09528 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
BU LDI NG PROJECT I DENTI FICATI ON PERMIT NUMBER
ADDRESS O ��
UI LDIN APPLICATION & PERMIT
BUILDING - ELECTRICAL-PLUMBING-MECHANICAL
ERS PLAN CHECK VALIDATION
NAE y/ QTY. ELECTRIC PERMIT FEE
.ONESI_I 9./l
CNTRNAME " s UTLETS-SWITCHES-RECEP 10.00/1.00
IS No. 70
LIGHTING FIXTURES 10.00/1.00
NIRA roar
ADDRESS PPLIANCES-RESIDENTIAL 4.00
( '� PHONE PANELS 10.00 DATE OF APPLICATION
ogcHlrE PANELS (OVER 200 AMP) 20.00 PLAN CHECK FEE P.C.No.
ENGINEER I
LIC.No, SIGNS TRANS. 3.00
` nooses ENG. SPECIAL CIRCUIT 5,00 PERMIT VAL
zlv EMP.METER OR POLE INS. 20.00 AUGqq eB
APPLICANT MOTORS SEE FEE SCH. NG 4 4� 19p5
AOOR EA
SERVICE CHANGE 20.00
woo LICENSED CONTRACTORS DECLARATION TEMP,POLE 30.00 City of Cupertino
aZ w 1 hereby affirm that 1 at,licensed under provisions of Chapter 9 ISSUANCE DATE
y a H (commencing with Section 7000)of Division 3 of the Business and BLDG. ELECT. PL MECH.
h z Professions Cod//err,and try license is in full force a d effec. ❑ ❑ ❑
oi!-n o License Clalyy� Lie Number
H y H w Date {ffY/� Contractor
a a s BUILDING PERMIT
¢ ¢ a OWNER-BUILDER DECLARATION
a o oU INFORMATION
w ; LL w I hereby affirm that I am exempt from lire Contractor's License MISC.- REFER TO ORD
LL O a Law for the following reason.(Sec.7031.5,Business and Professions VALUATION $/FT.
H _ < PERMIT ISSUANCE 10.00
4w E Code:Any city or county which requiresa permit toconstrcLalteq
¢ ¢ ¢ O improve,der....sir,or repair any structure,prior to its issuance,also ELEC.CONTR. LIG.NO. ELEC.
K c¢ requires the applicant fur such permit to file a signed statement that TOTAL PERMIT TO
n w m m he is licensed pursuant to the provisions of the Contractor's License
Hzr Law(Chapter 9(Commencing with Section 7000)of Division 3 Print,
i o Business and Professions Code)or that he is exempt therefrom and QTY. PLUMBING PERMIT FEE
¢ H Cr the basis for the alleged exemption.Any violation of Section 7031.5 STORIES VPE CONSTR.
c ; `0 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).1:
O 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,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.Fr.FLooR AREA TOTAL ACREAGE
himself re through his own employees,provided that such improve. QC7
marts aro not intended moRerel for sola If.howcveq the building GAS-EA.SYSTEM-11NC.4OUTLETS 6.00
nr improvement is sold within one year of completion, the Owner- GAS-EA.SYSTEM-OVER 4 (EA.) 2.00
builder will have'the burden of proving that he did not build or im- BUILDING USE
prove for purpose the
IND CON PB Other
of seJ'
❑ 1,as owner of the property,em exclusively contracting with INDUSTRIAL WASTE INTER. 30.00
licensed contractors to construct the project(Sec. 7044,Ilusines LAWN SPRINKLERS- 1 INC 5 V.B- 6.00 N ASSESSORS PARCEL NO.
and Professions Code:'flue 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 Por SOch prejectswrh a conlractorts)licensed pursuant t0 SEWER-SANITARY-STORM EA.200f[/10.00 00
the Contractors License Law. TRACT NO. PARCEL NO.
❑ 1 incxemptundefir Sec. ,B.&P.C.for this WATER HEATERW/VENT 6.00 Ov
reason
Owner Date WATER SYSTEM 5.00 -(.0 ACC.DATE ACC.FILE NO.
WORAERS'COMPENSATION DECLARATION WATER TREATING EQUIP. 5.00
I hereby affirm that I have a certificate of consent to scIpin, m ZONING ENG.SITE N0.
or a certificate of Workers'Compensation Insurance,or a certified
copy thereof(Sec.3800,LaIrC.).
Policy No. Company
0 ❑ Certified copy is hereby furnished. FIRE SPRINK ENERGY T-24
z Z m@ Cerific -copy is filed ith the city inspection division.
F p Al+{Aicant����,e� tc MISC.- REFER TO ORD. Y ❑ N Y ❑ NC]
CC m CER'I'1171CA'I'I;OF EXEMPTION FROM WORKERSPERMIT ISSUANCE 10.00 00 FLOOD ZONE A.L.U.C.
W > COMPENSATION INSURANCE PLG.CONTR. UC.NO. PLG. W � �
Z 1'fhis vection need not be completed if the permit is for one TOTAL Y NY N
hundred dollars IS 100)or less.)
C) O 1 certify that in the performance of the work for which this per OTY. MECHANICAL PERMIT FEE FEE SUMMARY
LL F not is issued, I shall not employ any person in any renter so as to
0 w become subject to lira Workers'Compensation Laws of California.
y Date Applicant BUILDING
} m NOTICE TO APPLICANT: If,after making this Certificate of Ex- ALTER OR ADD TO MECH. 5.00
H Z enlption,you should become subject to the Workers'Compensation APPLIANCE 5.00 PLAN CHECK
provisions of the Labor Code, you most forthwith comply with FEE
U such provisions or this permit shall be deemed revoked. AIR HANDLING UNIT(TO 10MC.F.M.) 4.00
CONSTRUCTION LENDING AGENCY AIR HANDLING UNIT(OVER 10=C.EM.) 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 i,csued(Sec. MICROFILM
3097,Civ C.) HEATING UNIT(TO 100,000 B.T.U.) 8.00
Lender's Name H EATI NG O N IT(OVER 100,000 B.T.U.)9.50
Lender's Address ELECTRIC
I certify her I have read this application and state the the shove VENTILATION FAN (SINGLE) 4.00
• Ornmtion is correct. I agree to comply with all city and county PLUMBING �U
ordinances and state laws relating to building construction. and BOILER-COM P(3 H.P.or100,000B.T.U.) 6.00
hereby authorize representatives OI 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, indemnify and keep It nordess the City of MISC.- REFER TO ORD.
Cupertino against,liabilities,judgments, costs and expenses which CONST.TAX
may inanya accrue against Arid City in consequence of the PERMIT ISSUANCE 10.00
gra Nj{rgol his mit. MECH.CONT. LIC NO, MECH.
TOTAL TOTAL
Sit, ; ryt c con a for '
INSPECTOR COPY
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APQLICANT TO FILL IN INFORMATION WITHIN RED LINES -USE BALL POINT PEN ONLY
BUILDING PROJECT IDENTIFICATION
APPLICATION & PERMIT
BUILDING - ELECTRICAL- PLUMBING - MECHANICAL
PERMIT NUMBER
09528RUILOME; E5
OWNER'S _
Na E
Ll P
QTY. ELECTRIC PERMIT FEE
PLAN CHECK VALIDATION
PHONE+ /
ONTRACTO 'S
NAME OUTLETS -SWITCHES -RECEP 10,001,00
LIGHTING FIXTURES 10,0011.00O,
CONTRACTOR'S
ADDRESS
PPLIANCES- RESIDENTIAL 4.00
PANELS 10.00PHONE DATE OF APPLICATION
ARCHITECT
OR
ENGINEER
61C. NO.
PANELS (OVER 200 AMP) 20.00
PLAN CHECK FEE P.C. NO.
SIGNS TRANS, 3,00
ADDRESS E"G' SPECIAL CIRCUIT 5.00 PERn}`IyPT1oN
EMP. METER OR POLE INS. 20,00ZIP
AUG``
AA1 i(JJ
A.r231985APPLICANT'S
ADDRESS
MOTORS SEE FEE SCH.
SERVICE CHANGE 20.00
fi
V
City Of CupeitfAOLICENSEDCONTRACTORSDECLARATIONTEMP. POLE' 30.00
I hereby affirm that 1 am licensed under, provisions of Chapter 9
commencing with Section 7000) of Division 3 of the Businessand
Professions Ca ,and my icense is in full force anrJ eifeq(.QLicenseLic. Number flCtl Cn[1C[aNumber-
ISSUANCE DATE
SLOG. ELECT.
El
PL MECH.
Dale COntraCtar
BUILDING PON "MIT
INFORMA IOWNER -BUILDER DECLARATION
1 hereby affirm that [ 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
MISC, -' REFER TO ORD
VALUATION SIFT.
PERMIT ISSUANCE 10.00
ELEC. CONTR. LIC- NO. ELM
TOTAL P RMIT TO
QTY. PLUMBING PERMIT FEE
Law (Chapter 9 (commencing with Section 7000) ofDivision 3 o€the
Business and Professions Code) Or that he is exempt therefrom and
STO IES 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
BACK FLOW PROTECT. DEVICE 4,00 OCC. GROUP RES. UNITS
DRAINS -FLOOR, ROOF, AREACOND. 5.00intendedorofferedforsale (Sec. 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. If, however, the building
FIXTURES -PER TRAP 5.
00Kr Sd 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 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 6utlotNG USE
NO CON PB Other
INDUSTRIALWASTEINTER. 30.00
LAWN SPRINKLERS- 1 INC 5 V.B. 6.00licensedcontractorstoconstructtheproject (Sec. 7044, Business
and Professions Cade: The Contractor's License Law does not apply
town Owner of property who builds or improves thereon, and who
ASSESSORS PARCEL NO.
LAWN SPR INKLERS - OVER 5 (EA,) 1.00
contracts for such projects with a contractors) licensed pursuant to
the Conlractor's License Law, SEW ER -SAN ITARY-STORM EA. 200ftl10.00 TRACT NO. PARCEL NO,
1 am 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.
WORKERS'COMPENSATION DECLARATION WATER TREATING EQUIP. 5.00
1 hereby affirm' that 1 have a certificate of consent to self -insure,
or a certificate of Workcrs' Compensation Insurance, or a certified ZONING ENG. SITE NO.
copy thereof (Sec. 3800. Lab.C.).
Policy No. Company
FIRE SPRINK
Y El
ENERGY T-24
Y [:]N[]
Certified copy is hereby furnished.
tr fi le v i3h the city inspection division, fr ,copy is' Ap cantMISC,
1 11CERTIFICATE
REFER TO ORD.
OF EXEMPTION FROM WORKERS' PERMIT ISSUANCE 10,00 FLOOD ZONE A.L.U.C,
PLG. CONTR. tic. ND. PLG, co
TOTAL
COMPENSATION INSURANCE
This section need not be completed if the permit is for one
Y [:] N Y N
QTY. MECHANICAL PERMIT FEE YFEESUMMARY
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 parson 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 forlhtvith comply with
such provisions or this permit shall be deemed revoked.
FEE
AIR HANDLING UNIT (TO IOPMCF.M.) 4,00
AIR HANDLING UNIT(OVERIO,000C.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 the work for which this permit is issued (Sec.
3097, Civ,C.).
MICROFILM
HEATING UNIT (TO 100,000 B.T.U.) 8.00
HEATING UNIT (OVER 100,000 B.T.U.)9.50 ELECTRIC
Lender's Name
Lender's Address
I 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 state laws relating to building construction, and
VENTILATION FAN (SINGLE) 4.00
PLUMBING O
BOILER- COMP(3 H,P-or 100,0008.T.U.} 6.00
BOJ LER-COMP'(Over 100,000 BTU) SEE FEE SCH, MECHANICALherebyauthorizerepresentativesofthiscitytoenteruponthe
abavc-mentioned property for Inspection purposes.
M15C. - 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 wa accrue against said City in consequence of the
gra o is rmit.
CONST. TAX
PERMIT ISSUANCE iO,OD
MECH. CONT. LIC.ND. MECH.
TOTAL
TOTAL
Si o plicant Con actor ate'
OFFICE COPY