12639 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
BUILDING PROJECT IDENTIFICATION PERMIT NUMBER
BUILDING APPLICATION & PERMIT
ADDRESS 12639
Oe
OWNERS
Q C BUILDING-ELECTRICAL-PLUMBING-MECHANICAL
OWNER'S JJ PLAN CHECK VALIDATION
NAME DIrlrAL riQoIpMCd7_' CITY. ELECTRIC PERMIT FEE
PHONE
CONTRACTOR'S
NAME (J OUTLETS-SWITCHES-RECEP 10.00/1.00 6o.00PF- A)6 et-CC- LIC.NO 7 0LIGHTING FIXTURES ;L-Wo?TQ-.e0H-00
AD RRAciomsDRESS PPLIANCES-RESIDENTIAL 4.00
J/GL Y/V PHONE 99i dao PANELS 10,00 DATE OF APPLICATION
Z.1ECi PANELS (OVER 200 AMP) 20.0020-00 PLAN CHECK FEE P.C.NO.
OR
ENGINEER
LIC.rvo. ISIGNS TRANS. 3.00
AS H.OR ENG. SPECIAL CIRCUIT 5.00 PERMIT VALIDATION
ADDRESS
ZIP EMP.METER OR POLE INS. 20.00
APPLICANTS MOTORS SEE FE SCHADOR EBB .
SERVICE CHANGE MANI) p
w
'02 LICENSED CONTRACTORS DECLARATION R- A7 - 1C -O f3 (0",f4 U 1 hereby affirm that I am licensed under provisions of Chapter 9 Ula 1 I SUANCE DATE
h z w (commencing with Section 7000)of Division 3 of the Business and BLDG. ELECT. PLG. MECH.
F y i Professions Code,and my license is in full force and effec ❑ ❑ ❑
o w T License 1. Lia Number 7 6 VI VMp"
o z F C Date Contractor 1111 �d��
y E� If CC. BUILDING PERMIT
¢ ¢ w 4 OWNER.BUILDER DECLARATION INFORMATION
o PI REFER TO ORD
wU. N I hereby affirm that I am exempt from the Contractor's License MISC.-
I. o¢ Law for the following mason.(Sec.7031.5,Business and Professions PERMIT ISSUANCE 10.00 V-Qct VALUATION $/FT.
FWCode:Any city orcounty whichregairesapermit toconstra1111 q
¢Q 0 improve,demolish,or repair any structure,prior to its¢nuance,also E EC.GDNTR. LIC.NO. ELEC.
D¢ requires the applicant for such permit to file a signed statement that D ". C C. 7 6 , TOTAL 165'.00 �^--PERMIT TO
d w m he is licensed pursuant to Ole provisions or the Contractor's License L•�
r z i Law(Chapter 9(Commmsing with Section 7000)of Division 3 ofthe '
4 Business and Professions Code)or that he is exempt therefrom and CITY. PLUMBING PERMIT FEE
Be ¢ O STORIES TYPE CONSTR.
Be e the basis for the alleged exemption.Any violation of Section 7031.5
n ; m by any applicant for a permit subjects the applicant a civil penalty ALTER-DRAIN&VENT-WATER (EA.) 5.00
tt
of not mom than five hundred dollars($500).):
❑ 1,as owner of the property,or my employees with wages as BACK FLOW PROTECT.DEVICE 4.00 OCC.GROUP RES.UNITS
their sole cont Penaation,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 License Law does not apply to an owner of
property who builds or improves thereon,and who docs such work FIXTURES-PER TRAP 5.00 EO.FT,FLOOR"EA TOTAL ACREAGE
himself or through his own employees,provided that such improve- GAS-EA.SYSTEM-I INC.4 OUTLETS 6.00
merits are not intended or offered for sale.If,however,the building
or improvement is sold within one year of completion,the owner GAS-EA.SYSTEM-OVER 4(EA.) 2.00 euILOING USE
Im Ider will have the burden of proving that he did not build or im- RES IND CON PB Omer
prove for . 00 purpose of sale.). INDUSTRIAL WASTE INTER30.
O 1,as owner of the property,am exclusively contracting with ❑ ❑ ❑ ❑ ❑
licensed contractors to construct the project(Sec. 7044,Rosiness LAWN SPRINKLERS-1 INC 5 V.B. 6.00 ASSESSORS PARCEL NO.
;rad Professions Code:The Contractors License Law docs not apply
to an owner of property who builds or improves thereon,and who LAWN SPRINKLERS-OVER 5(EA.) 1,00
contracts lot such projects with a contractood IRCS.,d pursuant to
the ConSEWER-SANITARY-STORM EA.200ft/10.00 TRACT NO. PARCEL NO.
O I'amtractors License Law.exempt under Sec. ,BAP.C.for this WATER HEATER W/VENT 6.00
reason
.Owner Date WATER SYSTEM 5.00
ACC.DATE ACC.FILE NO.
WORKERS'COMPENSAI'ION DECLARATION WATER TREATING EQUIP. 5.00
I hereby affirm that I have a certificate of consent to sell-insure, ZONING ENG.SITE NO.
or a certificate of Workers'Compensation Insurance,or a certified
Copy tlmreof(Sec 3800,1 b.C.).
Policy No.IOL 13/Company gree/c
O ❑ Certified copy is hereby 1'urnishcd. FIRE SPRINK ENERGY T-24
Z_ 2 OI (7vifld y s fi�wiOt,fhe city inspection division. MISC- REFER TO ORD.
O ApPicanl /It l'>` / E6rJQiG - Y ❑ N❑ V ❑ IN
Hy PERMIT ISSUANCE 10.00 FLOOD ZONE A.L.U.C.
� C17 RTI FICAT'li OI'li%EMPI'ION PROM WORKERS'
LU 1 COMPENSATION INSURANCE PLG.CONTR. LIC.NO. PLG. Y❑ NE] Y❑ IN
0. Z( This section need not be completed if the permit is for one TOTAL
hundred dollars(S 100)or I.,.)
U O 1 certify that in the performance of the work for which this per, CITY. MECHANICAL PERMIT FEE FEE SUMMARY
LL 1- mit is issued,1 shall not employ any person in any manner so as to
U become subject to the Workers'Compensation Laws of California.
a Date Applicant ALTER OR ADD TO MECH. 5.00 BUILDING
} N NOTICE TO APPLICANT: If,after making this Certificate of Ex-
(- ? emption,you should become subject to the Workers'Compensation APPLIANCE 5.00 PLAN CHECK
U su h visions
provisions the this
Code, you must forthwith comply with FEE
permit shall be deemed revoked. AIR HANDLING UNIT(TO 10MCF.M.) 4.00
CONSTRUCTION LENDING AGENCY AIRHANDLING UNIT(OVER 10=C.F.M.) 6.00 SEISMIC FEE
1 hereby affirm Ota( there is a construction lending agency for EXHAUST HOOD(WITH DUCT) 5.00
the performance of lite work lot which this permit is iSSUCII(Sec. MICROFILM
3097,Civ.C.L HEATING UNIT(TO 100,000 B.T.U.) 8.00 �7
Lender's Name
Lender's Address HEAT[NG U N IT(OV ER 100,000 B.T.U.)9.50 ELECTRIC l0J
1 certify that I have read this application and state that the above VENTILATION FAN (SINGLE) 4.00
m 1'o°nmlon is correct. I agree to comply with all city and county PLUMBING
ordinances and state laws relating to building construction, and BOILER-COMP(3H.P.or100,000B.T.U.) 6.00
hereby auOmri<e representatives of this city to enter upon the BOILER-COMP (Over 100,000 BTU)SEE FEE SCH. MECHANICAL
above-memioned property for imin,etion purposes.
(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
ry'iry any way accrue,against trod C. 'n con yuence of the PERMIT ISSUANCE 10.00
grantil of this permitMECH.CONT. LIC.NO. MECH.
CO TOTAL TOTAL
nature ol'ApplicmH/Contractor DifTe O
OFFICE COPY
APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
BUILDING PROJECT IDENTIFICATION PERMIT NUMBER
BUILDING APPLICATION & PERMIT
ADDRESS 12639
Oe
OWNERS
Q C BUILDING-ELECTRICAL-PLUMBING-MECHANICAL
OWNER'S JJ PLAN CHECK VALIDATION
NAME DIrlrAL riQoIpMCd7_' CITY. ELECTRIC PERMIT FEE
PHONE
CONTRACTOR'S
NAME (J OUTLETS-SWITCHES-RECEP 10.00/1.00 6o.00PF- A)6 et-CC- LIC.NO 7 0LIGHTING FIXTURES ;L-Wo?TQ-.e0H-00
AD RRAciomsDRESS PPLIANCES-RESIDENTIAL 4.00
J/GL Y/V PHONE 99i dao PANELS 10,00 DATE OF APPLICATION
Z.1ECi PANELS (OVER 200 AMP) 20.0020-00 PLAN CHECK FEE P.C.NO.
OR
ENGINEER
LIC.rvo. ISIGNS TRANS. 3.00
AS H.OR ENG. SPECIAL CIRCUIT 5.00 PERMIT VALIDATION
ADDRESS
ZIP EMP.METER OR POLE INS. 20.00
APPLICANTS MOTORS SEE FE SCHADOR EBB .
SERVICE CHANGE MANI) p
w
'02 LICENSED CONTRACTORS DECLARATION R- A7 - 1C -O f3 (0",f4 U 1 hereby affirm that I am licensed under provisions of Chapter 9 Ula 1 I SUANCE DATE
h z w (commencing with Section 7000)of Division 3 of the Business and BLDG. ELECT. PLG. MECH.
F y i Professions Code,and my license is in full force and effec ❑ ❑ ❑
o w T License 1. Lia Number 7 6 VI VMp"
o z F C Date Contractor 1111 �d��
y E� If CC. BUILDING PERMIT
¢ ¢ w 4 OWNER.BUILDER DECLARATION INFORMATION
o PI REFER TO ORD
wU. N I hereby affirm that I am exempt from the Contractor's License MISC.-
I. o¢ Law for the following mason.(Sec.7031.5,Business and Professions PERMIT ISSUANCE 10.00 V-Qct VALUATION $/FT.
FWCode:Any city orcounty whichregairesapermit toconstra1111 q
¢Q 0 improve,demolish,or repair any structure,prior to its¢nuance,also E EC.GDNTR. LIC.NO. ELEC.
D¢ requires the applicant for such permit to file a signed statement that D ". C C. 7 6 , TOTAL 165'.00 �^--PERMIT TO
d w m he is licensed pursuant to Ole provisions or the Contractor's License L•�
r z i Law(Chapter 9(Commmsing with Section 7000)of Division 3 ofthe '
4 Business and Professions Code)or that he is exempt therefrom and CITY. PLUMBING PERMIT FEE
Be ¢ O STORIES TYPE CONSTR.
Be e the basis for the alleged exemption.Any violation of Section 7031.5
n ; m by any applicant for a permit subjects the applicant a civil penalty ALTER-DRAIN&VENT-WATER (EA.) 5.00
tt
of not mom than five hundred dollars($500).):
❑ 1,as owner of the property,or my employees with wages as BACK FLOW PROTECT.DEVICE 4.00 OCC.GROUP RES.UNITS
their sole cont Penaation,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 License Law does not apply to an owner of
property who builds or improves thereon,and who docs such work FIXTURES-PER TRAP 5.00 EO.FT,FLOOR"EA TOTAL ACREAGE
himself or through his own employees,provided that such improve- GAS-EA.SYSTEM-I INC.4 OUTLETS 6.00
merits are not intended or offered for sale.If,however,the building
or improvement is sold within one year of completion,the owner GAS-EA.SYSTEM-OVER 4(EA.) 2.00 euILOING USE
Im Ider will have the burden of proving that he did not build or im- RES IND CON PB Omer
prove for . 00 purpose of sale.). INDUSTRIAL WASTE INTER30.
O 1,as owner of the property,am exclusively contracting with ❑ ❑ ❑ ❑ ❑
licensed contractors to construct the project(Sec. 7044,Rosiness LAWN SPRINKLERS-1 INC 5 V.B. 6.00 ASSESSORS PARCEL NO.
;rad Professions Code:The Contractors License Law docs not apply
to an owner of property who builds or improves thereon,and who LAWN SPRINKLERS-OVER 5(EA.) 1,00
contracts lot such projects with a contractood IRCS.,d pursuant to
the ConSEWER-SANITARY-STORM EA.200ft/10.00 TRACT NO. PARCEL NO.
O I'amtractors License Law.exempt under Sec. ,BAP.C.for this WATER HEATER W/VENT 6.00
reason
.Owner Date WATER SYSTEM 5.00
ACC.DATE ACC.FILE NO.
WORKERS'COMPENSAI'ION DECLARATION WATER TREATING EQUIP. 5.00
I hereby affirm that I have a certificate of consent to sell-insure, ZONING ENG.SITE NO.
or a certificate of Workers'Compensation Insurance,or a certified
Copy tlmreof(Sec 3800,1 b.C.).
Policy No.IOL 13/Company gree/c
O ❑ Certified copy is hereby 1'urnishcd. FIRE SPRINK ENERGY T-24
Z_ 2 OI (7vifld y s fi�wiOt,fhe city inspection division. MISC- REFER TO ORD.
O ApPicanl /It l'>` / E6rJQiG - Y ❑ N❑ V ❑ IN
Hy PERMIT ISSUANCE 10.00 FLOOD ZONE A.L.U.C.
� C17 RTI FICAT'li OI'li%EMPI'ION PROM WORKERS'
LU 1 COMPENSATION INSURANCE PLG.CONTR. LIC.NO. PLG. Y❑ NE] Y❑ IN
0. Z( This section need not be completed if the permit is for one TOTAL
hundred dollars(S 100)or I.,.)
U O 1 certify that in the performance of the work for which this per, CITY. MECHANICAL PERMIT FEE FEE SUMMARY
LL 1- mit is issued,1 shall not employ any person in any manner so as to
U become subject to the Workers'Compensation Laws of California.
a Date Applicant ALTER OR ADD TO MECH. 5.00 BUILDING
} N NOTICE TO APPLICANT: If,after making this Certificate of Ex-
(- ? emption,you should become subject to the Workers'Compensation APPLIANCE 5.00 PLAN CHECK
U su h visions
provisions the this
Code, you must forthwith comply with FEE
permit shall be deemed revoked. AIR HANDLING UNIT(TO 10MCF.M.) 4.00
CONSTRUCTION LENDING AGENCY AIRHANDLING UNIT(OVER 10=C.F.M.) 6.00 SEISMIC FEE
1 hereby affirm Ota( there is a construction lending agency for EXHAUST HOOD(WITH DUCT) 5.00
the performance of lite work lot which this permit is iSSUCII(Sec. MICROFILM
3097,Civ.C.L HEATING UNIT(TO 100,000 B.T.U.) 8.00 �7
Lender's Name
Lender's Address HEAT[NG U N IT(OV ER 100,000 B.T.U.)9.50 ELECTRIC l0J
1 certify that I have read this application and state that the above VENTILATION FAN (SINGLE) 4.00
m 1'o°nmlon is correct. I agree to comply with all city and county PLUMBING
ordinances and state laws relating to building construction, and BOILER-COMP(3H.P.or100,000B.T.U.) 6.00
hereby auOmri<e representatives of this city to enter upon the BOILER-COMP (Over 100,000 BTU)SEE FEE SCH. MECHANICAL
above-memioned property for imin,etion purposes.
(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
ry'iry any way accrue,against trod C. 'n con yuence of the PERMIT ISSUANCE 10.00
grantil of this permitMECH.CONT. LIC.NO. MECH.
CO TOTAL TOTAL
nature ol'ApplicmH/Contractor DifTe O
OFFICE COPY