09550 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
BUILDING PROJECT IDENTIFICATION PERMIT NUMBERAPPLICATION & PERMIT
BUILDING09550
aoGRESs
I BUILDING - ELECTRICAL-PLUMBING-MECHANICAL
ravamRIPLAN CHECK VALIDATION
• `Y V- DTV. ELECTRIC PERMIT FEE
J91 , y gory lYkI
NAMECUmTR oR OUTLETS-SWITCHES-RECEP 10.00/1.00
No. LIGHTING FIXTURES 10.00/1.00
l'D s
CONTRASDDRESS APPLIANCES-RESIDENTIAL 4.00
v ONE - PANELS 10.00
1 DATE APPLICATION
ORCR c PANELS (OVER 200 AMP) 20.00 PLAN CHECKK FEE P.C.NO.
ENGINEER
tirl
LIC,NO. SIGNS TRANS. 3.00
ARCH.OR ENG, PERMIT UL.Ip ATION
ADDRESS SPECIAL CIRCUIT 5.00 11+A1l)
ZIv TEMP.METER OR POLE INS. 20.00 - yy ryry
APPLICANT p
MOTORS SEE FEE SCH. AUG 4 C
ADDRESS
SERVICE CHANGE 20.00o. V^
o o LICENSED CON'PRACTORS DECLARATION TEMP.POLE 30.00 .City Of Cupertino
av w I hereby ufErm that I am licensed under provisions of Chapter 9 ISSUANCE OATVI
Iv rt 'w (connnencing with Section 7000)of Division 3 of the Business and BLDG. ELECT. P MECH.
o Z Prhlessions Coda,and h licensc is in(all force;ind c Ice{
C7, i o License loss Li<.Number .(,.
H m j Date Contractor
•a m s BUILDING PERMIT
¢ o u OWNER-BUILUfiR DECLARATION INFORMATION
w1 hereby allium that I am exempt from the Contractor's License MISC.- REFER TO ORD
urn VALUATION SIFT,
F LL o a Law for the following reason.(Sec.7031.5.Businessand Professions PERMIT ISSUANCE 10.00
m0 Codec Any city or county which requires a permit to construct,alter,
ac 2¢ improve,demolish,or repair any structure,prior to its issuance,also ELEC.CONTR. LIC.NO. ELEC.
u w m IL requires the applicant for such permit to file a signed statement that TOTAL PE MIT TO
he is licensed pursuant to ole provisions of the Contractor's License
H z A Law(Chapter9(commencing with Section 7000)of Division 3 ofihe
4 D Business and Professions Code)or that he is exempt therefrom and DTV. PLUMBING PERMIT FEE 1
¢ H m the basis for the alleged exemption.Any violation of Section 7031.5 I o TY CONSTR.
by any applicant for a permit subjects the applicant toa 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 F LOW PROTECT. DEVICE 4.00 OCC.GROUP RES.UNITS
their sole compensation,will do the work,:red the structure is not
intended or offered for sale (Sec. 7044, Business and Professions DRAINS-FLOOR,ROOF,AR EA,COND. 5.00
Code:The Contractor's License Law does not apply to an owner of
property who builds car improves thereon,and who does such workFIXTURES-PER TRAP 5.00 Q 5G.FT.FLooR ARE- TOTAL ACREAGE
himself or through his own employees,provided that such improve-
Incnlsarenotintendedorofferedforsale.if,however,the building GAS-EA.SYSTEM-I INC.4 OUTLETS 6.000
or improvement is sold within one year of completion,the owner- GAS-EA.SYSTEM-OVER 4 (EA.) 2.00
builder will have the burden of proving that he did not build or inF BUILDING USE
prove for purpose ofsale.). INDUSTRIAL WASTE INTER. 30.00 RE IND CDN PB Omer,
❑ 1,as owner of tire property,am exclusively'contracting with ❑ ❑ ❑ ❑
licensed contractors to construct the project(Sec. 7044,Business LAWN SPRINKLERS- 1 INC 5 V.B. 6.00SSESSORS PARCEL NO.
and Professions Code:The Contractor's License Law does not apply "
to un owner of property who builds or improves thereon,and who LAWN SPRINKLERS-OVER 5 IEA.) 1.00
commeS for such projects with a contractor(s)licensed pursuant to SEWER-SAN V-STORM EA.200ft 1
the Contractors License Law. / 0.00 1-11, TRACT NO. PARCEL NO.
❑ l am esempl under Sec. ,B.&P.C.fertile, WATER HEATER W/VENT 6.00 Q(
reason CC)
Owner Date WATER SYSTEM 5.00 "yo ACC.DATE ACC.FILE NO.
WORKIiRS'COM ITNSAT10N DECLARATION WATER TREATING EQUIP. 5.00
I 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 certified
copy thereof(Sec.3800.I-A.C.).
Policy No. Company
O ❑ Cetifiedeopy kir ere by l m dished. FIRE SPRINK ENERGY T-24
z 2 ,�'Certified c y Is Ocd ith the city inspection division.
f'- O ArpV%rant�l X4 r3 MISC.- REFER TO ORD. Y ❑ N❑ v❑ N❑
x N CERTIFICATE OP'EXEMPTION 17ROM WORKERS' PERMIT ISSUANCE 10.00 M OQ FLOOD ZONE A.L.0 C.
LL > COMCID
CL Z ('f his section need not he conhpleled if the permil is for one TOTAL G Y[:] N❑ Y ❑ NE]
hundred dollars(S 100)or less.)
U O 1 certify that in the performance of the work for which this per- DTV. MECHANICAL PERMIT FEE FEE SUMMARY
LL I- mit is issued.I shall not employ any person in any manner so a to
O w become subject to the Workers'Compensation Laws of Colifarnia.
Daw Applicant BUILDING
0. ALTER OR ADD TO MECH. 5.00
} to NOTICE TO APPLICANT: IL after making this Certificate of Es-
eruption,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 ITO 10SMQF.M.) 4.00
CONSTRUCTION L17NDINC AGI?NCY 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,Civ.C), H EATING UN IT(TO 100,000 B.T.U.) 8.00
Lender's Name H EATI NIS U N IT(OVER 100,000 B.T.U.)9.50
Lenders Address ELECTRIC
I certify that I have read this application and state that the above VENTILATION FAN (SINGLE) 4.00
C� information is correct. I agree to comply with all city and county PLUMBING /,
ordinances and state laws relating to building construction. and BOILER-COMP(3 H.P.or 100,000 B.T.U.) 6.00 OV
hereby authorize representatives of this city to enter upon flue
above ncentioned property for inspection purpamniBOILER-COMP IOver 100,000 BTU)SEE FEE SCH. MECHANICAL
ws.
(We) Agree to Save, indemnify cd keep harmless the City of MISC.- REFER TO ORD.
Cupertino against liabilities,judgments. costs and expenses which CONST.TAX
may in any y accrue against Bl City in consequence of the PERMIT ISSUANCE 10.00
grant' g flK Be am MECH.CONT. LIG NO. MECH.
TOTAL TOTAL
Shg u A hp ice t/Contractor ate
INSPECTOR COPY
APF4LICANT TO FILL IN INFORMATION WITHIN RFD LINES -USE BALL POINT PEN ONLY
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LIUI LDI NIS PROJECT I DENTI FICATION
APPLICATION & PERMIT
BUILDING -ELECTRICAL- PLUMBING -MECHANICAL
PERMIT NUMBER
09550
eVILOIN
129 /l/
OWNER'S(
N E v
PHONES7f
Off. ELECTRIC PERMIT FEE
PLAN CHECK VALIDATION
NONTRA OR s
E OUTLETS- SWITCHES- RECEP 10.0011.000
No. cM070
DATE OF APPLICATION
LIGHTING FIXTURES 10.0011.00
c o 's
ADORE SADORE ,
PHONE
APPLIANCES- RESIDENTIAL 4.00
PANELS 10.00
RRCHITECT
OR
ENGINEER
LIC. No.
PANELS (OVER 200 AMP) 20.00
PLANCHEGK FEE P.C. NO.
SIGNS TRANS. 3.00
ARCHE°ss ENG' SPECIAL CIRCUIT 5.00 j.}(ALIDATION
lfli rj
EMP. METER OR POLE INS. 20.00ZIP
AUG 231981985
APPLICANT'S
ADDRESS
MOTORS SEE FEE SCH.
SERVICE CHANGE 20,00
City of ClipertinoLICENSEDCONTRACTORSDECLARATIONTEMP. POLE 30.00
hereby affirm that I am licensed under provisions of Chapter 9
commencing with Section 7000) of Division 3 of the Business and
Professions C Py license Is in full force,a
License Lie. Number -or
ISSUANCE DATA
SLOG.
El
ELECT.
11
P MECH.
Date Contractor
BUILDING ERMIT
fl[FORM TIONOWNER-BUILDERDECL1RATlON
hereby affirm that 1 am exempt from the Contractor's License
Law for the following reason. (See. 7031.5, Business and Professions
Code: Any city or county which requires a permit to construct, alter,
improve, demolish, or repair any structure, prior to its issuance, also
requires the applicant for such permit to file a signed statement that
he is licensed pursuant to the provisions of the Contractor's License
Law (Chapter 9 (commencing with Section 7000) of Division 3 of the
Business and Professions Code) or that he is exempt therefrom and
MISC. - REFER TO ORD
VALUATION S/FT.
PERMIT ISSUANCE 10.00
ELEC. CONTR, LIC. N0. ELEC.
TOTAL
CITY. PLUMBING PERMIT FEE
PE MIT TO
O tEs Tv E CONSTR. the basis for the alleged exemption. Any violation of5ection 7031 3
by any applicant fora permit subjects the applicant to a civilpenafty
of not more than five hundred dollars (S500).). ALTER -DRAIN & VENT -WATER (EA.) 5.00
1, as owner of the property, or my employees with wages as
their sole compensation, will do the work, and the structure is not
BACK FLOW PROTECT. DEVICE 4.00 OCC. GROUP RES. UNITS
intended or offered for sale (See. 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
himself or through his own employees, provided that such improve-
ments are not intended or offered for sale. If, however, the building
I f FIXTURES -PER TRAP 5.00 SD.FT. FLOORAREA TOTALACREAGE
GAS- EA. SYSTEM -1 INC.4 OUTLETS 6.00O
or improvement is sold within one year of completion, the owner-
builder will have the burden of proving that he did not build or im-
prove for purpose ofsale.).-
1, as owner of the property. am exclusively contracting with
GAS - EA_ SYSTEM -OVER 4 (EA.) 2.00 BUILDING USE
kAtINDCONPBOther
INDUSTRIAL WASTE INTER. 30.00
LAWN SPRINKLERS - 1 INC 5 V.B. 6.00licensedcontractorstoconstructtheproject (Sec. 7044, Business
and Professions Code: The Contractor's License Law does not apply
to an owner of property who builds or improves thereon. and who
ASSESSORS PARCEL NO.
LAWN SPRINKLERS - OVER 5 (EA.) 1.00
contracts for such projects with a contractods) licensed pursuant to
the Contractor's License Law. SEWER SANITARYSTORM EA. 200ft110,00 / zu TRACT NO. PARCEL NO.
l am exempt under See. B&P.C, for this WATER HEATER WIVENT 6.00 00
reason
Owner Date WATER SYSTEM 5.00 '(JO ACC. DATE ACC. FILE NO.
WATER TREATING EQUIP. 5.00WORKERS'COMPENSATION DECLARATION
1 hereby affirm that I have a certificale of consent to self -insure,
or a certificate of Workers' Compensation Insurance, or a certified
ZONING ENG, SITE NO,
copy thereof (Sec. 3800, Lab.C.).
Policy No. Company
FIRE SPR INK
Y N
ENERGYT-24
Y N
Cert lfiedcopy ishcrebyfurnished.
Certified 5 fjI d w,ilh city inspection division.
A.p'can[( %i'!iv.s4 } MISC.- REFER TO ORD.
CERTIFICATE OF EXEMPTION FROM WORKERS' PERMIT ISSUANCE 10-007() FLOOD ZONE AA.U.C.
PLG, CONTR. LIC. No. PLG.
TOTAL 90
COMPENSATION INSURANCE
This section need not be completed if the permit is for one
Y N Y C] N
QTY. MECHANICAL PERMIT FEE FEE SUMMARY
hundred dollars (S 100) or less.)
1 certify that in the performance of the work for which this per,
mit is issued, I shall not employ any person in any manner so as to
BUILDING
become subject to the Workers' Compensation Laws of California.
Date Applicant ALTER OR ADD TO MECH. 5.00
NOTICE TO APPLICANT: If. after making [his Certificate of Ex-
APPLIANCE 5.00 PLAN CHECKemption, you should become subject to the Workers' Compensation
provisions of the Labor Code, you must forthwith comply with
such provisions or this permit shall be deemed revoked.
FEEAIRHANDLINGUNIT (TO 10P00 C.F.M I. 4.00
AIR HANDLING UNIT (OVER 10=C.RM.) 6.00 SEISMIC FEECONSTRUCTIONLENDINGAGENCY
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.
3097,Civ.C.).
MICROFILM
HEATING UNIT (TO 100,000 B.T.U.) 8.00
HEATING UNIT (OVER 100,000 B.T.U.19,50 ELECTRIC
Lender's Name
eLendr's Address
I certify that I have read this application and state that the above
information is correct. I agree to comply with all city and county
ordinances and state laws relating to building construction, and
VENTILATION FAN (SINGLE) 4.00
PLUMBING
f
oV
BOILER-OOIVIP(3 H.P. or 100,000 B.T.U.) 6.00
BOILER -COMP (Over 100,00(i BTU) SEE FEE SCH, MECHANICALherebyauthorizerepresentativesofthiscitytoenteruponthe
above-meniioncd property for inspection purposes.
MISC. - REFER TO ORD., We) agree to save, indemnify and keep harmless the City of
Cupertino against liabilities, judgments, costs and expenses which
may ' any y accrue gains[ 'd City in consequence of the
CONST. TAXPERMITISSUANCE10,00]
MECH. CONT. LIC. NO. ECAH
OTALrT
TOTAL
gran ' g t permit
Signatu e o Applicant/Contractor Date
OFFICE COPY