8494 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
.BUILDING PROJECT IDENTIFICATION PERMIT NUMBER
4UILDING APPLICATION & PERMIT
,n
10/ O WoL G '� BUILDING -ELECTRICAL-PLUMBING-MECHANICAL 8494
Y 0
OWNER'S PLAN CHECK VALIDATION
• NAME �p HONE s TV. ELECTRIC PERMIT FEE
1C. �/� e'I'A
NOMERAcrORs �NL. OUTLETS-SWITCHES-RECEP 98,60/1.00 F.i.-
F. C-1a &'B�uc.No. � LIGHTING FIXTURES U)rwl.00
/ CONTRACTOR'S E OILrL(� PPLIANCES-RESIDENTIAL 4.00
ADDRESS
2faa ,111Q d PHONE 60 /6' PANELS 10 OD DATE OF APPLICATION
ARCHITECT PANELS IOVER 200 AEON 20.00 PLAN CHECK FEE P.C.NO.
ENGINEER
LIc.No, SIGNS TRANS. 3.00
moo ESS ENG' SPECIAL CIRCUIT 5.00 PERMIT VALIDATION
ZIP EMP.METER OR POLE INS. 20.00
Ars
ADDDRESSDRESS MOTORS SEE FEE SCH.
SERVICE CHANGE 20.00
woo LICENSED CONTRACTORS DECLARATION TEMP.POLE 30.00
¢u I hereby affirm that I am licensed under provisions of Chapter 9 ISSUANCE DATE
z ca
6 (commencing with Section 7000)of Division 3 of the Business andAPR
BLDG. ELECT, PLG. MECH.
'v' Professions Code prd m �scense is in full forc�,��((e t. ❑ ❑ ❑
ca fZ= License Clas .ir- V Lia Number WYN, -
o y r w Ua[c Contractor Cupertino
Q x f j -� ' 1 '$Z4 L`i Q(' CiUp BUILDING PERMIT
¢ ¢w OWNER-BUILDER DECLARATION INFORMATION
w0 A H I hereby affirm that 1 am exempt from the Contractor's License MISC.- REFER TO ORD
3 u VALUATION $/FT.
LL0 ¢ Law for the following reason(Sec.703L5,Businessand Professions PERMIT ISSUANCE 98:9& --•
" w Code:Any city or county which requires a permit to construct,alter,
SE ¢ ¢ 0 improve,demolish,or repair any shmetme,prior to its issuance,also ELEC.CONTR. LIC.NO. ELEC. •� [�
O ¢ requires the applicant for such permit to file a signed statement that TOTAL / a � PERMIT TO
A se m" he is licensed pursuant to the provisions of the Contractor's License
0 s- Law.(Chapter 9(comnhencingwilh Section 7000)of Division 3 of the
4 D Business and Professions Code)or that he is exempt therefrom and
¢ I- the basis for the alleged exemption.Any violation of Section 7031.5 DTV. PLUMBING PERMIT FEE
STORIES TYPE CONSTR.
n; by any applicant for a permit subjects the applicant to a civil penalty ALTER-DRAIN III VENT-WATER (EA.) 5.00
of not more than five hundred dollars MINE).):
❑ 1,as owner of the property,or my employees with wages as BACK FLOW PROTECT.DEVICE 4.00 OCC.GROUP RES.UNITS
their sole compensation,will do the work,and the structure is not
intended or offered for sale (Sec 7044, Business and Professions DRAINS-FLOOR,ROOF,AREA,COND. 5.00
Code'1'he Contractor's License Law docs not apply to an owner of
property who builds or improves thereon,and who does such work FIXTURES-PER TRAP 5.00 SQ FT.FLOOR AREA TOTAL ACREAGE
• himself re through his own employees,provided that such improve-
ments ntelf a not through
or offered ee sale.provided
that s the building GAS-EA.SV STEM-11NC.40UTLET$ 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 im- . . . RES IND CON PB Omer
prove for purpose of sale.). INDUSTRIAL WASTE INTER. 30.00
❑ 1,as owner of the property,am exclusively contracting with ❑ ❑ Cl ❑ ❑
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 does not apply
to an owner of property who builds or improves thereon,and who LAWN SPRINKLERS-OVER 5(EA.1 1.00
contracts I'or such projects with a contructo(s)licensed pursuant 10
the Contractor's License Law. SEWER-SANITARY-STORM EA.200ft/10.00 TRACT NO. PARCEL NO.
❑ I am exempt under Sec. ,B.&I'.C.I'm this WATER HEATER W/VENT 6.00
reason
Owner Date WATER SYSTEM 5.00
ACC.DATE ACC.FILE NO.
W'ORKRRS'COMPENSAT'ION DECLARATION WATER TREATING EQUIP, 5.00
I hereby atfino that I have a certificate ofcoment to self-insure,
or a certificate of Workers'Compensation Insurance,or a certified ZONING ENG.SITE NO.
copy thereof(See.3800,Lab.C.)A1/1-S -INS,
Policy No. Company��
O ❑ Certified Copy is hereby famished. FIRE SPRINK ENERGY T-24
z Z O Certifie city is f d u)7 the ity inspection division. MISC.- REFER TO ORD.
O• Applicant / Y E] N❑ v F] N[_]
y CER 'ICA1'E F EX.1PTL0 PROM WORKERS' PERMIT ISSUANCE 10.00 FLOOD ZONE A.L.U.C.
LLE > COMPENSATION INSURANCE PLG.CONTR. ❑c.NO. PLO.
CL ❑ (This section need not be completed if the permit is Ibr one TOTAL Y❑ N❑ Y ❑ IN
D 2 hundred dollars(S 100)or less)
U O 1 certify that in the performance of the work for which this per- OTV. MECHANICAL PERMIT FEE FEE SUMMARY
LL F mit is issued,I shall not employ any person in any manner so as to
O become subject o the Workers''Compenution Laws of California.
Ed Date Applicant ALTER OR ADD TO MECH. 5.00 BUILDING
>- In NOTICE:TO APPLICANT: If,after making this Certificate of Ex-
F 2 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 ssmh provisions or this permit shall he 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 performance of the work for which this permit is issued(Sec. MICROFILM
3097,Cw.C.I. HEATING UNIT(TO 100,000 B.T.U.) 8.00
Lender's Name H FATE NG UNIT(OVER 100,000 B.T.U.)9.50 �'3
Lender's Address ELECTRIC
I certify that l have read this application and state that the above VENTILATION FAN (SINGLE) 4.00
. infnnnatinn is correct. 1 agree to comply with all city and county PLUMBING
ordinances and stale laws relating to building construction, and BOILER-COUP(3 H.P.or 100,000 B.T.U.) 6.00
hereby authorize representatives of this city to enter upon the BOILER-COMP lover 100.000 BTU)SEE FEESCH. 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 10.00 CONST.TAX
may in any way accrue agar t said City in conseyuenc of th PERMIT ISSUANCE H.
grantingo is per MECH.CONT, UC.NO. MECH.
\' TOTAL TOTAL
7( Signa! of Applicant/Contractor Dat
OFFICE COPY
APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
BUILDING PROJECT I DENT[F[CATION PERMIT NUMBER
BUILDING APPLICATION & PERMIT 84
94
AooREss
Y BUILDING -ELECTRICAL-PLUMBING-MECHANICAL
D E PLAN CHECK VALIDATION
NAME QTY. ELECTRIC PERMIT FEE
ONE
CONTRACTORS
rvnmE TuCOUTLETS-SWITCHES-RECEP 10.00/1.00 �
i
6T/-*°1Ic.No. IGHTING FIXTURES 1000/1.00
CONTRACTOR's
ADDRESS PPLIANCES-RESIDENTIAL 4.00
� J ��/�OATd C/q
O vROrvE PANELS 10.00 DATE OF APPLICATION
Opr e6qu -
RHrtecT
R PANELS (OVER 200 AMP) 20.00 PLAN CHECK FEE P.C.NO.
ENGINEER
uc.NO, SIGNS TRANS. 3.00
ADDRESS ENG. PERMIT CIRCUIT 5.00 PERMIT VALIDATION
ZIP fTEMP.METER OR POLE INS. 20.00
AMOTORS SEE FEE SCH.
ADDRESS ORE55
SERVICE CHANGE 20.00
oO0 LICENSED CON IRACTORS DECLARATION TEMP.POLE 30.00
Fi W I hereby affirm that I am licensed under provisions of Chaplet 9 ISSUANCE DATE
a w (commencing with Section 7000)of Division 3 of the Business and BLDG. ELECT. PLG. MECH.
r w z Professions Code,and my license is in full force and effect. ❑ ❑ ❑
Z O m - License Clws A- lf N Lie.Number
0 z r O � Date -x` a-�Contractor
H '_' -wt/
a a z 4 ! �lg{L BUILDING PERMIT
¢ o n O NF.R-BUILDER DECL ATION INFORMATION
F
a w I hereby affirm that I um exempt from the Contractor's License MISC.- , REFER TO ORD VALUATION
$/FT.
N O ¢ Law for lire following reason.(Sec.703 L5,tlusincss and Professions 1.O.D4
_ w PERMIT ISSUANCE _
acw Code:Anycolishcoo ntywhiny structurep riort oconsuancalter,
¢ ¢ Q improve,demolish,Or repair any Strllemf¢,prior lO its ISSUanCe.also ELEC.CONTE. LIG NO. ELEC.
wO es u requires the applicant for such permit to file a signed statement that TOTAL! 7�3 PERMIT TO
he is licensed pursuant m lire provisions of the Contractor's License
H i
Law(Chapter 9(ccmmencingwith Section 7000)of Division 3 of the
Z a Business and Professions Code)or that he is exempt therefrom and QTY. PLUMBING PERMIT FEE Fz- L7
s _ O the basis for the alleged exemption.An
p ge p he violation to action malty STORIES TYPE CONSTR.
n ; by any applicant fora permit subjects the applicant toacivil penalty
of not more than five hundred dollars(5500).1: ALTER-DRAIN&VENT-WATER (EA.) 5.00
❑ I,as owner of the properly,or my employees with wages as BACK F LOW PROTECT. DEVICE 4.00 OCG 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 does not apply to an owner of
property who builds or improves thereon,and who does such work FIXTURES-PER TRAP 5.00 SG.FT.FLOOR AREA TOTAL ACREAGE,
himself re through his own employees.provided tevl such imhravo
mo through
intendeughhis or offered employers.
provided that r.such
ebudding GAS-EA.SYSTEM-1INC.4OUTLETS 6.00
or improvement is sold within one year of completion,the owner- GAS EASYSTEM OVER 4(EA ) 200
builder will have the burden of proving that he did not build or int - . - . .
- BUILDING USE
prove for purpose of sale.). INDUSTRIAL WASTE INTER3000 RES IND CON Pa Omer
❑ 1,as owner of the property,ran exclusively contracting with . .
11 ❑ ❑ ❑ ❑
licensed contractors to construct the project(See. 7044.Business LAWN SPRINKLERS-1 INC 5 V.8. 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 corltractons)licensed pursuant to SEWER-SANITARY-STORM EA.200ft/10.00
the Contractor's License Law. TRACT NO. PARCEL NO.
O lain exempt under See..,IL&P.C.for this WATER HEATER W/VENT 6.00
reason
Owner Duce WATER SYSTEM 5.00 ACC.DATE ACC.FILE NO.
WORK ERS'COMPENSA'I'ION DECLARATION WATER TREATING EQUIP. 5.00
I hereby affirm that I have a certificate of conscnl to self-insure. ZONING ENG.SITE N0.
or a certificate of Workers'Compensation Insurance,or a certified
copy thereof(Sec.3800,Lai)C.).
Policy No. CampanY -
O ❑ Certified Copy rs hereby furpishc . RE SPRINK ENERGY T-Y4
ell
ZZO / 10 Certified Copy is lig cd w' the ity 'nspecti,n division. MISC.- REFER TO ORD, y N V N
T C I?R JC'ATE ° TIO ['ICOM WORKERS'1-X(;:! PERMIT ISSUANCE 10.00 FLOOD ZONE A.L.U.C.
LU > COMPIiNSATION INSURANCE PLG.CONTE. LIC.NO. PLG.
0-Z (This section need not be completed if the permit is for One TOTAL Y[] N� Y [:] NE]
hundred dollars($100)or less.)
U O 1 certify that in the performance of the work to,which this per- QTY. MECHANICAL PERMIT FEE FEE SUMMARY
LL F- mit is issued,I shall not employ any person in any manner sn as to
U w become subject to the Worked Compensation Laws of California.
Date Applicant ALTER OR ADD TO MECH. 5.00 BUILDING
} tail NOTICE TO APPLICANT: If,after making this Certificate of Ex-
t Z_ mnplfon,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 he deemed revoked. AIR HANDLING UNIT(TO 10=C.F.M.) 4.00
CONSTRUCTION LENDING AGENCY AIR HANDLING UNIT(OVER 10,000QEM.) 6.00 SEISMIC FEE
I hereby affirm that there is a construction lending agency for EXHAUST HOOD(WITH DUCT) 5.00
the perfonn:mee of the work for which this pennit is issued(Sea MICROFILM
3097,Civ.C.T HEATING UNIT(TO 100,000 B.T.U.) 8.00
Lender's Name HEATING UNIT(OVER 100,000 B.T.U.)9.50
Lender's Address ELECTRIC
I certify that I have read this application and state that the above VENTILATION FAN (SINGLET 4.00
in I'onnation is correct. 1 agree to csimply with all city and county PLUMBING
ordinances and stale laws relating to building 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) agree to save, indemnify and keep harmless the City of MISC.- REFER TO ORD.
Cupertino against liabilities,judgments, costs and expenses which pERMIT ISSUANCE 1000 CONST.TAX
may in any way accrue against said City in consequence of the .
granting of is permit. MECH.CONT. LIG NO. MECH.
TOTAL TOTAL
Signatu f'Applic et/Con to Dat
INSPECTOR COPY