4933 APPLICANT TO FILL-IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
BUILDING PROJECT„IDENTIFICATIONPERMIT NUMBER
BUILDING APPLICATION PERMIT � n�
AOOAOne Results `Way Cupertino BUILDING-ELECTRICAL='PLUMBING -MECHANICAL a7 J
OWNER'S . PLAN CHECK VALIDATION
NAMETY. ELECTRIC PERMIT .FEE
Measurex Corp.' PHONE.25.5-150(
CONTRACT OR'S '•r, - OUTLETS-SWITCHES-RECEP . 5.00/1.00'
Stop- Fire, Inc .LIC No.4331:14 LIGHTING FIXTURES - 5.00/1.00
CONTRACTORS RESS PPLIANCES-RESIDENTIAL 4.00
' Aoo47� E. Brokaw R40NE ''293-34-173-PANELS 5.00 DATE OF APPLICATION
ARCHITECT - PLAN CHECK FEE P.C.NO.
OR SIGNS - _ 6.00
ENGINEER
- 11allo, SIGNS TRANS. 3.00
ADDRESS ENG. PERMIT CIRCU IT. 5.00 PERMIT VALIDATION
- ZIP rrEMP.METER OR POLE INS. 15.00
APPUCANTs
ADDRESS -, MOTORS SEE FEE SCH.
VJ
SERVICE CHANGE 10.00 `
F 02 LICENSED CONTRACTORS DECLARATION /
a v w 1 hereby affirm that I am licensed under provisions of Chapter 1)
ISSUANCE GATE
w a H (commencing with Section 7000)of 1livision'J or the Business olid ,BLDG. ELECT.
, PLG. MECH.
mz Profcssi,,nsmyl for4:3tl,f �f�h4,
O
N 92 Qxt ' nc•
< ,E - t BUILDING PERMIT
¢ ¢ ¢ OWNER-BUILDER DECLARA'I DON - -
xx ;LL N I hereby afiiim that Ilam clear III from the Contractor's License MISC.- :i REFER TO ORD I, INFORMATION
wLUATION $/FT.
W o j Law for the following reason.(Sec.requires
a,Businessand Professions 6.00
H _ PERMIT ISSUANCE pyx -
f m i Code:Any city or county whiny structure,
permit prior
to construct,,Iter, t VUR
¢ 2 ¢ FO improv[,demolish,or repair any structure,prior to its issuance,also ELEC.CONTR. LIC.NO. ELEC. ( _ -
a ¢ requires the applicant for such permit to file a signed statement that TOTAL
d to
Z an he is licensed 9(come to the provisions of the Contractor's License �.I PER TO
O '�
w 'i Law(ChapterProcosionsCdwiNSection 7000)of Uivision3ofthe ICfs-• s..D
i o Business and Professions Coale)cr that he is exeramalaerefrm and DTV: PLUMBING PERMIT FEE
¢ 1-$ the hasis far the alleged ex,nption:Any violoipn of Suction 7031.5 STORIES -TYPE CONSTR, -
e. by any applicant for a permil subjects the applicant toe evil penalty ALTER-DRAIN (EA.)of not inure than five hundred dollars(55001.): -
❑. 1,as Owner of the property,Or my employees whh wages as BACK F LOW PROTECT. DEVICE 2.00 OCC.GROUP RES.UNITS
their sole compensation,will do the work,am lire structure is not
intended or offered for sale (Sec. 7044, Business aiulPml'essions ' DRAINS-FLOOR,ROOF,AREA,COND.'4.00
Code:The Contractor's License Law dues not apply to an owner of
property who builds or improves thereon,and who does such work FIXTURES,-PER TRAP 4.00 SO.FT.FLOUR AREA TOTAL ACREAGE
himself or through his own employees,provided that such improve-
mensare not interned orofferedfor mile.If,however,the budding GAS-EA.SYSTEM-11INC.4 OUTLETS 4.00 _
or improvement is sold within one year of completion,the owner- GAS-EA.SYSTEM-OVEBUILDING use;
R 4 (EA.) 1.00
builder will have the burden of proving that he Aid not huild or in, RES IND CON PB Omer
prove for purpose of Rahe.). INDUSTRIAL WASTE INTER. 2000
❑ I,as owner of the property,am exclusively contracting with . El Q 11 0
licensed contractors to construct the project(Sec. 7044,Business LAWN SPRINKLERS-1 INC 5 V.B. 5.00 ASSESSORS PARCEL N0.
and Professions Code:The Contractor's License law does not apply '
to an owner of property who builds ser improves thereon,and who 1 LAWN SPRINKLERS=OVER 5(EA.) 1.00
contracts forsuch projectswith acoutraclods)licensed purm,mt to SEWER-SANITARY-STORM EA, 200ft/8.00
.the Contractors License Law. _ TRACT NO. , PARCEL NO.
❑ Dani exempt under Sec. ,Id:&P,C.Inr this WATER HEATER W/VENT 4.00 -
reason
Date Owner WATER SYSTEM 4.00 ACC.DATE ACC.FILE NO.
wORKIiRS'COMPENSAT ION DECLARATION WATER TREATING EQUIP. 4.00
Thereby affirm that have,a c6thicate of consent to sell'-insure. - ZONING ENG.SITE NO.
or a certificate of Workers'Compensation Insurance,or a certified
copy t o,oc.f(Sac.3800,Lub.C.). a
_
Poky No. Company
-
0 C[tlified ' py is hereby furnished. FIRE SPRINK ENERGY T]4
Z Z ❑ Certif q� so11c with HIt inspection division.
O Applicum _d.Fa.y.liC•_IYnff. MISC.- REFER TO ORD. YEj NE] Y [:] NE]
CC w - PERMIT ISSUANCE 6.00
� - CIiRTIFICA'PEOF EXE MPTION FROM W'ORKYRS' ' FLOODZONE A.L.0 C.
LU > COMPENSATION INSURANCE - PLG.CONTR. LIC_.NO. PLG.
_ d a (This section need not be completed if the permit is for one TOTAL - Y[] N Y [:j N EJ
0 Z hundred dollars IS 100)0,loss.) -
:U O 1 certify that in the Perlintrancc of the work I'or which[his per. OTY. MECHANICAL PERMIT FEE FEE SUMMARY
LL H mil is issued,I shall not employ any person in any planner soasto
O w become Subject to lire Workers'Compc...ilmn Laws of California.
Dom Applicoot' -- BUILDING 56 50
} rail
NOTICE TO AI'I'LICAN'1': II,,ter making this Cert ific:nu'of Ex- ALTER OR ADD TO MECH. 4.00 -
�'? co Ption,you should become soiled in the Workers'CmmIaC.satiDn APPLIANCE 4.00 PLAN CHECK
provisions of to Labor Code, you must forthwith comply with - FEE
U such provisions or this Permit shall he deeme l revoked." AIR HANDLING UNIT(TO 70,000 C.F.M.) 3.00
CONSTRUCTION,L.ENDING AGENCY AIR HANDLINGUNIT(OVER IQOOOGF.M.15.00 SEISMIC FEE c>Q
.I
hereby affirm that•there is a mmstrLetion lending agency for - EXHAUST HOOD (WITH DUCT) 2.00
the perfornance-of the work for which this pernli[is issued(Sec. - - MICROFILM
3097,Civ.CA HEATING UNIT (TO 100,000 B.T.U.)' 4.00
LendExacer's NfutbAddr •' HEATI NG UN IT 100,000 B.T.U.P.50
Lender's Address ELECTRIC
I ordly-thus l have rani thisappliertion and stat,that th[above VENTILATION FAN (SINGLE) 3.00 - -
into dia...ion is correct:I agree to comply with all construction,
county PLUMBING
ordinances and Matet:I r relating nt I, with ep it"'ni ion,int,
BOILER-fbMP,(3 H.P.or 100,000 B.T.U.) 4.00
hereby aullamt, representatives of this city to enter upon the BOILER-COMP (Over 100,000 BTU)SEE FEE SCH. MECHANICAL
abovonxntioned properly fpr inspection purposes. _
^f
:,(We) agree tom ind,lnnif and keep hnnnless III, City of MISC.- REFER TO ORD.
Cupertino against I' bi ies,julgmemis, costs and expo Res which PERMIT ISSUANCE 3.00 CONST.TAX
may in any way cn a• ''1 Cily'in co-Roque ce of the
anti gofthriper } MECH.CONT: LIC.NO. TMECIT
OTAL
L 1 TOTAL
Signature or plican/ ontract r ate
- - - ,• OFFICE COPY - "