09536 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
BU LDI NG PROJECT 1 DENTI FICATI ON PERMIT NUMBER
oaaolNG APPLICATION & PERMIT
BUILDING - ELECTRICAL-PLUMBING-MECHANICAL 9536
O PLAN CHECK VALIDATION
NAME y�S QTY. ELECTRIC PERMIT FEE
PHONE,
NAMER r Rs UTLETS-SWITCHES-RECEP 10.00/1.00
s.No. LIGHTING FIXTURES 10.00/1.00
.oNTR e R OAPPLIANCES-RESIDENTIAL 4.00
nooness
PHONE _ PANELS 10.00 DATE OF APPLICATION
AOR "I PANELS (OVER 200 AMP) 20.00 - PLAN CHECK FEE P.c.No.
ENGINEER
LIC.NO. SIGNS TRANS. 3.00
ARCH.OR ENG. SPECIALCIRCUIT 5.00 PERMIT N
APPLICANTZIP EMP.METER OR POLE INS. 20.00 AUG Z oo[
ADDRESS SSMOTORS SEE FEE SCH. 3 IaOJ
SERVICE CHANGE 20.00
woo LICENSED CONTRACTORS DGCLARA'TION TEMP.POLE 30.00 .city Ot Cupertino
a v I hereby affirm that I am licensed under provisions of Chapter 9 ISSUANCE DATE
as i (commencin with Section 7000)of Division 3 of the Business and
a g w BLDG. ELECT. PL MECH.
H m i Professions Code.and m license is in f all fort•and eff
z o w - License .las Lie.Number / ,�"_�
oz -
Date Contractor
a Y f BUILDING P RMIT
o n D OWNER-BUILDIiR DECLARATION INFORM ION
F
0 a- r I hereby affirm that I ant exempt from the Contractor's License MISC.- REFER TO ORD
u_ o¢ Law for the following reason.(Sec.7031.5,Business and Professions PERMIT ISSUANCE 10.00 VALUATION $/FT.
vi Code:Any city or county which reyuiresa permit to wnMruct,alter,
rtQ ¢ p improve,demolish,or repair any structure,prior to its iss,mi also ELEC.CONTR. LIC.NO. ELEC.
- DLL
w requires the applicant for such permit to file a signed statement that TOTAL PE MI TO
a w m he is licensed pursuant to the provisions of the Contractor,s License
Hz >
Law(Chapte,9(commencing with Section 7000)of Division 3 of the
a Business and Professions Code)or that he is exempt therefrom and oTV. PLUMBING PERMIT FEE
¢ r o the basis for the alleged exemption.Any violation of Section 7031.$ 1 STORE TYPE ONSTR.
aim by any applicant for a permit suhjectslhe applicant lou civil penally ALTER-DRAIN& VENT-WATER (EA.) $.00
nl'not more than five hundred dollars(5500).1:
❑ I,as owner of the property,or my eniployecs with wages as BACK FLOW PROTECT. DEVICE 4.00 OCC.GROUP RES.UNITS
their sole compensation,will do the work,and the st rattan is not
intended or offered for safe (Sec. 7044, Business and Po lcssimis DRAINS-FLOOR,ROOF,AREA,COND. 5.00
Code:9'he Contractor's License Law does not apply Ia an owner of
property who builds or nlproves thereon,and who does such work FIXTURES-PER TRAP 5.00 rno So,FT.FLOOR AREA TOTAL ACREAGE
• himself or through his own employees,provided tial such improve-
mends are not intended roffered l'or sale.If,however,the building GAS-EA.SYSTEM-1 INC.4 OUTLETS 6.00 Qp
or improvement is rola within one yen,of completion, theowner- GAS-EA.SYSTEM-OVER 4(EA.) 2.00
builder will have the burden of proving That he did not build or int- BUILDING USE
RES IND CON PB Other
Prove for purpose of if,,J. INDUSTRIAL WASTE INTER. 30.00
❑ d as ownm of the property,ani exclusively e 7044. ins wish
licensed contractors to construct the project La 7044.Business LAWN SPRINKLERS-1 INC 5 V.B. 6.00 ASSESSORS PARCEL N0.
and Professions property Contractor's License Law does not apply
to tr owner of property who builds tr improvesensed p.and who LAWN SPRINKLERS-OVER 5(EA.) 1.00
contracts for such projects with a contruauil sl licensed pursuant to SEWER-SANITARY-STORM EA.200ft/10.00
IIIC GOntraet0!s License Law. CO TRACT NO. PARCEL NO.
❑ I um exempt under Sec. ,B.&P.C.for Diif WATER HEATER W/VENT 6.00
reason
Owner Date WATER SYSTEM 5.00 00
ACC.DATE ACC.FILE N0.
WORK ERS'COMPENSATION DECLARATION WATER TREATING EQUIP. 5.00
1 hereby affirm that 1 have a certificate of consent to self-insure. ZONING ENG.SITE N0.
or a certificate of Workers'Compensation Insurance,or a certified
copy thercof(Sec.3800,Lab.C.),
Policy No. Company
0 ❑ Certified copy is hereby furnished. FIRE SPRINK ENERGY T.24
z Z Certified opy is fled with the city inspection division.
FO Apicartt_K/tel•» ,n ;i MISC.- REFER TO ORD. Y0 N❑ Y0 N�
� N CERTIFICATEOF EXEMPTION FROM WORKERS' PERMIT ISSUANCE 10.00 OU FLOOD ZONE A.L.U.C.
Luh COMPENSATION INSURANCE PLG.CONTE. LIC NO. PLG. o(J Y J Np Y [3 NEI
CL Z (This section need not be completed if Ore permit is for one TOTAL
hundred dollars(S100)or less.)
U O I certify that in the performance of the work for which this per- OTV. MECHANICAL PERMIT FEE FEE SUMMARY
LL 1- mit is issued,I shall not employ any person in any manner so as to
Ow become subject to the Workers'Compensation Laws of California. BUILDING
a
Date-Applicant ALTER OR ADD TO MECH. 5.00
>_ to NOTICE 10 APPLICANT': If,after making this Certificate of Ex-
F ? 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
CJ such provisions or this permit shall be deemed revoked. AIR HANDLING UNIT(TO 10,000QF.M.) 4.00
CONSTRUCTION LENDING AGENCY AIRHANDLING UNIT(OVER 10=0OF.M.) 6.00 SEISMIC FEE
1 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
Lenders Nurse EATING LIN ET
(OVER 100,000 B.T.U.)9.50
Lender's Name HINELECTRIC
I certify that I have read this application and state That the above VENTILATION FAN (SINGLE) 4.00
information is correct. I agree to comply with all city and county PLUMBING UU
ordinances and state 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 BOILER-COMP (Over 100,000 BTU)SEE FEE SCH. MECHANICAL
above-mentioned property for inspection purposes.
(We) agree to save, indenmify and keep harmless the City of MISC.- REFER TO ORD.
Cupertino against liabilities,judgments, costs om expenses which PERMIT ISSUANCE 10.00 CONST.TAX
"my 'n any ay accrue ugai nsl said City in consequence of the
gra ft 'permit. MECH.CONT. LIC.NO. MECH.
((J� /e L�/ )1k TOTAL TOTAL
5 u Applicant ntmctor I aid
INSPECTOR COPY
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APPLICANT TO FILL. IN INFORMATION WITHIN RED LINES — USE BIL POINT PEN ONLY
BUI LDI NG PROJECT I DENTI FICATION
APPLICATION &PERMIT
BUILDING — ELECTRICAL— PLUMBING — MECHANICAL
PERMIT NUMBER
9536sOILOINGADDRESS
OWNER'S-
NAME
PHONE
QTY. ELECTRIC PERMIT FEE
PLAN CHECK VALIDATION
ONTRACYOR'S
NAME OUTLETS -SWITCHES - RECEP 10.0011,00
LIGHTING FIXTURES 10.0011.00Nfl,
CONTRA Ton•
ADESS APPLIANCES- RESIDENTIAL 4,00
PANELS 10.00PHONE DATE OF APPLICATION
ARCHITECT-
ORENGINEER
uc.No.
PANELS (OVER 200 AMP) 20,00
PLAN CHECK FEE P.C. NO.
SIGNS TRANS. 3.00
ADDRESS ENG. SPECIAL CIRCUIT 5.00 PEE}d I V QATION
f"
7 1,,
EMP. METER OR POLE INS. 20.00Zip
AUG 2 U'9$
APPLICANT'S
ADDRESS
MOTORS SEE FEE SCH.
SERVICE CHANGE 20,00
C city of CupertinoLICENSEDCONTRACTORSDECLARATIONTEMP. POLE 30,00
I hereby affirm that I am licensed under provisions of Chapter 9
commencing with Section 7000) or Division 3 of the Business and
ProfessionsAo%and y license is in Full Forq f
License Lic. Number/ t
Date Contractor
ISSUANCE DATE
BLDG.
I
ELECT. P MECH.
BUILDINGERMIT
OWNER -BUILDER DECLARATION
1 hereby affirm that 1 am exempt from the Contractor's License
Law for the following reason. (Sec. 7031.5, Businessand 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 a signed statement that
he is licensed pursuant to the provisions of the Contractor's License
Law (Chapter 9 (commencing with Section 7000) ofDivision 3 of the
Business and Professions Code) or that he is exempt therefrom and
INFORM TION
MISC. — REFER TO ORD
VALUATION SIFT.
I4
PERMIT ISSUANCE 10.00
ELEC. CONTR. LIC. NO, ELEC.
TOTAL
TOi
CITY. PLUMBING PERMIT FEE
STORI T PE ONSTR. the basis for the alleged exemption. Any violation of Section 7031.5
by any applicant for a permit subjects the applicant to acivil penalty
of not more than five hundred dollars (3500).):
ALTER -DRAIN -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 OCC. GROUP RES. UNITS
DRAINS -FLOOR, ROOF, AREA,COND. 5,00intendedorofferedforsale (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 docs such work FIXTUR ES -.PER TRAP 5.00 SO FY. FLOOR AREA TOTAL ACREAGE
himself or through his own employees, provided that such improve -
meats are not intended or offered for sale. If, however, the building
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 eontracting with
GAS - EA. SYSTEM -OVER 4 (EA.) 2,00 BUILDING USE
RES IND CON PB Other
INDUSTRIAL WASTE INTER. 30.00
LAWN SPRINKLERS- 1 ,INC 5 V.B. 6,00 ASSESSORS PARCELNO. licensed contractors 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 LAWN SPR INKLERS - OVER 5 (EA.) 1,00
contracts forsuch projects with a contractor(s) licensed pursuant to
the Contractor's License Law. SEWER -SANITARY -STORM EA. 200ft/1 D.00 C70Q TRACT NO. PARCEL NO.
lam exempt under Sec. B.&P.C. for this WATER HEATER WIVENT 6.00 L
reason
Owner Date WATER SYSTEM 5.00 ACC. DATE ACC. FILE NO.
WATER TREATING EQUIP. 5,00WORKERS'COMPENSATIONDECLARATION
1 hereby affirm that 1 have a certificate of consent to self -insure,
or a certificate of Workers' Compensation Insurance, or a certified
ZONING ENG. SITE NO.
copy thereof (Sec. 3600, Lab.C.).
Policy No. Company
FIRE SPRINK
Y E] N
ENERGY T-24
Y [:] NE]
Certified copy is hereby furnished.
Certifie¢ is filed with the city inspection division.
cant I1i'. C40n Is MISC. - REFER TO ORD.APP
CERTIFICATE OF EXEMPTION FROM WORKERS'
PERMIT ISSUANCE 10.00 G FLOOD ZONE A.L.U,C.
PLG. CONTR. LIC. NO. PLG. Q
TOTAL
COMPENSATION INSURANCE
This sectlon need not be completed if the permit is for one
Y N Y N
ITY, MECHANICAL PERMIT FEE FEESUMMARY
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.
FEE
AIR HANDLING UNIT ITO 10]J:IOC.F.M.) 4,00
AIR HANDLING UNIT (OVER 10=CF,M.) 6.00 SEISMIC FEECONSTRUCTIONLENDINGAGENCY
I hereby affirm that there is a construction lending agency for
the
3097 Cv }
rice of the work for which this permit is issued (Sec.
EXHAUST HOOD (WITH DUCT) 5.00
MICROFILM
HEATING UNIT (TO 100,000 B.T.U.) 8.00
HEATING UNIT (OVER 100,000B.T.U.)9.50 ELECTRIC
Lender'sA
Lender's Address
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 slate laws relating to building construction, and
VENTILATION FAN (SINGLE) 4.00
PLUMBING97
d
BOILER COMP (3 H,P.Or 100,000 B.T.U.) 6.00
BOILER -COMP lover 100,000 BTU) SEE FEESCH. hereby authorize representatives of this city to triter upon the
above-mentioned property for inspection purposes.
MECHANICAL
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 ay accrue against sai City in consequence of the
gran ' of permit.
TAX.
PERMIT ISSUANCE 10.00
MECH, CONT, LIC. NO. MECH.
TO TOTAL.
tUre of Applicant/Contractor Date
OFFICE COPY