14171 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
t BUILDING PROJECT IDENTIFICATION FICATION PERMIT NUMBER
BUILDING APPLICATION & PERMIT
°° E_= 14171
J0 J a/- �t BUILDING - ELECTRICAL-PLUMBING-MECHANICAL
NAME71's (9�v PLAN CHECK VALIDATION
NAME ✓y� QTY. ELECTRIC PERMIT FEE 7/
6 lam• • A...E /o ,a7�
CONTRACTORS OUTLETS-SWITCHES-RECEP 10.00/1.00
t�
T sec.NO. LIGHTING FIXTURES 10.00/1.00
-oNTRACTORs APPLIANCES-RESIDENTIAL 4.00
OUR
Ess
UPHONE�I/Iel Ie PANELS 10,00 DATE OF APPLICATION
AJ
A �CHIITTEECCT� }}���� 4 PANELS (OVER 200 AMP) 20.00 PLAN CNECK FEE P.C.NO.
ENAIj fA/ '1LC Juc.No. C1�'L SIGNS TRANS. 3,00
ARC�H..-�oRENa. SPECIALCIRCUIT 5,00 PERMIT VALIDATION
A° Ess
ZI EMP.METER OR POLE INS. 20.00
APPLICANT s MOTORS SEE FEE SCH.
A
Q ZSD SERVICE CHANGE 20.00
O O LICENSED CONTRACTORS DECLARATION yy
¢ v u I hereby affirm that I am licensed under provisions of Chapter 9 lD ISSUANCE DATE
as a if (commencing with Section 7000)of Division 3 of the Business anJ BLDG. ELECT, PLG. MECH.
H m Professions Code,anJ license is in full force' t 9 El 13z o w- License Clas Lia Number
Q F O Dutc Contractor
VILDING PERMIT
E ¢ w OWNER-BUILDER DECLARA'T'ION Q erfiWORMATION
K
;LL U 1 hereby affirm th I I am exempt fmm the Contractor's License MISC.- REFER TO ORD
ra_ Law for file following reason.(Sec.7031.5,Business and Professions pERM1T ISSUANCE 10.00 VALUATION $/FT.
m i 3 Code:Any city or county which rnluiresepernit toconslruct,alteq ELEC.CONTR. LIC.NO. /0 -C �0
¢ rt a O improve,demolish,or repair any structure,prior to its issuance,also ELEC.
¢ requires the applicant for such permit to file a signed statement that TOTAL PERMIT TO
a w Of
Of u. he is licensed pursuant to the provisions of the Contractor's License Q
rzt Law(Chapter 9(commencing with Section 7000)ofDivision
3ofthe /N�;&o,< R id
a Business and Professions Code)or that he is exempt therefrom and QTY. PLUMBING PERMIT FEE
I i O
¢ H the basis for the alleged exemptimt.Any violation.1 Section 7071.5 STORIES TYPE CONSTR.
n ; $ by any applicant for a permit subjects the applicant to a civil penally ALTER-DRAIN&VENT-WATER (EA.) 5.00
of not more than five hundred dollars($500).1:
❑ 1,as owner of the property,or my employees with wages as BACK FLOW PROTECT.DEVICE 4.00
their sole compensation,will do the work,and the structure is not OCC.GROUP RES.UNITS
intended or offered for sale (Sec. 7044, Business and Professions DRAINS-FLOOR,ROOF,AR EA,COND. 5.00
Code:The Contractor's License Law dols not apply to an owner of
property who builds or improves thereon,and who does such work FIXTURES-PER TRAP 5.00 s0.Fr.FLOOR AREA TOTAL ACREAGE
himselfor through his own employees,provided that such improve-
ments are not intended or offered for sale.If,however,the building GAS-EA.SYSTEM-1 INC.4 OUTLETS 6.00
or improvement is sold within one year of completion,the owner- GAS-EA.SYSTEM-OVER 4 (EA.) 2.00 BUILDING USE
builder will have the burden of proving that he did not build ser an- RES IND CON PB Omer
prove for purpose of sale.). INDUSTRIAL WASTE INTER. 30.00
❑ 1,us owner of the property,am exclusively contracting with ❑ ❑ ❑ ❑ ❑
licensed contractors to construct lite project(Sea.7044,Business LAWN SPRINKLERS- 1 INC 5 V.B. 6.00 ASSESSORS PARCEL NO.
and Professions Code:The Contractor's License Law does not apply
to an owner of property who builds or improves thereon.and who LAWN SPRINKLERS-OVER 5(EA.) 1.00
contracts for such projects with a contractoms)licensed pursuant to
SEWER-SANITARY-STORM EA.200$/10.00 TRACT NO. PARCEL NO.
the Contractor's License Law.
❑ I am exempt under Sec. ,B.&P.C.tin this WATER HEATER W/VENT 6.00
reason
Owner Date WATER SYSTEM 5.00 ACC.OATE ACC,FILE NO,
WORK ERS'COMPENSATION DECLARATION WATER TREATING EQUIP. 5.00
1 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 thereof I Se.3800,Lab CJI / �L,w
Policy No. Company.(trey
Q ` ❑ Certified copy is hereby furnish ed. FIRE SPRINK ENERGY T 24
Z Z ❑ Cntifitd - R RI d with nt` nspection divisio MISC.- REFER MOREL V N V N
Q Applicant' ❑ ❑ ❑ ❑
F w �' PERMIT ISSUANCE 10.00 FLOOD ZONE A.L.UO.
� > Cli Tl14CA'1'E OP SAI ION INS FROM W RKIi RS'
W needCOWnot
be completed
INSURANCE PLG.LOrvrR. LIC.NO. PLG. Y❑ N❑ Y ❑ N❑
� 0 (This section nccJ not be eumplttcJ it the permit is for one TOTAL
� Z hundred dollars IS 100)or Icss.) c
U 0 1 certify that in the performance of the work for which this per- QTY. MECHANICAL PERMIT FEE FEE SUMMARY
U_ I- mit is issued,I shall not employ any person in any manner sr n s to
Ow become subject to the Workers'Compensation Laws of California- BUILDING
Date Applicant ALTER OR ADD TO MECH. 5.00 s�M3
} H NOTICE 1'0 APPLICANT': If,after niaking this Cerilicutc of Ex-
F Z emption,You should become subject to the Workeri Compensation APPLIANCE 5.00 PLAN CHECK
provisions of the Labor Code, you must forthwith comply with FEE
U such provisions or this permit shall be deemed revoked. AIR HANDLING UNIT(TO 10=CF.M.) 4.00
CONSTRUC'DON LENDING AGENCY AIR HANDLING UNIT(OVER iO=C.F.M.) 6.00 SEISMIC FEE PO
1 hereby affirm that there is a construction lending agency for EXHAUST HOOD(WITH DUCT) 5.00
the performance of the work for which this permit is issued(Sec. MICROFILM
3097,Civ.CJ. HEATING UNIT(TO 100,000 B.T.U.) 8.00
Lender's Name HEATINGUNIT(OVER100,000B.T.U.)9,50 ELECTRIC
Lender's Address
1 certify that I have read this application and nate that the above VENTILATION FAN (SINGLE) 4.00
information is correct. I agree to comply with all city and county BOILER-COMP(3 H.P.or 100,000 B.T.U.) 6.00 PLUMBING
ordinances and state 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 harmless the City of MISC.- REFER TO ORD.
Cupertino against liabilities,inductors, costs and expenses which PERMIT ISSUANCE 10.00 CONST.TAX
Inlay in tlay way accrue a City in conn once of the
gran his p :If MECH.CONT. LIC.NO. MEL..
Z TOTAL TOTAL d7rj
- 1.1-of A pplicanrlContractor ate
OFFICE COPY
^r r11u 1 I u FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
BUILDING BUILDING PROJECT IDENTIFICATION
ADDRESS APPLICATION & PERMIT PERMIT NUMBER
17,OZ) - [:iy! I (�, BUILDING-ELECTRICAL-PLUMBING - 41 � �
NAMors MECHANICAL E•F
NAME
�✓w Ii _ CITY. ELECTRIC PERMIT PLAN CHECK VALIDATION
NON CHgCiOH'$ PNONE FEE �/ �7..
UTLETS-SWITCHES-RECEP 10.00/1.00
:oNTRACTOH� '�' G.NO' LIGHTING FIXTURES c% '� a
nc�
ADDRESS T 10.00/1.00
PLONE,Cf (�I�� I[ APPLIANCES-RESIDENTIAL 4.00
D
A cHECT PANELS 10.00
on
DATE OF APPLICATION
ENG E / PANELS (OVER 200 AMP) PLAN CHECK=FEE
C.NO
AENG. 1_111C..No. SIGNS TRANS.
AD 09AESS E$$ 3,60
�r�`/I ( SPECIAL CIRCUIT 5.66 PERMIT VALIDATION
. APPLICANTS 1/ ��` ZIP EMP. METER OR POLE INS.
ADDRESS 20.00
]r 7� MOTORS
SERVICE CHANGE SEE FEE SCR.
�0'T,crC(�S'v
r O O LICENSED CONTRACTORS DECLARA"PION 20.00 (�
v
¢ I hereby allinn Ihat I am licensed under prm'iaions Ili'Choptrr 9
H a (commencmb with Section 7000)01 Division 3 03III,Itusin,n and `u
w'^ Profemion,CoJr,IF licrtuc is in Tull liarc�ysq pJb�,l.
2
O n0. - Licenm Ci 7� (• ISSUANCE DATE
' O ?, ) LiC.Nmnbcr_/,. _ BLDG. ELECT. PLG. NIECE
I-j D'Jlc�/�f/` �LUI IIpr1 o_�±a• /f r 1, ;�
/ CJ J [J ❑
s ',, . OWNER.BUII.OER DECLARANON'��T �-
a 3 w I hereby a0inu that I am cernlp3 Iron Ihv Contru,mr'a Liccnx• MISC.- BUILDING PERMIT
H ur o a Low For Ili,lidlowing«vxm.lSec.7031.5,Itu.i REFER TO ORD I II Ef�101FORMATION
Code An I I and Prulasslona pERMI?ISSUANCE
$ Y 2 )'city ur county whidl ra imaa permit W col"Holl,uheq VALUATION
IL Q¢ O mlprove,Jemoli,h,ar repair any stun.«\Prior Ia i15 iaeuanca also ELEC..CGNTR, 10.00 $/FT.
O u Rel Il ac the aP UO,U'l I'm such pennil to
lite a signed It'lli L'nt lust LIC.NO. �L) �/�O
u m he is Cf,p d punuanl to the Provision of the Conbaaor'.v l.i,ulac ELEC.
a Law(Chupk'r9 f ullnlusullo wiO15eaiun 70001 ul UivisiunJ nl(lira rorAL
f z O Uusmns and I'rol,uimis Code)or that hr N ese alit Thorel rum and CITY. PERMIT TO
wEW the basis for Oleallrged 9xrnpltimur Any violation of S,nlon 7(131.5 PLUMBING PERMIT FEE /N7Z--,P/0,< RJJvOd&�
a ; by any aPPlleaut lora a P9nnit subi,Cn the aPplirunl Ioucivil plushy
ufnol nlo«'than lie,hundred douses($500).): ALTER-DRAIN STORIES TYPE CONSTH,
❑ I,a' of III,IMIomrry,ur n (EA.) 5.00
tlu•ir sole colo ensatioo, I Y`''^pl°>'°`+with wugc'a, BACK FLOW PROTECT.DEVICE
JuRsuded or offered for gala(Seep 7094 Ilus nn+a and P"a" ,'ions
4.00 OCC.GROUP
Cod,:The CularuClnr i nupo),law Ano nm a1gll)"mon auncr of DRAINS-FLOOR RLS UNITS
Progeny wild builds or inlpfan, Iherrall,and w'ho do,a Mm,work •ROOF,AREA,COND. 5.00
hinucll or Ihwugh his own,nl Pluyccs,p«n'id,,]Ilial arch improv FIXTURES-PER TRAP
Inenls ale 3101 i11l,II old Or filled far call It.however,the building GAS-EA.SYSTEM- 5.00 SD.FT.FLOOR AHEA
46 or
build,,
,d') Is sold willlin ung 1 INC.4 OUTLETS 6.00 TOTAL ACREAGE
builder Your ul cumplmioll, the owner.
wp hove 11'burden of proving That 11,did nut build or nn. GA$-EA,SYSTEM
Prove for I uqurx of r IcJ. -OVER 4 (EA.) 2.00
❑ I,as uwnrt of Ili,PruP,rty,]nI„clusiva'b'9nmraaing with INDUSTRIAL WgSTE INTER, aU I LOING USE
toall. ,nrnlaetora R, construct the 30.00 RES IND CON Pa O'o ,
and PIDIINlonx(bJf:'1'"'Col"CiLtorl Llca•Daa'Law 709dol-lill slid, LAWN SPRINKLERS- 1 INC ❑ ❑
m un owner al propeRy whu bu iA6 or inwo,,-,it"', n.and who C 5 V.B. 6'00
contracts fur snot LAWN SPRINKLERS-OVER 5 (EA.) 100 Asa"NURS PARCEL ND.
pmjcns wiOl a:uu tr,mtaH,l liwu, d pursluw 1.
Ili°Curlmnar License Law. SE W ER-SANITARY-STORM EA.2001t/10.00
❑ I um ca9nglt under ScC.
raueon ,13.3 P.C,lin lhi, TRACT NO, PARCEL NO.
Oxnrr WATER HEATER W/VENT 6.00 .
Dal` WATER SYSTEM
N'UkrR I"' I t.IPii N'S\PION DI:CLA RAI'IpN� 5.00 ACC.OATE
I herby,Dian That I Iwo,a n'rr.fi @ of C WATER TREATING EOU IP, ACC.FILE NO..
ora cenili9a R'nl .3800,La Cum un,cm Uu ml l:imw,, 5.00
COM Ihcn'oi ISeC.3800,Lab.0 I VCnvOOOlian hour na'. I :v tilicJ
O .PaIIC,ND. Cmnpun).C� ZONING ENG,$I rE NO.
❑ ceniO,J cop)'is hereby tumid cJ
z 2 ❑ Crnifird is Iil•J with
(- O APPlicum _ �Iupcc Nun Jiri,ion.
//// FIRE SPRINK ENERGY T]a
LU - Cli 1IFICA I'I:OF I:XEMP'I'ION I'KOAh�1Y kAIJ 'L:gS• REFER TO ORD.
LU CONPEN'SA710N INS URANCI! PERMIT ISSUANCE Y❑ N❑ Y ❑' N❑
G- O PLG.GDNTN, 1000 FLOOD ZONE
HILI' inion "I'd Doo bra eolnpl`'«'d i3'Ili.. - LIC.NO, A.L.U.C.
handlad A011arsU 1001 ar I,mJ Pcnnil Ia lire Cu, PLG.
U O 1 CeRily Thal in the p9rlunnancr of lb,uork Ibr wllicb this p, TOTAL Y❑ N❑ Y❑ ❑
LL mil ¢issued I shall not col Play ate'P9norl it any manner w ae Iu N
O w heconn'wbiccl m Gtr K'orken'Cunpan,aUall Law.olluill,nllu. CITY. MECHANICAL PERMIT
Dale FEE FEE SUMMARY
tl Lpplicunl
h2 NOTlcli "I'O nPl'LIG1 Nl': Ili u0er making Ibis C'rnih vte of lie. ALTER OR ADD TO MECH. BUILDING
- em Pliml,You'Luuld become subj9Cl In t11e ll'ork,ri Cum Puuation 5.00 /•C
C.1 Provisions of the Labor Code, you must I'urW wi Ol lonely wish APPLIANCE S �iIJ
aUC11 Provisions or this p,rmil shall be d,enmJ rcvak9d. 5.00 PLAN CHECK
AIR HANDLING UNIT(TO 10=1 C.F.lvt) 4,00 FEE
CONSTRUCTION LENDING AGENCY AIRHANDLINGUNIT(OVER10
I hereby shin. Ilial there is a cotutruct OD IenJin AW GFM.) 6.00 SEISMIC FEE
3109 Prrformunl:, of the work for which Eiji, g agency for EXHAUST HOOD (WITH DUCT) 5.00 /L'C•
3097,Civ.CJ. Penni) a issued ISee.
Lender's Name HEATING UNIT(TO 100,000 B.T.U.) 8.00 MICROFILM
LCnJeri Address HEATING UNIT(OVER 100,000B.T.U.)9.50
I rerlify that I have read 3his appli,,R011 and saute Thal the above ELECTRIC
information is corr,ct. I agree to CU,ply.,,III all Cil VENTILATION FAN (SINGLE) 4.00
OrdmOnres and stall laws relating to building L ranicE r u,ud BOILER-COMP(3 H.P.Dr 100,000 B.T.U.) 6.00
0hereby a-lh-6,, repr..Lmralivea D, Ihla city In ewer upon the PLUMBING
,a all fee.ion9d properly for inspection Pa,PUse s. BOILER-COMP agree to save, indenudf alld COMP I❑VBr 100,000 STUI SEE FEE SCR.
4 Cupertino axainsl liabilities, of n et keep Imnnless the it, of MISC.- MECHANICAL
i. s I ,o, 'a t, Id v.ymn+„w1dd, REFER TO ORD.
L. in a Y way a<c u, -/tit), in n•Ia, of till PERMIT ISSUANCE
gran lapis p II 10.00 CONST.TAX
y /
MICH.CONT. LIC.NO.
�`d Il.11 �.c _�_-�1J 'L�Z , MECH. ..
gnalurc of Applicant/Cummrtcq TOTAL
S TOTAL
OFFICE COPY �