09627 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
BUI LDI NG PROJECT I DENTI FICATI ON PERMIT NUMBER
BUILDING APPLICATION & PERMIT 096217
ADDRESS
_ BUILDING - ELECTRICAL-PLUMBING-MECHANICAL
NAMER'$
PLAN CHECK VALIDATION
OTV. ELECTRIC PERMIT FEE
PHONE 4
NDAme AcioRs UTLETS-SWITCHES-RECEP 10.00/1.00
O w LIC.No. 23 S LIGHTING FIXTURES 10.00/1.00
NTRACDRESCions
ADAPPLIANCES-RESIDENTIAL 4.00
CONTRACTORS
vH0 VkiT -y PANELS 10..0.0. DATE OF APPLICATION
ORnCNIiEGi �.- � /VA5';f PANELS (OVER 200 AMP) 20.00 PLAN CHECK FEE P.C.NO.
ENGINEER
LIC.NO SIGNS TRANS. 3.00
noo Ess Erva SPECIAL CIRCUIT 5.00 PERMIT VALIDATION
ZIP EMP.METER OR POLE INS. 20.00 SEP 0 h 1985
ADDRESS
S
AMOTORS SEE FEE SCH.
ORE /T
SERVICE CHANGE 20.00 .City Of CUpedino
'00 LICENSED CONTRACTORS DECLARATION TEMP.POLE 30.00
IS u w I herchy affirm that I am licensed under provisions of Chapter 9 ISSUANCE DATE
G w (commencing with Section 7000)Of Division 3 of the Business and BLDG. ELECT. PLG. MECH.
F v,z Professions Code,and my license is in full force and effect ❑ ❑ ❑
z o,n - License Clasf�.��-��-a/--tic.Number
DyF Date 't9-l!A T.at-Contractor nob
< y E .39- y-s4-° 'r - BUILDING PERMIT
¢ ¢ 4 OWNER-BOfLDER DECLARATION
o a u - INFORMATION
XI hereby affirm that I am exempt front the ContractorREFER TO ORD
's License MISC.-
.. o 4 Law for the following reason.(Sec.7031.5,Business:md Professions VALUATION $/FT.
H - PERMIT ISSUANCE 10.00
Code:Any city or county which requires a permit to construct,alter,
¢ IS ¢ FO improve,demolish,or repair any structure,prior to its issuance,also ELEC.CONTR. LIC.NO. ELEC.
u w m u requires the Ipplicml I'or such permit to file a signed strtemcnl that TOTAL PERMITTO
he is licensed pursuant to the provisions of the Contractor's License
H z i Law(Chapter 9(commencingwith Section 7000)of Division 3 ofthe
a Business and Professions Code)or that he is exempt therefrom and QTY. PLUMBING PERMIT FEE rV10 41
E E o
¢ t- m the basis for the uor.permit
mnpubje Any violation of Sc ct ion en,thy STO IE V DNSTR.
ate_ by any more
fora permit subjects S50he 0R.licenl ton civilpnmlty ALTER-DRAIN VENT-WATER IEA.) 5.00
of not more than five hundred dollars(5500).):
❑ 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,wad the sun clore Is not
intended or offered for sale (Sec. 7044, Business and Professions DRAINS-FLOOR,ROOF,AR EA,COND. 5.00
Core: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 50.FT.FLOOR AREA TOTAL ACREAGE
. utshimself re through his own employee,,fors le.If,ud that such impnwe` /I XI
mems are not.rid,his or employee,,sale. leveglhebullrlpg GAS-EA.SYSTEM-11NC.4OUTLETS 6.00 / t
or improvement is sold within one year of completion,the ow y-will have the burden of proving that he did not build or int- GAS-EA.SYSTEM-OVER 4 (EA.) 2.00 BUILDING USE
Piave for purpose of sole.). INDUSTRIAL WASTE INTER3000 RES IND CON PB Omer
. .
❑ 1,as owner of the property,am exclusively contracting with ❑ ❑ ❑ ❑
licensed contractors to construct the project(Sec. 7044,Business LAWN SPRINKLERS- 1 INC 5 V.B. 6.00 W ASSESSORS PARCEL NO.
and Professions Code:T'he 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 con of unto licensed pu¢umtt to
the Contractor's License Law. SEWER-SAN ITARV-STORM EA.200ft/10.00 TRACT NO. PARCEL NO.
❑ I an,exempt under Sec ,B.&P.C.for this WATER HEATER W/VENT 6.00
reason
Owner Dale WATER SYSTEM 5.00 ACC.DATE ACC.FILE NO.
WORKERS'COMPENSATION DECLARATION WATER TREATING EQUIP. 5.00
1 hereby attirnt that I have a certificate of consent to self-insure,
or a certificate of Workers'Compensation Insurance,or a cerlified ZONING ENG.SITE NO.
copy thereof(Sec 3800,Lab,C/. /1
-Pal ic O.,Pj4�trCoinpany 0
Certified copy is hereby Tarnished. FIRESPRINK ENERGY T24
z 2 ❑ Certified copy is tiled with the city inspection division. MISC.- REFER TO ORD.
O Applicant Y❑ N❑ Y ❑ N❑
~ rn PERMIT ISSUANCE 10.00
Lu - CIi R'I'I PICA'I'E OP SAEION INS FROM WORKERS' FLOOD ZONE A.L.II.C.
CL > COd not be coo INSURANCE if NCE PLG.CONTR. LIC NO. PLG. Y❑ N❑ Y ❑ N❑
CL O (This dollars need not be completed if the permit is for one TOTAL
csf
U ZO hundred dollars IS n tiro pe torr
I certify that h 1 n r employ an of the work for which this sur- DTV. MECHANICAL PERMIT FEE FEE SUMMARY
0 H mit is issued,I shall not employ any person in any manneror in to
O w become subject to the Workers'Compensation Laws of California.
Date Applicant ALTER OR ADD TO MECH. 5.00 BUILDING
} US NOTICE TO APPLICANT'. If,after making this Certificate of Ex-
F 2 caption.you should become subject to the W'oikers'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 10=CF.M.) 4.00
CONSTRUCTION LENDING AGENCY AIR HANDLING UNIT(OVER 10MC.EM.) 6.00 SEISMIC FEE
I hereby affirm that there is. a construction lending agency for EXHAUST HOOD(WITH DUCT) 5.00 F �.
the performance of the work Ill which this permit is issued(Sec. MICROFILM
3097,Civ.C.). HEATING UNIT(TO 100,000 B.T.U.) 8.00 0 -�,
Lender's Name HEATING UNIT 100,000B.T.U.)9.50
Lender's Ad/dres G ELECTRIC
Yrc�li i Is
I nnati'on is cc... pp imply with
all city at and
county VENTILATION FAN (SINGLE) 4.00
• information n correct I agree to comply with all city and county PLUMBING
ordinances am state laws relating In building construction, and 130ILER-COMPI3 H.P.Or 100,0008.T.U.1 6.00
hereby authorve representatives of this city to enter upon the
above-,ormioned property I'or inspection purposesBOILER-COMP (Over 100,000 BTU(BEE FEE SCH. MECHANICAL
,
(We) agree to save, indemnify and keels harmless the City of MISC.- REFER TO ORD.
Cupertino against liabilities,judgments, costs and expenses which PERMIT ISSUANCE 10.00 CONST.TAX
may in any way accrue against said City in consequence of the
granting of this permit MECH.CONT. LIC.NO. MECH.
TOTAL TOTAL
Sigbilureof Applicant/Contractor Date J519
INSPECTOR COPY
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APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
B01 LDI NG PROJECT I DENTI.FICATION
APPLICATION & PERMIT
ELECTRICAL --PLUMBING —MECHANICAL
PERMIT NUMBER
09627BUII.O1NG
ADDRESS
7_BUILDING
3 Cyt e ,.
OWNERSNAME
eo P-ONE
QTY. ELECTRIC PERMIT FEE
PLAN CHECK VALIDATION
croR s
NAMENAME OUTLETS - SW ITCHES - R ECEP 10.0011.00
f9 %0 C O IC.NG._?5/ D-6' LIGHTING FIXTURES 10,00/1.00
CONTRACTORS
ADDRESS PPLIANCES-RESIDENTIAL 4.00
PAN ELS 10.007-9L 5 7 DATE OF APPLICATION
ARCHITECT .
ORENGINEER
LIC.NO.
PANELS LOVER 200 AMP) 20,00
PLAN CHECK FEE P.C. NO.
SIGNS TRANS. 3.00
ARCH. OR ENG.SPECIALADDRESS ClRCU1T 5.OD PERMI V ON
TIEMP. METER OR POLE INS. 20,00SEpZIP
7npO4195APPLICANT'S
ADDRESSDDSERVICE
MOTORS SEE FEE SCH.
CHANGE 20.00
city Of CIU p$ffl(!ULICENSEDCONTRACTORSDECLARATIONTEMP. POLE 30.00
I hereby affirm that 1 am licensed under provisions of Chapter 9
commencing with Section 7000) of Division 3 of the Business and
Professions C e and r yy Iic nse is in full for
License C[a G Y- -Lic. Number
Dat6d 779_ S* -Contractor
3.3- 9-3-e,x
OWNER -BUILDER DECLARATION
I hereby affirm that I am exempt from the Contractor's License
Law for the following reason. (Sec. 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 stalemenI that
he is licensed pursuant to the provisions of the Contractor's License
ISSUANCE DATE
BLDG. ELECT, PLG. C .
BUILDING PERMIT
INFORMATION
MISC. — REFER TO ORD
VALUATION FT.
PERMIT ISSUANCE ]O.OD
ELEC, CONTR. LIC. NO. ELEC.
TOTAL PERMIT 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
the basis for the, alleged exemption. Any violation of Section 7031.5 STO IES TYPE CONSTR.
by any applicant for a permit subjects the applicant to a civil penalty
of not more than five hundred dollars (S500).): ALTER -DRAIN &VENT -WATER IEA,) 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 Dec. GROUP RES. UNITS
DRAINS -FLOOR, ROOF, AR EA, COND. 5.00intendedorofferedforsale (See. 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 does such work
himself or through his own employees, provided that such improve-
ments are not intended or offered for sale. I f, however, the building
FIXTURES - PER TRAP 5.00 SOFT. FLOOR AREA TOTALACREAGE
GAS - EA. SYSTEM -1 INC, 4 OUTL ETS 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 sate.).
1, as owner of rhe property, am exclusively contracting with
licensed convactorS to construct the project (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
GAS EASYSTEM -OVER 4 LEA) 200 BUILDING USE
RE IND CON PB Ocher
ASSESSORS PARCEL NO.
INDUSTRIAL WASTE WTER, 30,00
LAWN SPRINKLERS- 1 INC 5 V.B. 6.00
LAWN SPR INKLERS - OV ER 5 (EA.) 1.00
contracts for such projects with a contractor(s) licensed pursuant to
the Contractor's License Law. SEWER -SANITARY -STORM EA, 200tt11 O.OD TRACT NO. PARCEL NO.
0 1 am exempt under Sec. B.&P.C. for this WATER HEATER WIVENT 6.00
reason
Owner Date WATER SYSTEM 5.00 ACC. DATE ACC. FILE NO.
WATER TREATING EQUIP, 5,00WORKERS'COMPENSATIONDECLARATION
I hereby affirm that I have a certificate of consent to self -insure.
or a certificate of Workers' Compensation Insu nee, ora certified
cop re ec. 3800, Lab.C.),
Polis aYY Company
ZONING ENG. SITE NO.
FIRE SPR W K
Yo No
ENERGY T-24
y N
Certified copy is hereby furnished.
Certified copy is filed with the city inspection division.,
Applicant MISC. - REFER TO ORD.
CERT1171CATE OF EXEMPTION FROM WORKERS' PERMIT ISSUANCE 10.00 FLOOD ZONE A-LU.C.
PLG, CONTR. LIC. NO,,
TOTAL
COMPENSATION INSURANCE
This section need not be completed if the permit is for one
Y [:] N V [:]N
MECHANICAL PERMIT FEE FEE SUMMARY
hundred dollars (3100) or less.)
1 certify that in the performance of the work for which this, per -QTY.
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 CHECKemplion, you should become subject to the Workers' Compensation
provisions of the Labor Code, you must forthwith comply with
such provislons or this permit shall be deemed revoked.
FEEAIRHANDLINGUNITLTO10,[100 C.F.M.) 4,00
AIR HANDLING UNIT (OVER 10AOOC.F.M.) 6.00 SEISMIC FEECONSTRUCTIONLENDINGAGENCY
I hereby affirm that there is a construction lending agency for EXHAUST HOOD (WITH DUCT) 5.00
the performance of a work for which this permit is issued (Sec.
3097, Civ.C.).
MICROFILM
yEATiNG UNIT {TO 100,000 B.T,U.) 8.00
HEATING UNIT (OVER 100,000 B.T.U.)9.50 ELECTRIC
Lender's Name
Lender'sAd res
Icertify t havered fsapplicationandstatethattheabove
information is correct. I agree to comply with all city and county
ordinances and state laws relating to building construction, and
VENTILATION FANISINGLE) 4,00
PLUMBING
BOILER-COMP(3 H.P. Or 100,000 B.T.U.) 6.00
BOILER -COMP (Over 100,000 BTU) SEE FEE SCH. MECHANICALherebyauthorizerepresentativesofthisyitytoenteruponthe
above-mentioned property for inspect ion purposes.
MISC. - REFER TO ORD.
CONST- TAX
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 PERMIT ISSUANCE 10:00
grant, of this permit. MECH. CONT, LIC, NO. MECH.
TOTAL,
5.047
TOTAL_
Sign ure of Applicant/Contractor Date
OFFICE COPY