09629 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
BU LDI NG PROJECT I DENTI FICATI ON PERMIT NUMBER
BUILDING APPLICATION & PERMIT
ADDRESS ,O
BUILDING - ELECTRICAL-PLUMBING-MECHANICAL
09629
OWNER'S PLAN CHECK VALIDATION
NAME /1 OTY. ELECTRIC PERMIT FEE
RS arvE
NAMERAcroRs UTLETS-SWITCHES-RECEP 10.00/1.00
n LIC.NO. q,4n r LIGHTING FIXTURES 10.00/1.00
ADDRESS cross n APPLIANCES-RESIDENTIAL 4.00 '
-
^-�
CHITECT PANELS 10.00 DATE OF APPLICATION
AR
OR ��_ �ka.,�x.-,.7�Z'w� rJ5'-;;/ PANELS (OVER 200 AMP) 20.00 PLAN CHECK FEE P.C.NO.
ENGINEER
uc.NO SIGNS TRANS. 3.00
AARCH.OR DDRESS ENG. SPECIAL CIRCUIT 5.00 4`) PERMIT VALIDATION
ZIP TEMP.METER OR POLE INS. 20.00 PAID:
AES
ADDRESPILICS
MOTORS SEE FEE SCH.
7' __ 7r SERVICE CHANGE 20.00 SEP Q 4 1985
00 LICENSED CONTRACTORS DECLARATION TEMP.POLE 30.00
a Wa L hereby affirm that I am licensed under provisions of Chapter9 CIS�Uit14L$Y/A& Ilio
vi 2 'w (commencing with Section 7000)of Division 3 of the Business and BLDG. ELECT. PLG. I MEC
H y z Professions Code,and fly license is in full force and effect,
Z o m - License class .r Lie Number
z H °w Dau? �q �y Contractor
a y i SAs -39
ac
¢o i OR'NER-BUILDER DECLARATION BUILDING PERMIT
INFORMATION
w3 H I Iwrcby affirm Ron 1 am exempt from the Comuctors License MISC.- REFER TO ORD
E_ LL_ o¢. Law lin the following reason. 7031.5,Businessand Professions PERMIT ISSUANCE 10.00 VALUATION
Code Any city or county which requires a permit to construct,alter.
R ¢ ¢ FO improve,demolish,or repair any structure,prior to its issuance,also ELEC.CONTE. LIC.NO. ELEC.
a w- o BE requires the applicant for such permit to file a signed statement that TOTAL PERMIT TO
m w Ile is licensed pursuant to the provisions of the Contractor's License
r z a
Law(Clmpmr9(commencingwall Suction 7000)o f Dl,iaion3ofthe
E i o Business and Professions Code)or That he ix exempt therefrom andQTY. PLUMBING PERMIT FEE ...-'"
M H o the basis for the alleged exemption.Any violation of Section 7031.5 STORIES TYPE CONSTR.
n ;m by any applicant for a permit subjects the applicant to a civil penalty ALTER-DRAIN -WATER IEA.) 5.00
Of not more than five hundred dollars(5500).):
0 1,as owner of the property,or my employees with wages as BACK F LOW PROTECT.DEV ICE 4.00
their sole compensation,will do the work,arta the structure is not OCC.GROUP RES.UNITS
intended or offered for sale (Sec. 7044, Business rad Pnhfsssions DRAINS-FLOOR,ROOF,AREA,COND. 5.00
Code:'II Contractor's License Law does not apply to an owner of ------
property who builds or improves thereon,and who docs such work FIXTURES-PER TRAP 5.00 SO.FT.FLOOR AREA TOTAL ACREAGE
himself or through his own employees.provided that such improve-
menuarenot intended or offered for sale.IL howeveq the building GAS-EA.SYSTEM-I INC.4 OUTLETS 6.00
or improvement is sold within lite year of completion,the owner- GAS-EASYSTEM-OVER 4 (EA.) 200 BUILDING USE
builder will have the burden of proving that he did not huild o . . .
r im
prove for purpose R IND CON PB Otherof sale J' INDUSTRIAL WASTE INTER. 30.00
❑ I,as owner of the property,am exclusively contracting with D 0 El ❑
licensed contractors to construct the project(Sec. 7044,Business LAWN SPRINKLERS-1 INC 5 V.B. 6.00 ASSESSORSPARCELNO.
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 contractors s)licensed pursuant to
the Contractor's License Law. SEW ER-SAN TAR V-STORM EA.200tt/10.00 TRACT NO. PARCEL NO.
❑ 1....exempt coder Sec.-,B.&P.C.for this WATER HEATER W/VENT 6.00
reason
owner Date WATER SYSTEM 5.00 ACC.DATE ACC.FILE NO.
WORKS RS'COMPENSA"TION DECLARATION WATER TREATING EQUIP. 5.00
I hereby affirm that 1 have a certificate Of ernewnt to self-insure' ZONING ENG.SITE NO.
or a certificate of Workers'Compensation Insurance,or a certified
copy tlie reof(See.380QLab.CJ� . . ,
folic certified
Co hereby
y- C'C
Cetified copy I,ss filed(with the FIRESPRINK ENERGYT-24
z Z ❑ Certified copy is filed with the city inspection division.
Applicant MISC-- REFER TO ORD. Yo No YE) A[]
CERTIFICATE IPE EXEMPTION FROM WORKERS'CC o PERMIT ISSUANCE 10.00
FLOOD ZONE A.L.u.C.
W � COMI'ENSATI(1N INSURANCE PLG.CONTE. LIC.NO. PLG.
Cl- 0 ('this section need not be completed i1'the permit is for one TOTAL Y❑ IN Y N
hundred dollars(S 100)or less.)
U O I certify that in the performance of the work for which this per- QTY. MECHANICAL PERMIT FEE FEE SUMMARY
W H mit is issued.I shell not employ any person in any insurer so as to
O w become subject to the Worker Compensation Laws of California.
Dale Appl'cant ALTER OR ADD TO MECH. 5.00 BUILDING
} ton NO]ICE TO APPLICANT: If,after making This Certificate of ISx-
F 2 cludion,you Should become subject to the WorkersCompensation APPLIANCE 5.00 PLAN CHECK \
provisions of lire labor Code, you must 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 10SWC.F.M.) 6.00 SEISMIC FEE
I hereby affirm that there is a construction lending agency for EXHAUST HOOD (WITH DUCT) 5.00 q 00
the performance of the work for which this permit is issued(Sec. MICROFILM
3097,Civ.C.). HEATING UNIT TO 100,000 B.T.U.) 8.00 .n0
Lender's Name HEATING UNIT(OVER 100,000B.T.U.18.50 ELECTRIC
' Name-
Lender's Address r-,Z,e.�,-
I cel i IY'ttffel h vixie�Jfihis applicar ion a n d St ate that the above VENTILATION FAN (SINGLE) 4.00 a,qp x
insinuation is correct. I agree to comply with all city and county PLUMBING
ordinances and slate 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
above-mentioned property for inspection purposes. BOILER-COMP(Over 100,000 BTU)SEE FEE SCH. MECHANICAL
(We) .gree to save, rude nmify and keep harndess the City of MISC.- REFER TO ORD.
Cupertino against liabilities,judgments, costs and expenses which CONST.TAX
may it any way accrue against said City in consequence of the PERMIT ISSUANCE 10.00 b.00
granting Of this permit. MECH.CONT. LIC.NO. MECH. -
TOTAL TOTAL
Sign ADPlicantCon'actor
rein Date 3'S'eb
INSPECTOR COPY
O
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APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
BUILDING PROJECT IDENTIFICATION
APPLICATION &PERMIT
BUILDING - ELECTRICAL- PLUMBING - MECHANICAL
PERMIT NUMBER
09629
N's
ADDRI)OA ESS
OWNER'S
NAME
CITY, ELECTRIC PERMIT FEE
PLAN CHECK VALIDATION
PHONE 7/-
CONTRACTOR'S
NAME OUTLETS - SWITCHES - RECEP 10.00/1.00
LIGHTING FIXTURES 10.00/1.001
Q LIC. ND.csG-SI.o3
cranesCONTRAADDRESSADDRESS PPLIANCES- RESIDENTIAL 4.00
PANELS 10.00qONE(:/ DATE OF APPLICATION
ARCHITECTPLAN
OR moi- `
ENGINEER
LIC, No.
PANELS (OVER 200 AMP) 20.00
CHECK FEE P,C._ NO.
SIGNS TRANS. 3.00
ARCH. OR ENG.PERMIT
ADDRESS SPECIAL CIRCUIT 5.00'` 1 AT N
B
EMP. METER OR POLE INS. 20.0021P
City of 04080140ADDRESSAPPLICANT'S MOTORS SEE FEE SCH.
SERVICE CHANGE 20.0037-4a
LICENSED CONTRACTORS DECLARATION TEMP. POLE 30.00
1 hereby affirm that I am licensed under provisions of Chapter 9
commencing with Section 700D) of Division 3 of the Business and
Professions Code, and my license is in full force and effect.
Lic.'Number
Datta'' Contractor
ISSUANCE DATE
BLDG.
El
ELECT.
1-1
PLG.
1:1LicpgsSCl
MEC .
BUILDING PERMIT
INFORMATION
V
OWNER -BUILDER DECLARATION
I hereby affirm that I am exempt from the Contractors License
Law for the following reason. (Sec. 7031.5, Business and Professions
Code: Any city or county which requires permit to construct, alter,
improve, demolish, or repair any, structure, prior, to its issuance, also
requires the applicant for Such permit to file aCont statement that
he is licensed pursuant to the provisions of the Contractor sLicense
MISC. -- REFER TO ORD
VALUATION SIFT.
PERMIT ISSUANCE 10.00
ELEC. CONTR, LIC. NO. ELEC,
TOTAL PE MITTO•
CITY. PLUMBING PERMIT FEE
Law (Chapter 9 (commencing with Section 7000) of Division 3 of the
Business and Professions Code) or that he is exempt therefrom and
S T 0 R 'S TYPE CONSTR. the basis for the alleged exemption. Any violation of Section 7031.5
by any applicant for a permit subjects the applicant to a civil penalty
of not more than five hundred dollars (5500).): 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
intended or offered for sale (Sec. 7044, Business and Professions
BACK FLOW PROTECT. DEV ICE 4.00 OCC. GROUP RES. UNITS
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 docs such work
himself or through his own employees, provided that such improve-
ments are not intended or offered for sale. If, however, the building
F IXTUR ES - 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 purpose of sale,).
1, as owner of the property, am exclusively contracting with
GAS - EA. SYSTEM -OVER 4 (EA.) 2.00 BUILDING USE
IND. CON PB Other
INDUSTRIAL WASTE INTER. 30.00
licensed contractors to construct the project (Sec. 7044, BusinessLAWN
and Professions Codc: The Contractor's License Law does not apply
to an owner of property who builds or improves thereon• and who
SPRINKLERS - 1 INC 5 V.B. 6.04 ASSESSORS PARCEL NO.
LAWN SPRINKLERS -OVER 5 (EA.) 1.00
contracts for such projects with a contractor(s) licensed pursuant to
the Contractor's License Law. SEWER -SANITARY -STORM EA, 200ft/10.00 TRACT NO. PARCEL NO.
111 am exempt under Sec. B.&P.C. for this
reason
WATER HEATER W/VENT 6.04
Owner Date WATER SYSTEM 5.00 ACC. DATE ACC, FILE NO.
WATER TREATING EQUIP. 5.00WORKERS'COMPENSATION DECLARATION
1 hereby affirm that I have a certificate of consent to self -insure,
or a certificate of Workers' Compensation Insur ce, ora certified
copyth rev (Sec. 3809,
ZONING ENG. SITE NO.
Pylic o 8G9Company
Certified copy is hereby furnished.
Certified copy is filed with the city inspection division.
Applicant -
FIRESPRINK
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 (5 100) or Icss.)
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 Law_ s of Catifomia.
DateApplicant
NOT]CE TO APPLICANT: If, after making this Certificate of Ex-
ALTER OR ADD TO MECH. 15.00
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 10AW C.F.M.) 4.00
AIR HANDLING UNIT (OVER 10,000C.F.M.) 6.00 SEISMIC FEECONSTRUCTIONLENDINGAGENCY
I hereby affirm that there is a construction lending agency for EXHAUST HOOD (WITH DUCT) 5.04 &.Qp
the performanw oft work for which this permit is issued (Sec.
3097, Civ.C.).
MICROFILM
HEATING UNIT (TO 100,000 B.T.U.) 8.00 8,0d
HEATING UNIT LOVER 100,00D B,T.U.19,50 ELECTRIC
Lender's Name
Lender's ,qq re
qo -
I certify,tLhay t!id lTf1I j plication 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
3 VENTILATION FAN (SINGLE) 4.00 /.p.p4
PLUMBING
BOILER -COMP (3 H.P. or 100,000 B.T.U.) 6.00
BOILER -COMP (Over 100,000 BTUI SEE FEESCH. MECHANICALherebyauthorizerepresentativesofthiscitytoenteruponthe
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
CONST. TAXPERMITISSUANCE10.00 /,0.00
grantin of this permit. MECH. CONT. LIC. NO. MECH.
TOTAL
TOTAL
Signa Applicant/Contractor Date
OFFICE COPY