09610 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
BU LDI NG PROJECT I DENTI FICATI ON PERMIT NUMBER
D
ADRESSILDIN APPLICATION & PERMIT 69610
nAy BUILDING-ELECTRICAL-PLUMBING-MECHANICAL
OWNER'S � ^ PLAN CHECK VALIDATION
NAME
QTY. ELECTRIC PERMIT FEE
/- PHONE _t` 7/-/y.F
NoMERacroRs UTLETS-SWITCHES-RECEP 10.00/1.00
i) - uc.rvo. LIGHTING FIXTURES 10.00/1.00
RRA
ADDcioR's
ADDRESS PPLIANCES-RESIDENTIAL 4.00
C
q I �, PHOrve% � , PANELS 10,00 DATE OF APPLICATION
RCHRECi / G yA 5-3,9 PANELS (OVER 200 AMP) 20,00 PLAN CHECK FEE P.C.NO.
OR U f L4/
ENGINEER
LIC No, SIGNS TRANS. 3.00
ADDRESS ErvO' SPECIAL CIRCUIT 5.00 PERMIT VALIDATION
ZIP EMP.METER OR POLE INS. 20.00 PAID
APPLICANT MOTORS SEE FEE SCH.
ADDREpoor SSS '
/•////e _ SERVICE CHANGE 20.00 SEP 041965
o C LICENSED CONI'RACTORS DECLARATION TEMP.POLE 30.00 n .{
a u-. 1 hereby affirm that 1 an licensed under loo v"loms of Chapter 9 •q I�q N�tSA. @el lino
mz a (cmnmencin wish Section 7000)of Division 3 of the Business and
H m z Professions Code,and my license is in full force and effect. BLDG. ELECT. PLO. E
C i m o License Classee-�- Lia tractor y � ❑ ❑ ❑
.9,5 - +._a -�. Contractor /J-./�_6 ��y_.y�[-!P _
a y a st 93 - 9-3-bs - BUILDING PERMIT
¢ ¢ a OWNERBUILDERDECLARATION
A o 1. U INFORMATION
w g LL N I hereby affirm that I amt exempt from lite Contractor's License MISC.- REFER TO ORD
u_ oa Law for the following reason,(Sec.7031.5,Business and Professions PERMIT ISSUANCE 10.00 VALUATION 5/
� - Code:Any cityorcounty which requires a permit to construct,alter,
/yFit
�
2 2 ¢ p improve,denmlish,or repair any structure,prior to its issuance,also ELEC.CONTR. LIC.NO. ELEC,
as
o u requires the applicant for such permit to lila u signed statement that TOTAL OCOry
wm be is licensed pursuant to the provisions of lite Contractor's License /J jY'yl
H z¢ Law(Chapter 9(Commencing with Section 7000)of Division 3 ofthe
i P 0 Business and Professions Code)or that he is exempt therefrom and QTY. PLUMBING PERMIT FEE
tkl
¢ H m the basis for the alleged exemption.Any violation of Section 7031.5 STORIES TYPE CONSTR.
ai- by any applicant for a permit subjects lite applicant to a civil penalty ALTER-DRAIN -WATER (EA.) 5.00
of not more than five hundred dollars(S500).1:
❑ I,as owner of the property,or my employees with wages as BACK FLOW PROTECT. DEVICE 4.00
their sole compensation,will do the work,and the stnmture is not OCC.GROUP RES.UNITS
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 hadds or improves thereon,and who dna such work FIXTURES-PER TRAP - 5.00 {, SQ,FT.FLOOR ARE. TOTAL ACREAGE
• u.,islare of ugh intended
..nnemred for sale.
If,ed however.the
improve- GAS-EA.SYSTEM-1 6.00
meets are not intended or offered for sults If,however,the building
or improvement is sold within one year of completion,Lite owner- GAS-EA.SYSTEM-OVER 4(EA ) 2.00
builder will have the burden of proving that he did not build or int- . BUILDING USE
prove for purpose of sated. - INDUSTRIAL WASTE INTER. 30.00 RE IND CON PB omen
❑ d as owner of the property,he project
vo e contracting with ❑ ❑ ❑ ❑
licensed contractors m construct the project La 7044,Business LAWN SPRINKLERS-1 INC 5 V.B. 6.00 ASSESSORS PARCEL NO.
and Professions Code:The Contractor's License Law does not apply
to tr owner of property who builds or improves thereon,and who LAWN SPRINKLERS-OVER 5(EA.) 1.00
contracts for such project with a contra<Inrl s)licensed pursuant to
me 1draexempt
License Sec. SEWER-SANITARY,-STORM EA.200ft/10.00 RACT NO. PARCEL NO.
❑ tont exempt under Sec.-, 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 I have a certificate of consent to sell'-insure. ZONING ENG.SITENO.
or a certificate of Workers'Compensation Insurance,or a certified
copy thereof(Sec 3800,Lab C.).
PrdicY/N..."o-40;g4Company 2�-
O 0/Certified copy is hereby furnished FIRE SPRINK ENERGY T 7
Z Z ❑ Certified Copy is fled with the oily irlspedi division. MISC.- REFER TO ORD.
Q Applicant Y ❑ N❑ Y ❑ N❑
~ va PERMIT ISSUANCE 10.00
� - CER'fIPIGCI'MPENEAEAIPTINSURAFROM WORK1iRS' FLOOD ZONE A.L.u.C.
W > COM1IPENSATION INSURANCE PLG.CONTR. LIC.NO. PLG.
0 ('Phis Section need not he completed if the permit is for one TOTAL Y❑ N❑ Y ❑ N❑
hundred dollars(S 100)or Ics0
U O 1 certify mat in the performance of the work for.],tell this per- QTY. MECHANICAL PERMIT FEE FEE SUMMARY
UL U mit is issued,I Shall not employ any person in any manner so as to
become subject m the Workeri Compensation Laws of California.
Go Duic Applicant BUILDING
} W NO'flcE 1"0 APPLICAN"f: 11,after making this Ceffificatu of fix- ALTER OR ADD TO MECH. 5.00
F Z cn,ptlon,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 10=C.F.M.) 4.00
CONSTRUCT ION LENDING AGENCY AIR HANDLING UNIT(OVER 10MC.F.M.) 6.00 SEISMIC FEE '
I hereby affirm that mere is a construction lending agency for EXHAUST HOOD (WITH DUCT) 5.00
the performance of the work for which this permit is issued(Sec. It ie MICROFILM
3097,Civ.CJ. �_ HEATING UNIT ITO 100,000 B.T.U.) 8.00
Lender's Name HEATING UNIT(OVER 100,000 B.T.U.)9.50
Lender's Addre �,Cy' �! •- viy✓ ELECTRIC
Icertity fiaPl'fi�e m3J•ts aphcarYnn algid state that me above VENTILATION FAN (SINGLE) 4.00 yen
• information is correct. I agree to Comply with all city and county PLUMBING
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 BTW SEE FEE SCH. MECHANICAL
above-ntenniomed property 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
may in any way accrue against said City in consequence of the I PERMIT ISSUANCE 10.00
gmntin of this permit. MECH.CONT. LIC.NO, MECH,
A` TOTAL TOTAL
'Slgnn of Applicant/Contrd6lor Date 0/. O
INSPECTOR COPY
APPLICANT TO FILL IN INFORMATION WITHIN RED LINES -USE BALL POINT PEN ONLY
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BUILDING PROJECT IDENTIFICATION
APPLICATION & PERMIT
PERMrTNUMBER
BUILDINGADDRESS
o-
BUILDING
7o -14 t17
BUILDING- ELECTRICAL- PLUMBING --MECHANICAL O O
OWNER'S
NAME
QTY. ELECTRIC PERMIT FEE
PLAN CHECK VALIDATION
y}r
PHONE
CONTRACTOR'S
NAME OUTLETS -SWITCHES- RECEP 10.0011.00
LIGHTING FIXTURES 10.0011.00caLIC. NO. Q
ADDRAcroRs
ADDRESS
PPLIANCES- RESIDENTIAL 4.00
PANELS 10.00ONEf}/ DATE OF APPLICATION
ARCHITECT fj 0 5_36
OORENGINEER
LIC. No.
PAN ELS. (OV ER 200 AMP) 20.00
PLAN CHECK FEE
PA
P.C. NO.
Jr% SIGNS TRANS. 3.00
ADDRESS ENG. SPECIAL CIRCUIT 5.00 PERMIT ALIDIVACIN
TEMP. METER OR POLE INS. 20.00ZIP SEP U 4 7985APPLICANT'S
ADDRESS
MOTORS SEE FEE SCH.
SERVICE CHANGE 20.002-4_1 5? City Of CupertiRB
LICENSED CONTRACTORS DECLARATION TEMP. POLE 30.00
I hereby affirm that I am licensed under provisions of Chapter 9
commencing with Section 7000) of Division 3 of the Business and
Professions Code, and my license is in full force and effect.
Lice se'C[ass'a 9L Lie. Number
DS ' - '+`- Contractor
ISSUANCE DATE
BLDG.. ELECT. PLG. H.
INFORMATION
IF-Ifl3UILDINGPERMIT
OWNER -BUILDER DECLARATION
1 hereby affirm that I am exempt from Lite Contractor's License
Law for the following reason. (Sec. 7031,5, Business and 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 Contractors License
Law (Chapter 9 (commencingwith Section 7000) of Division 3 of the
Business and Professions Code) or that he is exempt therefrom and
MISC. - REFER TO ORD
PERMIT ISSUANCE 10.00
VALUATION S/FT.
ELEC. CONTR. LIC. NO. ELEC.
TOTAL
QTY. PLUMBING PERMIT FEE
STORIES TYPE CONSTR. the basis for the alleged exemption. Any violation of Section 703 1. 5
by any applicant for a permit subjects the applicant to a civil penalty
of not more than five hundred dollars (5500).): PETER -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, AREA,COND. 5.00intendedorofferedforsale (Sec. 7044, Business and Professions
Code: The Contractor's Llcense'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
F IXTURES - PER TRAP 5.00 SO. FT. FLOOR AREA TOTALACREAGE
INC.
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 BUILDING USE
R IND CON PB other
INDUSTRIAL WASTE INTER. 30.00
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 SPRINKLERS- 1 INC 5 V.B. 6.00 ASSESSORS PARCEL NO.
LAWN SPRINKLERS - OVER 5 (EA.) 1.00
contracts for such projects with a contractor(s) licensed pursuant to
the Contractor's License Law. SEWER$ANITARY-STORM EA..2DOft/10.00 TRACT NO. PARCEL NO,
lam exempt under Sec. BAP.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
1 hereby affirm that I have a certificate of consent to self -insure,
or a certificate of Workers' Compensation tnsura ce, or a certified ZONING ENG. SITE NO,
copy thereof Sec. 31300, Lab.C.).
Pofic o, ompany
gir Certified copy is hereby furnished.
Certified copy is Glcd with the city inspection division.
Applicant
FIRE SPR INK
Y N
ENERGY T-24
Y N MISC. - 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 Workers Compensation Laws of California.
Date Applicant ALTER OR ADD TO MECH. 5.00
NOTICE TO APPLICANT: If, after making this Certificate of Ex-
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 10,000 C. F.M.) 4.00
AIR HANDLING UNIT (OVER 10p00C.F.M.) 6.00 SEISMIC FEECONSTRUCTIONLENDINGAGENCY
I hereby affirm that Ihcre is a construction lending agency for
the performance of the work for which this permit is issued (Sec.
3097. Cir.C.).
EXHAUST HOOD (WITH DUCT) 5.00 p
MICROFILM
HEATING UNIT (TO 100,000 S.T.U.) 6.00 8.OD
HEATING UNIT (OVER 100,OODB.T.U.}9.50 ELECTRIC
Lender's Name
Lender's Ad re -
1ccrlify t at tavArca t isappltcallonandstaIctha. ttheabove
information is correct. I agree to comply with all city and county
ordinances and stale laws relating to building construction, and
VENTILATION FAN (SINGLE) 4.00 p,po
PLUMBING
BOILER -COMP 13 H.P. or 100,000 B.T.U.} 6.00
BOILER -COMP (over 100,000 BTU) SEE FEE SCH. MECHANICALherebyauthorizerepresentativesofthiscitytoenteruponthe
above-mentioned property for inspection purposes.
MISC. - REFER TO ORD. We) agree to save, indemnify and keep harmless the City of
Cupertino against Babilities, judgments, costs and expenses which
may in any way accrue against said City in consequence of the
CONST. TAXPERMITISSUANCE10.00 fp, pp
gr ntin f this permit. MECH. CONT, LIC. NO. MECH.
TOTAL
TOTAL
Signat licant[Contractor Date
OFFICE COPY