDUSTRIAL WASTE INTER. 20.00
❑ 1,as owner of the property,am exclusively contracting with ❑ ❑ ❑ ❑
licensed contractors to construct the Trend(Sea 7044,Business LAWN SPRINKLERS- 1 INC 5 V.B. 5.00 ASSESSORS PARCEL NO.
and Professions Code:'I he C'ontractor'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 enntractor(v)licensed pursuant to
the Contractor's Liceew law. SEWER-SANITARY-STORM EA.200ft/6.00 TRACT NO. PARCEL NO.
❑ lam exempt under Sec. .B.&P.C.tin this WATER HEATERW/VENT 4.00
reason
Owner Date WATER SYSTEM 4.00 ACC.DATE ACO.FILE NO.
WORKS RS'COMPENSA'IION DECLARATION WATER TREATING EQUIP. 4.00
I hereby Aft en that I have a certificate olcunsenl to,velfmome, ZONING ENG.SITE NO.
a ccrrt�tiillwaaate of Workers'Comp/e]nsatioo Insurance.or a certified
copy
policy No Afto .
O `Cl/Ce rlllmd ropy is hereby'lL ....a FIRE SPRINK ENERGY T 24
Z Z J4 L'efifil,d tiled with the city it,,,lion division. MISC.- REFER TO ORD.
O Applicanl_-47j/� Y ❑ N❑ Y ❑ N❑
fr ran Cfi R'I'IFICAI'1:017 EXli MITION FROM WORKERS' PERMIT ISSUANCE 6.00FLOOD ZONE A.L.U.C.
UJ > COMITNSA110N INSURANCE PLG,CONTR. LIC,NO. PLG.
CL O ('Phis section used not be consp)cled if the porn,it is for mu, TOTAL V❑ NF] V E] N❑
D Z hundmd doll ars 0100)or IessJ
U O I certify that in the performance of file work fur which this per- GTY. MECHANICAL PERMIT FEE FEE SUMMARY
LL F mit is issueJ, I shall nut employ any person in any manner so as to
O w become subject to the Workerc'Compensallnn Liwsol'California. BUILDING 6e
Dale Applicam ALTER OR ADD TO MECH. 4.00
} N N077CE'TO APPLICANT: If,after making this Certificate of Ex.
F_ Z_ cotillion,you should become subject to the Workers Compensation APPLIANCE 4.00 PLAN CHECK
p...... m, M the Labor Code, you most forthwith Comply with FEE
U vuClu provisions or this permit shall be deaned revoked. AIR HANDLING UNIT(TO 10,Opp GF.M.) 3.00
CONSTRUCTION LENDING AGENCY AIR HANDLING UNIT(OVER 10SWC.EM.) 5.00 SEISMIC FEE
1 hereby affirm 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(See. MICROFILM
3097,Civ.C.). HEATING UNIT(TO 100,000 B.T.U.) 4.00
Lender's Name HEATING UNIT(OVER 100,000 B.T.U.)7.50 ELECTRIC
Lenders Address
I certify that I have read this application and slate that the above VENTILATION FAN (SINGLE) 3.00
infor...dim
information n correct. I agree to comply with all city ucti county BOILER-COMP(3 H.P.or 100,000 B.T.U.) 4.00 PLUMBING
m do urui Sime laws relating to building construction, and
hereby authorize representatives of this city to enter upon the BOILER-COMP (Over 100.000 BTU)SEE FEE SCH. MECHANICAL
above-mentioned property for inspection purposes.
(We) agree to save, indemnify and keep harmess 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 3.00
/ gran ting ofit perm) MECH.CONT. LIC.NO. MECH.
TOTAL TOTAL �D
Siynaiure nl Applicant/Contractor Date
OFFICE COPY
APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
BUILDING PROJECT IDENTIFICATION PERMIT NUMBER
BUILDING APPLICATION & PERMIT n
` ADDRESS BUILDING-ELECTRICAL-PLUMBING-MECHANICAL 2
d O
77
PLAN CHECK VALIDATION
AME OTY,:;, "ELECTRIC PERMIT '4 ys1FEC
I �q� PNONEZljZ .
,CONTRACTORS UTLETS-SWITCHES-RECEP 5,00/1.00
NAME nn /n� ^ �y
61.1 (1-C- F�-r Lt..No.'3)9-rJO�J LIGHTING FIXTURES 5.00/1.00
CONTTBACTORS Fre....4-.�L*- &, \ PPLIANCES-RESIDENTIAL 4.00 '
442:Ll (Dr�wNer F�,1<{rG(�PNDNC61S_t 31 ( PANELS 5.00 DATE OF APPLICATION
..// ARCHITECT
OR SIGNS b6.00PLAN CHECK FEE P.C.NO.
ENGINEER
LIC.rvD. SIGNS TRANS. 3.00
A-CH.08 ENG. SPECIAL CIRCUIT 5.00 PERMIT VALIDATION
ADDRESS
ZIP TEMP.METER OR POLE INS. 15.00 /
APPLICANT MOTORS SEE FEE SCH. 10
/1 qj�tk
SERVICE CHANGE 10.00
w O a LICENSED CONTRACTORS DECLARATION Q'
a v D I bumby a,inn 11,31 1:.in licensed under provisions of Chapter 1) _ �_ ISSUANCE DATE
m ZQ
a N (commencing will,Section 7000)of Division 3 of the Business and libluli. ELECT. I PLG. MECH.
H w z profession,Code n license is in full for 4offe� ❑ ❑
O imp License C�d Q_I- r
Lie Number - ❑
Date_ _f$.rA;4_CoIdmcta
a x < '`eBl'JIL"OINGE,RMIT
w¢ OWNIi R-BUILDER DECLARATION � INFORIYIATiIUN
REFER TO ORD
w 3 LL y I hereby affirm Thal 1 am exempt from the Contractor's License MISC.- -VALUATION f/FT.
,. o J Law for the followingmuson.(Sec.7031.5,Business and Professions PERMIT ISSUANCE 6.00
� - Code:Any eityoreounty which requires a permit to construct,alter,
/
QaImprove,demolish,or repair any structure.prior to its issuance.also ELEC.CONTR. LIC.NO, ELEO.
O¢ requires the applicant for such permit to file a signed statement that TOTAL ERMIT TO
u w m w he is licensed pursuant to the provisions of the Contractor's License
Fzr
Law(Chapter 9(commencing with Section 700()of Division 3 oflhe
- a 1lusmess and professions Code)ar that he is exempt theuefnm,and OTY. PLUMBING PERMIT FEE
¢ r o the basis for the alleged exemption.Any violation of Section 7031.5 - STORIESTYPE CONSTR.
by any applicant for a permit subjects the applicant toa civil penally ALTER-DRAIN& VENT-WATER (EA.) 4.00
.Fuel more than five hundred dollars(5500).1:
❑ I,as owner of the property,or my employees with wages as BACK FLOW PROTECT.DEVICE 2.00 OCC.GROUP RES.UNITS
their sole cmn pensation,will do the work,and the etmcture is not
immoded or offered far sale (Sec. 7044, Business and I'mieseioos 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 does such work F IXTUR ES-PER TRAP 4.00 SO.IT.FLOOR AREA TOTAL ACREAGE
himself or through his own employees,provided that such improve-
mentsarenotinteadedorofferedl'ot sale.If,however,the building GAS-EA.SYSTEM-I 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 int' R IND CON PO Omer
prove for purpose of sale.). INDUSTRIAL WASTE INTER. 20.00
❑ 1,as owner of the property,am exclusively contracting with ❑ ❑ ❑ ❑
licensed contractors to construct the Trend(Sea 7044,Business LAWN SPRINKLERS- 1 INC 5 V.B. 5.00 ASSESSORS PARCEL NO.
and Professions Code:'I he C'ontractor'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 enntractor(v)licensed pursuant to
the Contractor's Liceew law. SEWER-SANITARY-STORM EA.200ft/6.00 TRACT NO. PARCEL NO.
❑ lam exempt under Sec. .B.&P.C.tin this WATER HEATERW/VENT 4.00
reason
Owner Date WATER SYSTEM 4.00 ACC.DATE ACO.FILE NO.
WORKS RS'COMPENSA'IION DECLARATION WATER TREATING EQUIP. 4.00
I hereby Aft en that I have a certificate olcunsenl to,velfmome, ZONING ENG.SITE NO.
a ccrrt�tiillwaaate of Workers'Comp/e]nsatioo Insurance.or a certified
copy
policy No Afto .
O `Cl/Ce rlllmd ropy is hereby'lL ....a FIRE SPRINK ENERGY T 24
Z Z J4 L'efifil,d tiled with the city it,,,lion division. MISC.- REFER TO ORD.
O Applicanl_-47j/� Y ❑ N❑ Y ❑ N❑
fr ran Cfi R'I'IFICAI'1:017 EXli MITION FROM WORKERS' PERMIT ISSUANCE 6.00FLOOD ZONE A.L.U.C.
UJ > COMITNSA110N INSURANCE PLG,CONTR. LIC,NO. PLG.
CL O ('Phis section used not be consp)cled if the porn,it is for mu, TOTAL V❑ NF] V E] N❑
D Z hundmd doll ars 0100)or IessJ
U O I certify that in the performance of file work fur which this per- GTY. MECHANICAL PERMIT FEE FEE SUMMARY
LL F mit is issueJ, I shall nut employ any person in any manner so as to
O w become subject to the Workerc'Compensallnn Liwsol'California. BUILDING 6e
Dale Applicam ALTER OR ADD TO MECH. 4.00
} N N077CE'TO APPLICANT: If,after making this Certificate of Ex.
F_ Z_ cotillion,you should become subject to the Workers Compensation APPLIANCE 4.00 PLAN CHECK
p...... m, M the Labor Code, you most forthwith Comply with FEE
U vuClu provisions or this permit shall be deaned revoked. AIR HANDLING UNIT(TO 10,Opp GF.M.) 3.00
CONSTRUCTION LENDING AGENCY AIR HANDLING UNIT(OVER 10SWC.EM.) 5.00 SEISMIC FEE
1 hereby affirm 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(See. MICROFILM
3097,Civ.C.). HEATING UNIT(TO 100,000 B.T.U.) 4.00
Lender's Name HEATING UNIT(OVER 100,000 B.T.U.)7.50 ELECTRIC
Lenders Address
I certify that I have read this application and slate that the above VENTILATION FAN (SINGLE) 3.00
infor...dim
information n correct. I agree to comply with all city ucti county BOILER-COMP(3 H.P.or 100,000 B.T.U.) 4.00 PLUMBING
m do urui Sime laws relating to building construction, and
hereby authorize representatives of this city to enter upon the BOILER-COMP (Over 100.000 BTU)SEE FEE SCH. MECHANICAL
above-mentioned property for inspection purposes.
(We) agree to save, indemnify and keep harmess 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 3.00
/ gran ting ofit perm) MECH.CONT. LIC.NO. MECH.
TOTAL TOTAL �D
Siynaiure nl Applicant/Contractor Date
OFFICE COPY