09628 APPLICANT TO FILL IN INFORMATION WITHIN-RED LINES - USE BALL POINT PEN ONLY
BUILDING PROJECT IDENTIFICATION
PERMIT NUMBER
emLmSG APPLICATION & PERMIT O��^�
ADDRESS
UILDIN A
BUILDING-ELECTRICAL-PLUMBING-MECHANICAL
G A'
OWNER'5 PLAN CHECK VALIDATION
NAME OTY. ELECTRIC PERMIT FEE
C...tr PHONE
NOMERACTORs UTLETS-SWITCHES-RECEP 10.00/1.00
// t Uc..O. . LIGHTING FIXTURES 10.00/1.00
CONTRACTOR PPLIANCES-RESIDENTIAL 4.00
ADDRESS
PRONE PANELS 10.00 DATE OF APPLICATION
OR ARCHITECT �/ - .x� PANELS (OVER 200 AMP) 20.00 PLAN CHECK FEE P.C.NO.
ENGINEER
' uc.No. SIGNS TRANS. 3.00
ADDRESS ENG. SPECIAL CIRCUIT 5,80 PE I LIGATION
�I•��D'
zm EMP.METER OR POLE INS. 20.00 •�
ADDRESS MOTORS SEE FEE SCH. SEP 04 7(105
ADDRESS 1JOJ
q SERVICE CHANGE 20.00 Y
° s z TEMP.POLE 30.00 `illy Of /
D LD LICENSED CONI DECLARATION �uDert'
a U 1 hereby affirm that I am licensed under provisions of Chapter 9 ISSUANCE DATE
Nz a (commencing with Section 7000)of Division 3 of the Business and
a BLDG. ELECT. PLG. EC
F N z P ofessinns Code,and my license is in full Ponce and effect ❑ ❑ ❑
zo i w W License CIasY_!V- " _Lie Number
Pale-/e.�v_ R_--b �C.Tumetor
P
, f f-93 - BUILDING PERMIT
¢ ec 6 U OWNER-BUILDER DECLARATION INFORMATION
ve ; LL y I hereby affirm that I am exempt from the Contractor's License MISC.- REFER TO ORD
LL o a Law for the following reason.(Sec.7031.5,Businessand Professions
VALUATION,J, $/FT.
_ PERMIT ISSUANCE 10.00
Code: e,de ity or coon pair any reqstructure,es a
prior
to construct,after,
t[ ¢ si O improve,demolish,or repair any sruQurc,prior Ie Els is4lueec,also ELEC.CONTR. LIC.NO. ELEC.
- ° IC requires the applicant for such permit In IIIc u signed statement that TOTAL
n ww he is licensed pursuant to the provisions of the Contractor's License PERMIT TO
F z r Law(Chapter 9(commenciagw'ith Section 7000)of Division 3 oflhe
Z o Business and Professions Code)or that he is exempt therefrom and OTY. PLUMBING PERMIT FEE mefeh
¢ r � the basis Ibr the alleged exemption.Any violation of Section 7031.5 STORIES TYPE tONSTR.
a ; 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($500).):
❑ I,as owner of the property,or my employees with wages as BACK FLOW PROTECT. DEVICE 4.00 DEC.GROUP RES.UNITS
their sole compensation,will do the work,and the structure is not r
intended or Meted for sale (Sec. 7044, Business and Profeseions DRAINS-FLOOR,ROOF,AREA,COND. 5.00
Code:The Contractor's License Law does not apply to an owner of
properly who builds or improves thereon,and who does such work FIXTURES-PER TRAP 5.06 SO.FT.FLOOR AREA TOTAL ACREAGE
himself or or through his own employees,provided that such improve-
Tntes are not intended or offered for sale.If,however,the huilding GAS-EA.SYSTEM-11NC.40UTLETS 6.00
or improvement is sold within one year of completion,the owner- GAS-EA.SYSTEM-OVER 4 (EA.) 2.00
�bailder will have the burden o'proving that he did not build or im- BUILDING USE
prove for purpose ofsale.). INDUSTRIAL WASTE INTER3000 RE IND CON PB Other
❑ 1,as owner of the property,am exclusively contracting with . .
❑ ❑ ❑ ❑
licensed contractors to construct the project(Sec. 7044,Business LAWN SPRINKLERS-I INC 5 V.B. 6.00 sJ ASSESSORS PARCEL NO.
and Professions Code:The Contractor's License Law does not apply
to an owner of properly who builds or improves thereon.and who LAWN SPRINKLERS-OVER 5(EA.) 1.00
contracts for such projects with a contraclorfs)licensed pursuant to SEWER-SANITARY-STORM EA.200ft/10.00
the Conlmttor's License Law, TRACT NO. PARCEL NO.
❑ 1 an,exempt under Sec.-.BAPTC.for this WATERHEATER W/VENT 6.00 n
reason /'
Owner Date WATER SYSTEM 5.00 t,,k ACC.DATE ACC.FILE NO.
WORKERS'COMPENSATION DECLARATION WATER TREATING EQUIP. 5.00
I hereby affirm that I have a certificate ofemment to self-insure. ZONING ENG.SITE NO.
or a certificate of Workers'Compensation Insurance,or a certified
copy thereof(Scc.3800,Lab.C.)��
Policy n.��„4f�:5(:omp:uiy
Cc rifled copy is hereby furnished. FIRE SPRINK ENERGY T-24
Z_ Z ❑ Certified copy is fled with [lie city inspection division. MISC.- REFER TO ORD.
O Applicant v N Yo N
~ w -
LU - CERTIFICATE OP EXEMPTION FROMWORKERS' PERMIT ISSUANCE 10.00
FLOOD ZONE A.L.U.C.
W > COMPENSATION INSURANCE PLG.CONTR. LIC.N0. PLG.
0 (This xclion need not be completed if the permit is for one TOTAL
hundred dollars IS 100)or Icss,)
U 0 1 certify that in the performance of me work for which this per- OTY. MECHANICAL PERMIT FEE FEE SUMMARY
LL f mit is issued.I shall not employ any person in any manner so as to
Q W become subject to the Workers'Compensation Laws of California.
n Date Applicant ALTER OR ADD TO MECH. 5.00 BUILDING
} to NOTICE'1'0 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 such provisions or this permit shall be deemed revoked. AIR HANDLING UNIT(TO 10MOC.F.M.) 4.00
CONSTRUCTION LENDING AGENCY AIR HANDLING UNIT(OVER IOPODGEM.) 6.00 SEISMIC FEE'
1 hereby affirm that there is a construction lending agency for EXHAUST HOOD (WITH DUCT) 5.00 A-
the performance of the work for which this permit is issued(Sec. MICROFILM
3097,Civ.C.). r
Lender's Addie HEATING UNIT ITO 100,000 B.T.U.) 8.00 p „o
Lender's Name /�� a _ E HEATING UNIT(OVER 100,000 B.T.U.)9.50 ELECTRIC
I certify that l have rQdilirt'SppheaHndarTd'ftnlrth3t"Ihe above VENTILATION FAN (SINGLE) 4.00 A.dn
t� information is correct, 1 ogre,to comply with all city unA co um, PLUMBING
ordinances and slate laws relating to building construction, and BOILER- H.P.or 100,000 B.T.U.) 6.00
hereby authorize roperty tativea ec this city Io enter upon the BOILER-COMP iover 100,000 BTU)SEE FEE SCH. MECHANICAL
hereby
nice mrO property Ibrinspection purpoxs.
(We) agree to save, indenmify and keep hurmless the City of MISC.- REFER TO ORD.
Cupertino against liuhilities,judgments, costs mid expenses which CONST.TAX
may in any way accrue against said City in conwquence of the PERMIT ISSUANCE 10.00 /Am
granting O(this permit, MECH.CONT, LIC.NO. MECH.
TOTAL
/--? >7/ .1 y a - 3100 TOTAL
SIgn3lure oC Apphcanl/Contractor ` Date
INSPECTOR COPY
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APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
BUI LDI NG PROJECT l DENTI FICATION
APPLICATION & PERMIT
BUILDING -ELECTRICAL- PLUMBING -MECHANICAL
PERMIT NUMBER
6
1• •1/
N
nQ9JVLJ
BUILDINGADDRESS
OWNER'S
NAME
PHONE
PTY. ELECTRIC PERMIT FEE
PLAN CHECK VALIDATION
CONTRACTOR'S
NAME OUTLETS -SWITCHES -RECEP 10,00/1,00
LIGHTING FIXTURES 10.0011.009136.0 Ic.ND S'/30-f
CONTRACTOR'S
ADDRESSAPPLIANCES
ADDRESS
RESIDENTIAL 4.00
PANELS 10.007' NE DATE OF APPLICATION
ARCHITECT
ORENGINEER
LIC. NO.
PANELS COVER 200 AMP) 20-00
PLAN CHECK FEE P.C. NO.
P -10SIGNSTRANS, 3.00
ARCH. OR ENG'
SPECIAL CIRCUIT 5.00 PER T VALIDATION
EP
EMP. METER OR POLE INS. 20.00ZIP 4 7985
CitiV of
APPLICANT'S
ADDRESS
MOTORS SEE FEE SCH.
SERVICE CHANGE 20,003f [.-,
ti
Lipenlq
LICENSED CONTRACTORS DECLARATION TEMP. POLE 30.00
1 hereby affirm that I am licensed under provisions of Chapter 9
commencing with Section 7000) of Division 3 of the Business and
Professions Co je, and m license is in full force and efrect.
L cppnse C1 Number
ISSUANCE DATE
BLDG. ELECT. PLG. EC
3I5: -'t-9 ContractorCo
BUILDING PERMIT5't -%6Z
OWNER -BUILDER DECLARATION
I herebyaffirm that I am exempt from the Contractor's Licensep
Law for the following reason. (Sec. 7031.5, Businessand 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
INFORMATION
MISC. -- REFER TO ORD
VALUATION SFT. -
PERMIT ISSUANCE 10.00
ELEC. CONTR. LIC. NO. ELEC.
TOTAL PE IT TO
QTY. 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 01
STORI S TYPE ONETR. the basis for the alleged exemption. Any violation of Section 7031.5
by any applicant for a permit subjects the applicant to civil penalty
of not more than five hundred dollars (5500).): ALTER -DRAIN & VENT -WATER {EA.} 5.00
0 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 (Sec. 7044, Business and Professions
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 50. FT, FLOORAREA TOTALACAEAGE
himself or through his own employees, provided that such improve-
mems are not intended or offered for sale. If, however, the building 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.).
O 1, as owner of'the property, am exclusively contracting with
GAS - EA. SYSTEM - OVER 4 (EA.) 2.00 BUILDING USE
RE IND CON PB Other
INDUSTRIAL WASTE INTER. 30.00
LAWN SPRINKLERS -I 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
N ASSESSORS PARCEL NO.
LAWN SPRINKLERS - OVER 5 (EA.) 1.0
contracts for such projects with a ConlraCIOT(s) licensed pursuant to
the Contractor's License Law. SEWER -SANITARY -STORM EA, 200ft110.00 TRACT NO, PARCEL NO.
lain exempt under Sec. B.&P.C, for this WATER HEATER W/VENT 6.00
reason
Owner Date WATER SYSTEM 5.00 ACC. DATE ACC: FILE NO.
WATER TREATING
EQUIMORD.
WORKERS! COMPENSATION DECLARATION
I hereby affirm that I have a certificate of consent to self -insure,
or a Certificate of Workers' Compensation Ins u nce, or'a certified
ZONING ENG. SITE NO.
copy thereo (Sec. 3800, Lab.C.).
fir,LSCompany
Certified copy is hereby furnished.
Certified copy is filed with the city inspection division.
Applicant
FIRE SPRINK
Y N
ENERGY T-24
Y
NCERTIFICATE
MISC. -
OF EXEMPTION FROM WORKERS' PERMIT ISSUANCEFLOOD ZONE A,L.u,C.
PLG, CONTR. LIC. NO. PLG.
TOTAL
COMPENSAT10N 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 (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
NOTICE TO APPLICANT: If, after making this Certificate of Ex-
ALTER OR ADD TO MECH. 5.00
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 10AWC.F.M.) 4.00
AIR HANDLING UNIT (OVER 10MC.F.M.) 6.00 SEISMIC FEECONSTRUCTIONLENDING.AGENCY
I hereby affirm that there is a construction lending agency for EXHAUST HOOD (WITH DUCT) 5,00-6-",
the perrormance of to work for which this permit is issued (Sec
3097, CIY,L.),
MICROFILM
HEATING UNIT {TO 100,000 B.T.U.I 8.00 •UV
HEATING UNIT (OVER 100,D00 B.T.U.I9.50 ELECTRIC
Lender's Name
Lendcr'sAddress
3
I certify that I have read thisapplica ronandii te ihheabove
information is correct. 1 agree to comply with all city and countyPLUMBING
ordinances and state laws relating to building construction,and
VENTILATION FAN (SINGLE) 4.00 •tlD
BOILER -COM P(31-I.P.or100,000B.T.U.I 6.00
BOILER -COMP IOver 100,000_ BTU) SEE FEE seH. 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 whichCONST.
may in any way accrue against said City in consequence of the
TAX
PERMIT ISSUANCE 10.00
MECH. CONT. LIC. NO, 7ME9 TOTAL
grantin of this permit
Signa pplicantlContractor Date
OFFICE COPY