09632 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
BUILDING PROJECT lDENT[FICATION PERMIT NUMBERAPPLICATION & PERMIT
ADDRESS
09632
'
BUILDING-ELECTRICAL-PLUMBING-MECHANICAL
i
OWNER PLAN CHECK VALIDATION
NAME OTY. ELECTRIC PERMIT FEE
n roosts T �o
NAMEnncTons UTLETS-SWITCHES-RECEP 10.00/1.00
.n LIC,NO-2 �. - LIGHTING FIXTURES 10.00/1.00
NTRA AcrOR's
ADDREPPLIANCES-RESIDENTIAL 4.00
CO
7 yea y Com..,,• . t PROM �iio' 79x1_ PANELS 10.00 DATE OF APPLICATION
ARCHITECTksr.e.'-Kt CCti 9fJ96 H3 PANELS (OVER 200 AMP) 20.00 PLAN CHECK FEE P.C.NO.
ENGINEER
LIC,NO, SIGNS TRANS. 3.00
ADDRESS ENG. SPECIAL CIRCUIT 5.00 PERMIT A IDA 1 N
ZIP TEMP.METER OR POLEMNS. 20.00 SEP 0 4 1985
APPLICANTS MOTORS SEE FEE SCH.
ADDRESS
/r.-_„T SERVICE CHANGE 1 20.00 City of Cupertino
° ¢ TEMP.POLE 30.00
Hoo
LICENSED CONTRACTORS DECLARATION
Q U u I hereby affirm [hat I am licensed under provisions of 0u ptcr 9 ISSUANCE DATE
vHi i (commencing with Section 7000)of Division 3 of the Business and
Q BLDG. ELECT. PLG. MEC
H H i Professions Code, my license is in full force and effect.
License ❑ ❑ ❑
Z o m - License Class - -- I Li tic.Number
a y f 'V': ' A''-3-efli BUILDING PER
ce ¢o n a OWNER-BUILDER DECLARATION INFORMATION
wg
L.y I hereby affirm that 1 am exempt from the Coutkactor's License MISC.- REFER TO ORD
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APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
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BPI LDI NG PROJECT] DENTI FICATION
APPLICATION &PERMIT
BUILDING — ELECTRICAL— PLUMBING— MECHANICAL
PEAMIT NUMBER
09632BUILDINGADDRESS
7 —597 (!
OWNER'S
NAME
PHpNTy'
QTY. ELECTRIC PERMIT FEE
PLAN CHECK VALIDATION
CONTRACTOR'S
NAME NAME
OUTLETS - SWITCHES-RECEP 10.0011.00
LIGHTING FIXTURES 10.0011.0036pIC. ND
CONTRACTOR'S
ADDRESS
APPLIANCES - RESIDENTIAL 4,00
IPA ELS 10.007•.If-'A 9 PHON e 4: %'9A DATE OF APPLICATION
ARCHITECT V
ORENGINEER
LIC, NO,
PANELS (OVER 200 AMP) 20,00 PLAN CHECK FEE P.C. NO.
SIGNS TRANS, 3.00
ARCH. OR ENG.SPECIALADDRESS CIRCUIT 5.00 PERMIT VALIDATION
TEMP. METER OR POLE INS, 20,00ZIP
APPLICANT'S
ADDRESS
MOTORS SEE FEE SCH.
SERVICE CHANGE 20,00
SEP 0 4198SLICENSEDCONTRACTORSDECLARATIONTEMP, POLE 30.00
I hereby affirm that I am licensed under provisions or Chapter 9
commencing with Section 7000) of Division 3 of the Business and
Professions Co a and m lice se is in full force and effect.
Li cgg lse !a s -tic. Number
1 ANCE DATE
BLDG, y
DW - ontractor
OWNER -BUILDER DECLARATION: BUILDER DECLARATION:
I hereby affirm that I am exempt from the Contractor;MISC. License
Law for the following reason. (See, 703 1.5, 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
requites the applicant for Such permit to file a signed statement That
he is licensed pursuant to the provisions of the Comtnctor s License
BUILDING T
REFER TO ORD
VALUATION SIFT.
PERMIT ISSUANCE 10.0.0
ELEC. CONTA. LIC. NO.
ELEC. TOTAL PEMIT TO
QTY. PLUMBING PERMIT FEE
Law (Chapter 9 (commencing with Section 7000) of Division, 3 of the
Business and Professions Code) or that he isexempt therefom and
STO IES TYPE CONSTR. the basis for the, alleged exemption. Any violation of Section 7031.5
by any applicant for a permit subjects the applicant to aciQpenalty
of not more than five hundred dollars ($500).): 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 -
DRAINS -FLOOR, ROOF, AREA, COND. 5.00intendedorofferedforsale (See. 7044, Business and Professions
Code: The Contractor's License Law does not apply to an owner of
properly who builds or Improves thereon, and who does such work
himself or through his own employees, provided Ihat such improve-
ments are not intended or offered for sale. If, however, the building
FIXTURES - PER TRAP 5.00 SO FT, FLOOR AREA TOTAL.ACREAGE
GAS - EA. SYSTEM -1 I NC. 4 OUTLETS 6.00
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 purposeofsale.).
1, as owner of the property, am exclusively contracting with
GAS EASYSTEM OVER 4 {EA.) 200 BUILDING USE
RE IND CON PB Other
INDUSTRIAL WASTE INTER. 30,00
licensed contractor to construct the project (Sec. 7044, Business
and Professions Cade: 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 - 1 INC 5 V.B. 6.00
LAWN SPR IN KLERS - OVER 5 (EA,) 1,00
contracts far such projects with a contractor(s) licensed pursuant to
thethe CoContractor's License Law, SEWER-SANITARY-STORM EA. 200ftli 0.00 TRACT NO, PARCEL NO.
l am exempt under Sec. BAP.C. for [his WATER HEATER W/VENT 6.00
reason
Owner Date WATER SYSTEM 5.00 ACC. DATE ACC. FILE NO.
WATER TREATING EQUIP, 5.00WORKERS'COMPENSATIONDECLARATION
1 hereby affirm that [ have a certificate Of consent, to self -insure.
a certificate of Workers' Compensation Insu ce, or a certified ZONINGorENG. SITE NO.
copy th re Sec. 380 , Lob.C. . t _WO
Po[ic o
Certifled copy is hereby furnished,
Certified ropy is filed with the city inspection division.
Applicant
FIRE SPRINK
y N
ENERGY T•24
y N MISC. REFER TO ORD.
CERTIFICATE OF EXEMPTION FROM WORKERS' PERMIT ISSUANCE 10.00 FLOOD ZONE A.L.U.C.
PLG. CONTR, LIC. NO. PLG. TOTAL
COMPENSATION INSURANCE
This section need not be completed if the permit is for one
Y N Y N
QTY. MECHANICAL PERMIT FEE FEE SUMMARY
hundred dollars ($100) or less.)
I 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 this 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.
FEE
AIR HANDLING UNIT (TO 10)=C.F.M.) 4.00
AIR HANDLING UNIT(OVER10,000C.F,M:) 6.00 SEISMIC FEECONSTRUCTIONLENDINGAGENCY
1 hereby affirm that there is a construction lending agency for
the performance of a work for which this permit is issued (Sec.
3097, Civ.C.).
Lender's Name
Len rcydire
EXHAUST HOOD (WITH DUCT) 5.00 —T.e I
MICROFILM
HEATING UNIT (TO 100,000 B.T.U.) 8.00 if. Q0
HEATING UNIT {OVER 100,000 B.T.U.) ELECTRIC
I certify thafl have rea this application and state that the above
information is correct. 1 agree to comply with all city and county
ordinances and state laws relating to building construction, and
VENTILATION FAN (SINGLE) 4.00
PLUMBING
BOILER -OOMP(3H.P. or 100,000 B.T.U.) 6.00
BOILER -COMP (Over t00.000.BTUISEE FEE SCH. MECHANICALherebyauthorizerepresentativesorthiscitytoenteruponthe
above-mentioned 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 in any way accrue, against said City in consequence of the
gr tin f this permit.
CONST. TAXPERMITISSUANCE10,00 /d•ao
MECH. CONT. LIC. NO. MECH.
TOTAL
35 TOTAL
igna of pplicant/Contractor Date
OFFICE COPY