09618 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
BUILDING PROJECT IDENTIFICATION PERMIT NUMBERAPPLICATION & PERMIT
BD'L°'"° 09618
ADOR115
A � �L _Y BUILDING-ELECTRICAL-PLUMBING -MECHANICAL
OWNER'S PLAN CHECK VALIDATION
"AME /J CITY. ELECTRIC PERMIT FEE
PRONECONT
NAAMERADTDRs OUTLETS-SWITCHES-RECEP 10.00/1.00
/,R's LIC.NO. T LIGHTING FIXTURES 10.00/1.00
ADDRESS DDAPPLIANCES-RESIDENTIAL 4.00
ADDRESS
.1 /`� ,,,pyorvET p o PANELS 10.00 DATE OF APPLICATION
ARCHITECT // / 7L.1�•fp• PANELS (OVER 200 AMP) 20.00 PLAN CHECK FEE P.C.NO.
OR �i
ENGINEER
uc.No. SIGNS TRANS. 3.00
ADDRRESS ENG, PERMIT CIRCUIT 5.00 FERMI ON
ZIP EMP.METER OR POLE INS. 20.00 SEP U 41955
ADDRESSTs / MOTORS / SEE FEE SCH.
.z, I/,.-� SERVICE CHANGE 20.00 City Of Cupertino
0 0 Z.
LICENSED CONTRACTORS DECLARATION TEMP.POLE 30.00
a u 1 hereby affi.e that I am licensed under provisions of Chapter 9 ISSUANCE DATE
w w (c
H ommencing with Section 7000)of Division 3 of the Business and
¢ BLDG. ELECT. PLG.Professions C
F w z Professions Code,and my license is in full force and effect. ❑ ❑ ❑
o i m w License Claxx/Z�,L jC as-Lic.Number - D
r Datz4 -/n_�v-•v�.a-Contractor n / /
a x rr-33 9-g 8�.{ --T_ BUILDING PERMIT
n' o a o OwNtiR-BU 171:RIECLSRATION INFORMATION
F
g N I hereby affirm that 1 am exempt from the Contractor's License MISC.- REFER TO ORD
LL o¢ Law for the following reason.(Sec.7031.5,Business and Professions VALUATION B/FT.
_ u, PERMIT ISSUANCE 10.00 \I
Code:Any city or county which requires permit to construct,Ater,
rt 2 ¢ p improve,demolish,or repair any structure prior to its issuance,also ELEC.CONTR. LIC.NO. ELEC.
LL requires the applicant for such permit to file a signed statement that TOTAL P MIT TO
a w m m he is licensed pursuant to the provisions of the Contractors License
Hz > Law.(Chapter 9(commencing with Section 7000)of Division 3 ofte
h
¢ Business and Professions Code)or that he is exempt therefrom andDTV. PLUMBING PERMIT FEE '
¢ r m the basis for the alleged exemption.Any violation of Section 7031.5 BTO I S TYPE CONSTR.
a _ by any applicant for a permit subjects the applicant Ica civil penalty ALTER-DRAIN -WATER (EA.) 5.00
of not more than five hundred dollars($500).1:
❑ 1•as owner of the property,or my employees with wages as BACK FLOW PROTECT. DEVICE 4.00 OCC.CROUP RES.UNITS
their sole compensation,will do the work,and the structure is not
intended or offered for sale (Sec: 7044, Business and Professions 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 does such work FIXTURES-PER TRAP 5.00 So.FT.FLOOR AREA TOTAL ACREAGE
• himself or through his own employees,provided that such iniprove'
C en us are not intended or offered for sale.It,howeveq the building GAS-EA.SYSTEM-I INC.4 OUTLETS 6.00
or improvement is sold within one year of completion,the owner- GAS-EA.SYSTEM-OVER 4 IEA.) 2.00 BUILDING USE
builder will have the burden of proving that he did not build or iln- RES IND CON PB OtM1er
prove for purpose of sale.). INDUSTRIAL WASTE INTER. 30.00
❑ 1,as owner of the property,am exclusively contracting with ❑ ❑ ❑ ❑
licensed contractors In construct the project(Sec.7044,Business LAWN SPRINKLERS-1 INC 5 V.B. 6.00 ASSESSORS PARCEL N0.
and Professions Code: I'lie Contractor's License Law dues 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 cimtG,IoG,)licensed pursuant to
the Contractor's Lice...C Law. SEWER-SANITARY-STORM EA.200ft/10.00 '✓ TRACT NO. PARCEL NO.
❑ I:un exempt under Sec. ,B.&P.C.for tbix WATER HEATER W/VENT 6.00 ',
reason
Owner Dale WATER SYSTEM 5.00 ACC.DATE ACC.FILE NO.
WORKP.RS'COMPENSA'1ICON UGCLARA'IION WATER TREATING EQUIP. 5.00
I hereby affirm Thal I haven certificule of cun,vent IIIscl Ginsure,
or a certificate of Warkcrs'Compensation Insurunca,or a cetlilicd ZONING ENG.SITE NO.
copy thereof(Sec.3800,Lab C.)
Policy OA2,Ayq�Qonhpany
0 Certified Copy is hereby furnished.
FIRE SPRINK ENERGY T 2
Z Z ❑ Certified ropy is tiled with the city inspection division. MISC.- REFER TO ORD.
O Applicanty❑ ry❑ y ❑ N❑
~ PERMIT ISSUANCE 10.00
M CERI'1I'ICEE EXEMPTION FROM WORKERS' PERMIT ZONE A.L.U.C.
W > COMPIiNSA'I'ION INSURANCE PLG.CONTR. LIG NO. vLG.
CL Z CL 0 (This section need not be Completed if the pi:nnil is lo, one TOTAL y❑ N❑ y ❑ NE]
hundred dollars(S)OO)or Icss.l
0 O I certify that in the performance of the work for which this per. CITY. MECHANICAL PERMIT FEE FEE SUMMARY
I W mit is issued,I shall not employ any person in any e,amerso as m
become subject to the Workers'Conprensution Laws of California.
0 a Date Applicant ALTER OR ADD TO MECH. 5.00 BUILDING
} w NOTICE TO APPLICANT: If,after making this Certificate ul'E.-
Z emption,you should become subject to the Workers'Compensation APPLIANCE 5.00 PLAN CHECK
provisions of IIIc Labor Code, you most forthwith comply will FEE
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 10=C.F.M.) 6.00 SEISMIC FEE
I 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), HEATING UNIT(TO 100,000 B.T.U.) 8.00
Lender's Name HEATING UNIT(OVER 100,000B.T.U.16.50 ELECTRIC
Lender's Name Q�f /�..N�' l
I certify thAidve RLt[hl4IAeLtion and state that the above VENTILATION FAN (SINGLE) 4.00
nn
• information n correct I agree Ii comply with all City and county PLUMBING
ordinances ori state laws relating to building construction, and BOILER-COME(3 H.P.Or 100,000 B.T.U.) 6.00
hereby enthorim representatives ec This city to ewer upon the 601 LER-COMP (Over 100,000 BTU)SEE FEE SCH. MECHANICAL
abovrmentioned properly for inspection purposes.
(We) agree to save, indemnify and keep harmless the City of MISC.- REFER TO ORD.
Cupertino against liabilities,judgments, costs and expenses which CONST.TAX
A
in any wayacerae against said City in consequence of the PERMIT ISSUANCE 10.00 /n 00
gramingoi- his permit. MECH.CONT. LIC.NO. MECH.
I-Pi
TOTAL TOTAL
igdelure o'Applicant/Contractor ate - -
INSPECTOR COPY
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APPLICANT TO FILL IN INFORMATION WITHIN RED LINES -- USE BALL POINT PEN ONLY
BbILDING
PERMITNUMBERPROJECTIDENTIFICATION
APPLICATION &PERMIT
BUILDING - ELECTRICAL- PLUMBING - MECHANICAL 09618BUILDINGADDRESS
OwNER'S
NAME
4• y PHONE
QTY. ELECTRIC PERMIT FEE
PLAN CHECK VALIDATION
CONTRACTOR'S
NAME UTLETS-SWITCHES-RECEP 10.00/1,00
LIGHTING FIXTURES 10.00/1.00puc.NO Q,'
CONTRACTOR'S -
ADDRESS APPLIANCES- RESIDENTIAL 4.00
PANELS 10.00J7 -- Q- + NE .jL/ 7 DATE OF APPLICATION
ARCHITECT ..Q
OR
ENGINEER
LIC. NO.
PANELS (OVER 200 AMP) 20.00 PLAN CHECK FEE P,C.NO.
SIGNSTRANS. 3.00
ADDR, Ss ENG, SPECIAL CIRCUIT 5.00 PERMIT M'AWN
r L
EMP, METER OR POLE INS. 20,00ZIP
SEP4 9(]p[
City of CuAerfino
APPLICANT'SADDRESS
374 9
MOTORS SEE FEE SCH.
ISERVICE CHANGE 20.00
LICENSED CONTRACTORS DECLARATION TEMP. POLE 30.00
hereby affirm that I am licensed under provisions of Chapter 9
commencing with Section 7000) of Division 3 of the Business and
Professions C9nd m_y j cense is in full fore and eff ct.3LiceSeCIIS -Lic. Number
Dat26 '}O y.•a-Cogtrastor
OWNER -BUILDER DECLARATION
hercby affirm that 7 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 statement that
he is licensed pursuant to the provisions of the Contractor's License
ISSUANCE DATE
BLDG.
I
ELECT. PLG. C
BUILDING PERMIT
INFORMATION
MISC. - REFER TO ORD
PERMIT ISSUANCE 10.00
VALUATION SIFT.
ELEC. CONTR. LIC. NO. ELEC.
TOTALMIT TO
QTY. PLUMBING PERMIT FEE '
Law (Chapter 9 (commencing with Section 7000) of Division 3 of the
Business and Professions Cade) or that he is exempt therefrom and
the basis for the alleged exemption. Any violation of Section 7031.5 STMITES TYPE CONSTR.
by any applicant for a permit subjects the applicant to a civil penalty
of not more than Five hundred dollars (5500).): ALTER -DRAIN 8t 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
intended or offered for sale (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 does such work
himself or through his own employees, provided that such improve-
ments are not intended or offered for sale. If, however, the building
DRAINS -FLOOR, ROOF, AREA COND. 5,00
FIXTURES - PER TRAP 5.00 SO. FT, FLOOR AREA TOTAL ACREAGE
GAS - EA, SYSTEM -1 INC.4 OUTLETS 6.00
or improvement is sold within one year of completion, the owner-
builder will have The burden of proving that lie did not build or int
proveforpurposeofsale.).
1, as owner of the property, am exclusively contracting with
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
GAS EA. SYSTEM OVER 4 {EA,) 2.00 BUILDING USE
NO CON PB Ocher
ASSESSORS PARCEL NO.
INDUSTRIALWASTE INTER. 30.00
LAWN SPRINKLERS - 1 INC 5 V.B. 6,00
LAWN SPRINKLERS - OVER 5 (EA.) 1,00
contracts for such projects with a contractor(s) licensed pursuant to
the Contractor's License Law. SEWER-SANITARYSTORM EA, 200fill0.00 TRACT NO. PARCEL NO.
El I am exempt under Sec. B.&P.C, for this
reason
WATER HEATER W/VENT 6.00
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 lnsu ce, or a certified
copy th re (Se .3800, Lab.C.);
Polic 0.ompany
ZONING ENG. SITE NO.
FIRE SPR INK
Y N
ENERGY T.24
Y N
MO Certified copy is hereby furnished.
Certified copy is filed with the city inspection division.
Applicant M1SC, - 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 (S 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 ,Workeri Compensation Laws of California.
Date Applicant
NOTICE TO APPLICANT: If, after making this Certificate of Ex-
ALTER OR ADD TO MECH. 5,00
JAPPLIANCE 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 10,000 C.F.M.) 4.00
AIR HANDLING UNIT (OVER I0=QF,M.) 6.00 SEISMIC FEECONSTRUCTIONLENDINGAGENCY
I hereby affirm that there is a,construction lending agency for EXHAUST HOOD (WITH DUCT) 5.00 .rO O
the performance of the work for which this permit is issued (Sec.
3097, Civ.C.)_
MICROFILM
HEATING UNIT {TO 100,000 B.T,U.} 8.00f 8.00
HEATING UNIT (OVER 100,000 B.T.U.) 9,5Q ELECTRIC
Lender's Name
Lender'sAddre O • //do
1 certify that ave read tltis'oapplication and slate that the above VENTILATION FAN (SINGLE) 4,00 X'DD
information is correct. I agree to comply with all city and county
ordinances and state laws relating to building construction, and
PLUMBING
BOILER OOMP (3 H.P. or 100,00D B.T.U.} $.00
BOILER -COMP IOver 100,000 BTW SEE FEE SCH. MECHANICALherebyauthorizerepresentativesofthiscitytoenteruponthe
above-mentioned property for inspection purposes.
MISC. - REFER TO ORD. We) agree ED 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
granti of this permit.
7
CONST. TAX
PERMIT ISSUANCE 10.00 !b• 00
MEONT. LIC. NO, CH. C T MECH.
TOTAL/ O C TOTAL
Signa pplican[1Contractor Date
OFFICE COPY