8528 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
BUILDING PROJECT IDENTIFICATION PERMIT NUMBER
\ BUILDING APPLICATION & PERMIT /�
/'• ADDRESS �� �� 8528 C '/g
BUILDING-ELECTRICAL-PLUMBING-MECHANICAL l!!1 J G
Ow R'S PLAN CHECK VALIDATION
1 y" �(jU ''''// GTY. ELECTRIC PERMIT FEE
/11(BWNE �yb- 0
•
CONTRACTORS
NAUTLETS-SWITCHES-RECEP 10.00/1.00
ME
Ic.rvo. 019 LIGHTING FIXTURES 10.00/1.00
roNTRAcaons �'415-� APPLIANCES-RESIDENTIAL 4.00
&t&UPON -02 PANELS 10.00 DATE OF APPLICATION
ORCHrtECTPANELS (OVER 200 AMP) 20.00 PLAN CHECK FEE P.C.NO.
DR
ENGINEER
LIC.NO. SIGNS TRANS. ' 3.00
ARCH.OR ENG. SPECIAL CIRCUIT S.00 PERMIT VALIDATION
ADDRESSZIP TEMP.METER OR POLE INS. 20.00
AFPLIGINT'S MOTORS S H.
AOOREBa� • •`-'vim--1
M1V-V_,'^/�,y'Z•1/.�' A-(/E • SERVICE CHANGE 20.00 ;AA w o o LICENSED CONT'RACT'ORS DECLARATION TEMP.POLE MAY 2 3
rt U I hereby affirm that I am licensed under provisions of Chapter 9 ISSUANCE DATE
wQ w (commencing with Section 7000)of Division 3 of the Business and BLDG. ELECT. PLG. MECH,
r m a Professions Co ad�j y license is in full for ❑ ® ❑ ❑
License Class Lic.Nltmbcr 7
< y Uate �� Contactor yi ,-n
L d BUILDING PERMIT
z w 4 OWNER-BUILDER DECLARATION INFORMATION
X 3 u y I herebyaffirm that I am exempt from the Contractor's License MISC.- REFER T ORD
f VALUATION §/FT,
F LL N j Law for the (firm that
reason.(Sec. t from.Business and Professions PERMIT ISSUANCE .x}&89
Code:Any city or county which requires a permit to construct,alter, M,
IS ea a-0 improve,demolish,or repair any structure,prior t0 Its Issuance,ah, ELEC. LIC.NO. ELEC. UV
Kate requires the applicant for such permit to file a signed statement that TOTAL PERMIT TO
n $ he is licensed pursuant to the provisions of the Contractor's License 6C,�G7
Har Law(Chapter 9(commencing Willi Section 7000)ofDivision 3 ofthe
- a Business and Professions Code)nr that he is exempt therefrom and QTY. PLUMBING PERMIT FEE
t$ the basis for the alleged exemption.Any violation of Section 7031.5 STORIES TYPE CONSTR.
y3 � by any applicant for a permit subjects the applicant to a civil penalty ALTER-DRAIN -WATER (EA.) 5.00
of not more than five hundred dollars(8500)):
❑ 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 for sale (Sec. 7044, Business and Professions DRAINS-FLOOR,ROOF,AREA,COND. 5.00
Code:The Contractor's License Law docs not apply to an owner of
property 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- GAS-EA.SYSTEM-1 INC.4 OUTLETS 6.00
meats 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 IEA.) 2.00 BUILDING USE
builder will have the harden of proving that he did not build or im- RES IND CON PB Other
Prove for purpose ofsale). INDUSTRIAL WASTE INTER. 30.00 ❑ ❑ ❑ ❑ ❑
❑ 1,as owner,of the property,am exclusively contracting with
licensed contractors to construct the project(Sec. 7044,Business LAWN SPRINKLERS-1 INC 5 V.B. 6.00 ASSESSORS PARCEL NO.
and Professions Code:The Contractor's License Law dues not apply
to an owner of property who builds or inmroves thereon,and who LAWN SPRINKLERS-OVER 5 IEA.) 1.00
contracts for such projects Willi a contractors)licensed pursuant to SEWER-SANITAR V-STORM EA.200ft/10.00
the Contractors License Law. TRACT NO, PARCEL NO.
❑ lam¢xemptunder Sec. ,B.&P.C.forthis WATER HEATER W/VENT 6.00
reason
Owner Date WATER SYSTEM 5.00
ACC.GATE ACC.FILE NO.
WORKERS'COMPENSATION DECLARATION WATER TREATING EQUIP, 5.00
I hereby affirm that I have a certificate of consent to self-insure. ZONING ENG.SITE NO.
Qr a certificaze of Workers'Compensation Insurance,or a certified
copy dmreof(Sec.3800,Lab.C.).
Policy No. Company
O ❑ Certified copy is hereby furnished. FIRE SPHINK ENERGY T-24
Z Z ❑ Certified copy is fled with the city inspection division. MISC.- REFER TO ORD.
O Applicant Y [:] N❑ v ❑ N[_
CC W CERTIFICATE OF EXIiMY'I']ON PROM WORKERS' PERMIT ISSUANCE - 10.00 FLOOD ZONE A.L.U.C.
LU > COMPENSATION INSURANCE. PLG.CONTR, UC.No. PLG.
CL O ('Phis section need not be completed i1the permit is for one TOTAL Y❑ N❑ Y ❑ N❑
D Z hand red dollars IS 100)or less.)
U 0 I certify Ilial in the performance of the work for which this per- QTY. MECHANICAL PERMIT FEE FEE SUMMARY
EL H mil is issued,I shall not employ any person in any manner so as to
U b¢cot CE�µP WGAs Workers�', gcatuop1��s of Cali Cpf�ia.
O U DatT¢� lap rke (ylR�• J• //[L L-W BUILDING
} T`�f'�C ALTER OR ADD TO MECH. 5.00
NO E TO APPLICANT: If,after making This Certificate of Ex-
♦- emption,you should become subject to the 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 10=CF.M.) 4.00
CONSTRUCTION LENDING AGENCY AIR HANDLING UNIT(OVER 10=C.F.M.) 6.00 SEISMIC FEE
1 hereby aft'inn 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. HEATING UNIT(TO 100,000 B.T.U.) 6.00 MICROFILM
3097,Civ.C).
Lender's Name HEATING UNIT(OVER 100,000 B.T.U.)9.50
Lender's Address ELECTRIC
I certify That 1 have read this application and state that the above VENTILATION FAN (SINGLE) 4.00
information is Correct.I agree to comply with all city and county PLUMBING
ordinances and state laws relating to building construction, and BOILER-COW(3H.P.or 100,000B.T.U.) 6.00
hereby authorize representatives of this City to enter upon the BOILER-COMP Over 100,000BTUISEE FEESCH. 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,judgments, costs and expenses which PERMIT ISSUANCE 10.00 CONST.TAX
ma in any way ace against said City in consequence of the
gr t of this perm MECH.CONT. LIC.NO. MECH.
S • _)_ TOTAL TOTAL
ignamrc of Applin /Contractor Dale
OFFICE COPY
APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
BU I LDING PROJECT I DENTIF I CATION PERMIT NUMBER
\, SOILDING APPLICATION & PERMIT
Jl ADDRESS
- BUILDING -ELECTRICAL-PLUMBING-MECHANICAL
8152.8
o PLAN CHECK VALIDATION
NAME /) '/ pTY. ELECTRIC PERMIT FEE
• / NE y MaTR ~
Acrrns OUTLETS 10.00/1.00
NAME
c.no. LIGHTING FIXTURES 10.00/1.00
ANTR cTo gf3cqd( :) PPLIANCES-RESIDENTIAL 4.00
� 'ADOREss 1
ROry PANELS 10.00 DATE OF APPLICATION
OORC T LT PANELS (OVER 200 AMP) 20.00
PLAN CH ECK FEE P.0.NO.
ENGINEER
tit.No. SIGNS TRANS. 3.00
ARCH.
DD ESS ENG. SPECIAL CIRCUIT 5.00 PERMIT VALIDATION
ZIP TEMP.METER OR POLE INS. 20.00
APPLICANTS MOTORS 4 SEE FEE SCH.
ADDRESS f�^
9-27 IEEW SERVICE CHANGE 20.00 a ps i
u�0+l02 LICENSED CONTRACTORS DECLARATION TEMP.POLE 30.00
¢ v. I hereby affirm that I am licensed under provisions of Clla Ater 9 ISSUANCE DATE
yu (commencing with Section 7000)of Division 3 of the Business and
a BLDG. ELECT. PLG. MECH.
F w Professions Codc`and my license is in full force rff t ❑ ❑ ❑
z o,� - License Class -/� Lie.Number
o m F Doty__ n .tor
a Y E -+ $ BUILDING PERMIT
¢ ¢ ¢ OWNER-BUILDER DECLARATION
A o a u INFORMATION
W 0 LL n I hereby affirm that I am exempt from the Contractor's License MISC.- REFER TO ORD
LLoa Law for the following reason.(Sec.7031.5,Businessand Professions pERM1T ISSUANCE / VALUATION S/FT.
rya Code:Any city or county whieb'rcquires a permit to construct,alter .1L.D0
IS Q a zO Improve,demolish,or repair any structure,prior to Its Issuance,also ELEG CONTR. LIC.NO. ELEC.
a wm LL requires the applicant fur sgeh IT permit to file a signed statement that TOTAL / PERMTO
he is licensed pursuam tg,the provisions of the Contractor's Liccnse `
r z i Law(Chapter9(commfncing with Section 7000)of Division 3 ofthe
a Business and Pref'essh5es Codc)or thin he is cxcrrmpt therefrom and OTY, PLUMBING PERMIT FEE
g i o
¢ I- ro '
the basis for the alleged exemption.Any violation of Section 7031.5 STORIES TYPE CONSTR.
ate _ hany apPlle.fid fnr a permit subjects the applicant to a civil penally ALTER-DRAIN&VENT-WATER (EA.) 5.00
of not more than five hundred dollars(S500L):
01,as owner of the property,or my employees with wages as BACK FLOW PROTECT.DEVICE 4.00 OCC.GROUP RES.UNITS
their sole corn
ns
peation,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 does such work FIXTURES-PER TRAP 5.00 So.FT.FLOOR AREA TOTAL ACREAGE
himself or of in In his own employees, le.III cd[hal such inlprovo-
an c through
onemoffered oyees.provided
that
such
building GAS-EA.SYSTEM-1INC.4OUTLETS 6.00
or improverewit 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 or int- RES IND CON PB One,
prove for purpose ofsale.). INDUSTRIAL WASTE INTER. 30.00
❑ I,as owner of the property,am excluly sivecontracting with ❑ ❑ ❑ ❑ ❑
licensed contractors to Construct the project(Sec. 7044,Business LAWN SPRINKLERS- 1 INC 5 V.B. 6.00 ASSESSORS PARCEL NO.
and Professions Code:The Contractors License Law does not apply
to an owner of properly who builds or impmvcs thereon.and who LAWN SPRINKLERS-OVER 5(EA.) 1.00
contracts for such projects with a contractors)licensed pursuant to SEWER-SAN V-STORM EA.200ft/10.00
the Contractors License Law. TRACT NO. PARCEL NO.
❑ 1 am exempt under Sec. ,BAP.C.for this WATER HEATER W/VENT 6.00
reason
Owner Date WATER SYSTEM 5.00
ACC.GATE ACC.FILE NO.
W'ORKERS'COMPENSAI'ION DECLARATION WATER TREATING EQUIP. 5.00
1 hereby affirm that I have a certificate of consent to self-insure, ZONING ENG.SITE NO.
or a certificate of Workers'Compensation Insurance,or a ec.dried
'Copy thereof(Scc.3800,Lab.C.L
Policy Nn. Company
❑ Certified copy is hereby furnished. FIRE SPRINK ENERGY T 24
Z Z ❑ Certified copy is filed with the city inspection division.
O Applicant MISC.- REFER TO ORD. Y ❑ N❑ Y ❑ N❑
~ va PERMIT ISSUANCE 10.00
CCCF:R'I'IPIGt'I'Ii OF EXEMPTION FROM WORKERS' FLOOD ZONE A.L.U.C.
LU COMPENSATION INSURANCE PLG.CONTR. LIC.NO. PLG,
CL Z (This section need not be completed if the permit is for one TOTAL Y[:] NE] Y ❑ NF]
hundred doll...(8100)or less.)
U O 1 certify that in the perfornlmme of the work for which this per- QTY. MECHANICAL PERMIT FEE FEE SUMMARY
LL j- mit is issued,I shall not employ any person in any mann..sn as to
U becom�e ubye�c l�u the\4 orkers�'CQoJm�pensa't�ion upw�s o.�f C/�:difmnia.
\w DatclN?E ?O A'1'19.A pplicant '�fi•�r 311 �t1(I't TfT�� ALTER OR ADD TO MECH. 5.00 BUILDING
} NOT 1CANT: IL v er m in s er Cale of E.-
F _ caption,you should become subject In the Workers'Compensation APPLIANCE 5.00 PLAN CHECK
provisions of the Labor Code, you most forthwith comply with FEE
U such provisions or this permit shall be deemed revoked. AIR HANDLING UNIT(TO 10=C.F.M.) 4.00
CONSTRUCTION LENDING AGENCY AIR HANDLING UNIT(OVER 10=C.F.M.) 6.00 SEISMIC FEE
I hereby affirm that there is a construction lending agency for EXHAUST HOOD (WITH DUCT) 5.00
the perfornance of the work for which this permit is issued(Sec. MICROFILM
3097,CN.CJ. HEATING UNIT(TO 100,000 B.T.U.) 8.00
Lender's Name
Address
Lender's Address HEATING UN IT(OVER 100,000 B.T.U.)9.50 ELECTRIC
I certify that I have read this application and state that the above VENTILATION FAN (SINGLE) 4.00
-� information is correct. I'agree to comply with all city and county PLUMBING
ordinances and state laws relating to buildingconstruction,'and BOILER-COMP(3 H.P.or 100,000 B.T.U.) 6.00
hereby authorite representatives of this city m enter upon the BOILER-COMP (Over 100,000 BTU)SEE FEE SCH. MECHANICAL'
above-mentioned properly for inspection 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
may in any way accrue against said City in consequence of the PERMIT ISSUANCE 10.00
gra it g of this no MECH.CONT, LIC.NO. MECH.
\ OTAL TOTAL
/�/� I n ontr aor ate
INSPECTOR COPY