09960 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
BUILDING PROJECT IDENTIFICATION _ PERMITNUMBER
BUILDING APPLICATION & PERMIT
ADDRESS
10123 N. Wolfe Road #9f)0)1A BUILDING-ELECTRICAL-PLUMBING-MECHANICAL 09960
OWNER'S PLAN CHECK VALIDATION
NAME QTY. ELECTRIC PERMIT FEE
• Benetton 288-8300
ArvTRAcaoRs
NAME OUTLETS-SWITCHES-RECEP 10.00/1.00
N
1-Neon Sigm 385565 C-45 LIGHTING FIXTURES 10.00/1.00
CONTRACTORS
ADDRESS PPLIANCES-RESIDENTIAL 4.00
1577 Almden g -11883 PANELS 10.00 DATE OF APPLICATION
ARCHITECT PANELS (OVER 200 AMP) 20.00 PLAN CHECK FEE P.C.N0,
OR
ENGINEER
UC.rvo. SIGNS TRANS. 3.00
ARCH,OR ENG. SPECIAL CIRCUIT 5.00 PEW-nompWATION
ADDRESS
ZIP TEMP.METER OR POLE INS. 20.00 NOV
APPUCANTs MOTORS SEE FEE SCH. - 7 1985
ADDRESS
SERVICE CHANGE 20.00
Doo LICENSED CONT RACPORS DECLARATION
Z.
TEMP.POLE 30.00 City of Cupertino
M v u I hereby affirm that I am licensed under provisions of Chapter 9 ISSUANCE DATE
y Q w (commencing with Section 7000)of Division 3 of the Business anJ LOG. ELECT, PLG. MECH.
r y Z Professions Code,and my license is in full force and of feel.
z o u - License Classh5-Lia Number�g56 ❑ El ❑
o u H w Daf�Q=3�� Contractor-ray MM_
Q y f j BUILDING PERMIT
¢ tc w¢ OWNER-BUILDER DECLARATION INFORMATION
o> DMISC.- REFER TO ORD
X S LL H I hereby affirm that I am exempt Iron) the Contract.",essanl License VALUATION SIFT.
Lc 04 Law fur Rm following reason.(Sec.7031.5.Business Professions PERMIT ISSUANCE 10.00
0 Code:Anycity or County which requires a permit to construct,alter,
Qo improve,demolish,or repair any structure,prior to its issuance,also ELEC.CONTR. LIC.NO. ELEC. 1457.00
O a,requires the applicant for such permit to file a signed statement that TOTAL P RMIT.TO
A W m he is licensed pursuant to the provisions of the Contractor's License
Hii Law(Chapter 9(commencing with Section 7000)of Division 3 ofthe
¢ Business and Professions Code)or that he is exempt therefrom and QTY. PLUMBING PERMIT FEE
¢ a the basis for the alleged exemption.Any violation 01 Section 7031.5 STORIES TYPE CONSTR.
w. w- by any applicant for a permit subjects the applicant Loa civil penalty ALTER-DRAIN -WATER (EA.) 5.00
of not more than five hundred dollars(5500).):
❑ I,as owner of the property,or my employees with wages as BACK FLOW PROTECT. DEVICE 4.00 OCC.GROUP RES.UNITS
their sole compensation,will do the work,and the structure is not
intended or offered fur sale (Sec. 7044, Business and Professions DRAINS-FLOOR,ROOF,AREA,COND. 5.00
Code:'fhe Contractor's License Law does not apply to an owner of
properly who builds or improves thereon,and who does such work FIXTURES-PER TRAP 5.00 SO.FT.FLOOR AREA TOTAL ACREAGE
• himself or through his own employees,provided that such improve-
mems arc not intended or offered for sale.If,however,the building GAS-EA.SYSTEM-1INC.4 OUTLETS 6.00
or improvement is sold within one year of completion,the owner- GAS-EASYSTEM-OVER 4 (EA.) 200 BUILDING USE
builder will have the burden of proving that he did not build or ire- GAS .
- RES INDC PB Other
prove ID,purpose ofsale.L INDUSTRIAL WASTE INTER. 30.00 ❑ ❑ ❑ El
I,as owner of the property,um exclusively contracting with
licensed contractors to construct the project ISec.7044,Business LAWN SPRINKLERS-1 INC 5 V.B. 6.00 ASSESSOR 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 ILAWN SPRINKLERS-OVER 5(EA.) 1.00
tare Cont for su License
Lwithacontructor(s)licenced pursuant to SEWER-SANITARY-STORM EA.200ft/10.00 TRACT NO. PARCEL NO.
the Contractor's h projects
roj c Law.
❑ I and exempt under SLC-,B&P.0 for this WATER HEATER W/VENT 6.00
reason
Owncr_W Duce 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 self-insure. ZONING ENG.SITE N0.
or a certificate of Workers'Compensation Insurance,or a certified
copy the��ii{{ .Cd.
Policy NrA _���}�rJyP{�'. y Ind, I
O C'rt 10 py�rXlI '!f Iy FIRE SPRINK ENERGY T-24
Z_ Z c 1 e co (/3 l s Ispection division. MISC.- REFER TO ORD.
O PPlifa V❑ N❑ V ❑ IN ID
My PERMIT ISSUANCE 10.00 FLOODZONE A.L.U.C.
lr 1 GIiRT1 FICC0 OI' :KEMPT ION PROM special
W COMPENSATION INSURANCE PLG.CONTR. LIC.NO, PLG. Y❑ N❑ Y ❑ NE]
O Cfhis section need not he completed if the punnit is for one TOTAL
Z) Z hundred dollars(5100)or less.)
U O 1 certify that in the performance of the work for which(his per- OTY MECHANICAL PERMIT FEE FEE SUMMARY
mit is issued,I shall not employ any person in any manner so as to
O W become subject to tiro workers'Compensation Laws of California. BUILDING
Date APPlicant ALTER OR ADD TO MECH. 5.00 S
} h NOTICE 10 APPLICAN'1: If,after making this Certificate of Ex-
? emption,you should become subject to lire Workers 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 10SWC.F.M0 4.00
CONSTRUCTION LENDING AGENCY AIR HANDLING UNIT(OVER 110MC.F.M.) 6.00 SEISMIC FEE
I 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 C.). I HEATING UNIT(TO 100,000 B.T.U.) 8.00
Lender's Name-WA HEATING UNIT(OVER 100,000 B.T.U.)9.50 ELECTRIC
Lender's Address
I certify that I have read this application and state that the above VENTILATION FAN (SINGLE) 4.00
. information m with
correct y with I agree to complwall city and county PLUMBING
ordinances and state lows relating construction, and BOILER-COMP(3 H.P.or 100,000 B.T.U.) 6.00
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) a to save, indemnify and keep harmless the City of MISC.- REFER TO ORD.
Cupertl as
bilines,judgments,ZIexpenseswhich CONST.TAX
may i awr against sa'd Csequence of the PERMIT ISSUANCE10.00
gran f lh I / MECH.CONT. LIC.NO. MECH��- TOTAL TOTAL
Signa urc fApplicant/ ontractor Date
OFFICE COPY -