09522 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
BU LDI NG PROJECT I DENTI FICATI ON PERMIT NUMBER
BUILDING APPLICATION & PERMIT ^^
ADDRESS G G
BUILDING-ELECTRICAL-PLUMBING -MECHANICAL
OWNS
Na
IN E N
CITV. ELECTRIC PERMIT FEE PLAN CHECK VALIDATION
PHONE
®' NAMe ncroRs UTLETS-SWITCHES-RECEP 10.00/1.00
uC.NO. LIGHTING FIXTURES 10.00/1.00
CONTRACTORS APPLIANCES-RESIDENTIAL 4.00
ADDRESS
vROrvE PANELS 10.00 DATE OF APPLICATION bj4
OR
OR
PANELS (OVER 200 AMP) 20.00 PLAN CHECK FEE P.C.NO.
ENGINEER
LIC No. SIGNS TRANS. 3.00 t
ARCH ADDRESS END' SPECIAL CIRCUIT 5.00 PERMIT VALIDATION
TS
ZIP EMP.METER OR POLE INS. 20.00 �'ryryA3�D
APPLICANMOTORS SEE FEE SCH.
ADDRESS
1985
' SERVICE CHANGE 20.00 4
AUG
woo LICENSED CONTRACTORS DECLARATION TEMP.POLE 30.00 Citi/of CI1Q�
IS u u I�hereby affirm that 1 am licensed under provisions of Chapter 9 ISSUANCE WOW
a, i (commencing with Section 7000)of Division 3 of the Business and
Q BLDG. ELECT. P MECH.
H ¢ i Poll'CSSm"S Cod and t ly license is in full IRic• nd f c ❑ ❑ ❑
o Z w W License Cl s Lie,.Numbcr�7
Date Contractor
BUILDING PERMIT
or ¢o M o OWNER-BUILDER DECLARATION INFORMATION
w1 hereby affirm that 1 am exempt from the Contractor's License MISC.- REFER TO ORD
3 VALUATION SIFT.
F u o j Law lin the following reason.(Sec.7031.5,Business and Professions PERMIT ISSUANCE 10.00
Code:Any city or county which requires a permit to construct,alter,
eroa¢ 0 Improve,demolish,or repair any Structure,prior to ILS issuance,also ELEC.CONTR. LIC.NO. ELEC.
ii:- I] ¢ requires the applicant for such permit to file a signed statement that TOTAL ERMIT TO
w m u, he is licensed pursuant to the provisions of the Contractor's License
HZ >
Law(Chapter 9(cotimencing with Section 7000)of Division 3 ofthe
a Business and Professions Code)or that he is exempt therefrom andOTV. PLUMBING PERMIT FEE
rc r Do the basis for the alleged enemption.Any violation of Section 7031.5 ST RIS TYPE CONSTR.
n ; m by any applicant for a permit subjects the applicant to a civil penalty ALTER-DRAIN -WATER (EA.) 5.00
of not more than five hundred dollars($500y):
❑ I,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,AR EA,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 7 FIXTURES-PER TRAP 5.00 SO.FT.FLOORAREA TOTAL ACREAGE
himself or through his own employees,provided that such improve-
ment,are notintended.,Offered Rlrsalc.If,however,the building GAS-EA.SYSTEM-11NC.4OUTLETS 6.00 CIF
or imm
proveent is sold within one year of conlpleilon,the 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 sale.). INDUSTRIAL WASTE INTER. 30.00 R he IND CON PB Omer
❑ 1,as owner of the property,am exclusively contracting with I0 El El El
licensed convectors to construct the project(Sec 7044, BusinessLAWN SPRINKLERS- 1 INC 5 V.B. 6.00 A ASSESSORS PARCEL NO.
and Professions Code The Contractor's License Law docs not apply
to an owner of property who builds or improves thereon,and who LAWN SPRINKLERS-OVER 5 IEA.) 1.(0
contracts forsueh projectswith a contractorts)licensed pursuant to / SEWER-SANITARY-STORM EA.200ft 1 (�
the Contractors License Law. 0.00/ TRACT NO. PARCEL NO.
O lam exempt under Sec.-,B&P.C.for this WATER HEATER W/VENT 6.00
Owncr Date WATER SYSTEM 5.00 ACC.DATE ACC.FILE NO.
WORKERS'COMPL'NSATION DECLARATION WATER TREATING EQUIP. 5.00
1 hereby affirm that I have a certificate ofconseat to self-insure. ZONING ENG.SITE N0.
or a certificate of Workers'Compensation Insurance,or a certified
copy thereof(Sec.3800,Lab.C.). - -
_ Policy No. Company
O Certified copy is hereby furnished. FIRE SPRINK ENERGY T 2
z Z Certified py is Eled with the city inspection division.
O Ap icantr•� LY'1 SS MISC.- REFER TO ORD. Y� NE] YE] N[-] ,
CC rn PERMIT ISSUANCE 10.00
LU CIiRTIF-ICCOMOFEAIIOP ION FROM WORKERS' FLOOD ZONE A,LU.C.
W feed not be coo INSURANCE tiePLG.CONTR. LIC.N0. PLG. Y� NE] Y EJ N❑
CL O hundred
section Reed not be completed if the permit is for one TOTAL
� Z hundred dollars(5100).,less.)
U O 1 certify that in the performance of the work for which this per- CITY. MECHANICAL PERMIT FEE FEE SUMMARY
LL F alit is issued,1 shall not employ any person in any manner so as to
O L) become subject to the Workers'Compensation Lows of California.
d Dat° ApplicantALTER OR ADD TO MECH. 5.00 BUILDING
1, } W N'O'IICE TO APPLICANT: If,after making this Cerbuicale of Its-
F- Z emption,you should became 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.NL) 4.00
f CONSI'RUCl10N 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 perfo,mance)of the work for which this permit is issued(Sec. MICROFILM
3097,Civ.C.). ( HEATING UNIT(TO 100,000 B.T.U.) 8400
Lenders Name HEATING UNIT(OVER 100,000 B.T.U.)9.50
Lender,Address• ELECTRIC
Icertify that(have read this application andstate that the above VENTI LATION FAN (SING LE) 4.00
. information is correct I agree to comply with all city and c.Duty
BOILER-COMP13 H.P.or 100,000 B.T.U.) 6.00 PLUMBING
ordinances and state IBW, relating to building construction. and
hereby authorize representatives of this city to enter upon the BO
OILER-COMP(Over 100,000 BTUI SEE FEE SCH. MECHANICAL
above-mentioned property for inspection purples.
(We) agree to save, indemnify and keep hurndess the City of MISC.- REFER TO ORD.
Cupertino against liabilities,judgments. costs and expenses which PERMIT ISSUANCE 10.00 CONST.TAX
may in any ay accrue ago.ost said City in consequence of the
gran oft rspenniL MECH.CONT. LIC.NO. MECH.
0 our ' TOTAL TOTAL
SI nate ep�llCunlTCo�i lfclor Date
INSPECTOR COPY
I MPPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
O
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ZUI LDI NG PROJECT I DENTI FICATION
APPLICATION &PERMIT
BUILDING -ELECTRICAL- PLUMBING -MECHANICAL
PERMIT NUMBER
09522
DUILDING -
AD RES w, r
oV
OWNER'S
NAME QTY, ELECTRIC PERMIT FEE
PLAN CHECK VALIDATION
aAmPHONE
CONTRACTOR'S
NAME OUTLETS -SWITCHES - RECEP 10.0011.00
LIC. NO. LIGHTING FIXTURES 10.00/1.00
r-DDRAACTQR'SOORAE55PPLIANCES - RESIDENTIAL 4.00
PAN ELS 10.00VM' PHONE + OATS OF APPLICATION
ARCHITECT
ORENGINEER
LIC. Na.
PANELS (OVER 200 AMP) 20.00 PLAN CHECK FEE P.C. NO.
SIGNS TRANS. 3.00
AARCH.
ORDDRESS ENG. SPECIAL CIRCUIT 5.00 PE 11 ALIDATiON
P DEMP. METER OR POLE INS. 20.00ZIP
AUa' ' ADDRESNT•s
ADDRESS
MOTORS SEE FEE SCH.
SERVICE CHANGE 20.00
City Off r UlANC1
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 Cod andi license is in full fore] n
Llcens Lie. Number
ISS#A%
B 00-G. ELECT. MECH.
Dale Contractor
BUILDING P RMIT
OWNER -BUILDER DECLARATION
I hereby affirm that 1 am exempt from the ContraclorsLicense
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
Law (Chapter 9 (commencing with Section 7000) of Division 3 of the
Business and Professions Code) or that he is exempt therefrom and
INFORMATION
MISC. - REFER TO ORD
VALUATION SIFT,
PERMIT ISSUANCE 10._00
ELEC. CONTR. LIG. NO. ELEC.
TOTAL PERMIT TO
QTY. PLUMBING PERMIT FEE
the basis for the alleged exemption. Any violation of Section 7031.5 5 IES TYPE CONSTR.
by any applicant for a permit subjectstheapplicant toacivilpenally
of not more than five hundred dollars (5500).): gLTER-DRAIN&VENT-WATER(@A.} 5.00
1a 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 (See. 7044, Business and Professions
Code: The Contractor's_ License Law does not apply to an owner of
property whobuilds or improves thereon, and who does such work
himself or throt7gh his own employees, provided lira[ such improve-
tnents are not intended or offered for sale. If, however, the building
FIXTURES - PER TRAP 5.00",so FT. FLOOR AREA 70TAL pCREAGt
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 III at he did not build or im•
prove for purpose of sale.).
131, as owner of the property, am exclusively contracting with
GAS - EA. SYSTEM - OVER 4 (EA.) 2.00 BUILDING USE
S IND CON PB Other
INDUSTRIAL WASTE INTER. 30.00
LAWN SPRINKLERS - 1 INC 5 V.B. 6.00licensedcontractorstoconstructtheproject (See. 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
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 -SANITARY -STORM EA. 200ft/10.00 D TRACT NO. PARCEL NO.
1 am exempt under Sec. B.&P.C. for this 1 WATER HEATER W/VENT 6.00 ZIV
I
reason
Owner Date WATER SYSTEM 5.00 ACC. DATE ACC: F I LE NO,
WATER TREATING EQUIP. 5.00WORKERYCOMPENSATIONDECLARATION
1 hereby affirm that I 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. 3800, Lab.C.).
Policy No. Company
FIRE SPRINK
Y N
ENERGY T-24
Y N
Certified Copy is hereby furnished.
Certified epy is Gled with shhe city inspection division.
pp 'cant
fl/
I.5 MISC.- REFER TO ORD.
CERTIFICATE'OF EXEMPTION FROM WORKERS' PERMIT ISSUANCE 10.00 O FLOOD ZONE A.L.U.C.
PLG.CONTR. LIC. NO. PLG. 7
TOTAL /
COMPENSATION INSURANCE'
This section need not be completed if the permit is for one Y E] NE] Y NE]
CITY. MECHANICAL PERMIT FEE FEE SUMMARY
hundred dollars (S ion) 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
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 Lo the,Workers' Compensation
provisions of the Labor Code, you must forthwith comply with
such provisions or Lhis permit shall be deemed revoked.
FEEAIRHANDLINGUNIT (TO 10=C.F.M) 4.00
AIR HANDLING UNIT(OVER10j000C.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.) 0.00
H EAT I NG 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, slate that the above VENTILATION FAN (SINGLE) 4.00
information is correct. I agree to comply with all city and county
ordinances and state laws relating to building construction, and
PLUMBING
BOILER-COMP(3 H.P. Or 100,000 B.T.U.) 6.00
BOILER -COMP (Over 100,000 BTU)SEEFEESCH. MECHANICALherebyauthorizerepresentativesofthiscitytoenteruponthe
above-mentioned property for inspection purposes.
MISC. - REFER TO ORD. We) agree to save, indemnify and keep harmless the City of
Cupertino against liabilities, judgments, costs and expenses which
may iu any ay accrue %3mst said City in consequence of the
gra of s permit.
CONST. TAX
PERMIT ISSUANCE 10.00
MELH. CONT. LIC. NO. MECH.
TOTAL
TOTAL
Sr a leo App 'cant/ onlractor Date
OFFICE COPY