09612 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
BU LDI NG PROJECT 1 DENTI FICATI ON PERMIT NUMBER
ADI RESS APPLICATION & PERMIT 09612
oOREss
BUILDING -ELECTRICAL-PLUMBING-MECHANICAL
OWNER'S
PLAN CHECK VALIDATION
NAME OTY. ELECTRIC PERMIT FEE
A _ PHOrvE -
NOMERcroRs
OUTLETS-SWITCHES-RECEP 10.00/1.00
)09 /-j i /tLIC.NO. r- LIGHTING FIXTURES 10.00/1.00
CONTRACTORS
DRns
ADPPLIANCES-RESIDENTIAL 4.00
,PL 4i' ` f PHOry PANELS 10.00 DATE OF APPLICATION
ARCHITECT - �.x-n�rsum-•rt yif-�Yj PANELS (OVER 200 AMP1 20.00 PLAN CHECK FEE P.C.NO.
OR
ENGINEER
LIC.No. SIGNS TRANS. 3.00
ARC
ADDRESS ENG. SPECIAL CIRCUIT 5.00 PERMIT VA
ZIP EMP.METER OR POLE INS. 20.00 SEP
APPLICANTS - MOTORS SEE FEE SCH. O 41985
aooREss
aA /- _-,,,,.may SERVICE CHANGE 20.00
IS o LICENSED CONTRACTORS DECLARATION TEMP.POLE 30.00 City of Cupertino
a i w I hereby affirm (hat I am licensed under provisions of Chaptcr 9 ISSUANCE DATE
w rt w (commencing with Section 7000)of Division 3 of the Business and / .BLDG. ELECT. PLG. EC .
H w z Professions Code,and my license is in full force and effect ❑ ❑ ❑
Z a i m License Cliws/ e Number
oxHo out dq . ? - Conractor - '! .
BUILDING PERMIT /
¢ ¢ a OWNFR-BUILDER DECLARATION
d 0 a u INFORMATION
X gLL y I hereby affirm that I am exempt from the Contractor - REFER TO ORD
's License MISC.
LL 0 a Law for Lite following reason.(Sec.7031.5.Business and Professions PERMIT ISSUANCE 10.00 VALUATION g/FT.
Code:Any city orcounty which requires a permit to construct,alter,
¢ ac ¢ 2 improve,demolish,or repair any structure,prior to its issuance,also ELEC.CONTE. LIC.NO. ELEC.
u 0 ¢ requires the applicant for such permit to file a signed statement that TOTAL
m" he is licensed pursuant to the provisions of the Contractor's license PERMIT TO
to Law(Chapter 9(commencing with Section 7000)of Division 3 ofthe
F4 sL 0 Business and Professions Code)or that he is exempt therefrom and FEE
¢ H o the basis for the alleged exemption.Any violation of Section 7031.5 DTV. PLUMBING PERMIT
STORIE13 TYPE CONSTR.
u ; a by any applicant for a permit subjects the applicant to civil
penalty ALTER-DRAIN&'VENT-WATER (EA.) 5.00
of not more than live hundred dollars($500)1'.
❑ I,as owner of the property,or my employees with wages as ggCK FLOW PROTECT. DEVICE 4.00 OCC,GROUP RES.UNITS
their sole compensation,will d0 the work,and the structure 1s not
intended or offered for sale (Sec. 7044. Business and Professions DRAINS-FLOOR,ROOF,AREA,COND. S.00
Code:The Contractor's License Law does not apply to an owner of
property who builds or improves thereon,and who docs such work FIXTURES-PER TRAP 5.00 SO.FT,FLOOR AREA-'TOTAL ACREAGE
® himsellor'lhrough his Own employees,provided that such improve-
menu are not intended or offered for sale.If,however,the building GAS-EA.SYSTEM-11NC.40UTLETS 6.00
or improvement is sold within one year of completion.the owner- GAS EASYSTEM OVER 4 (EA.) 200
builder will have the burden of proving that he did not build or im- - . - . .
BUILDING USE
prove for purpose ofsaleJ. INDUSTRIAL WASTE INTER. 30.00 IND CON PB Omer
❑ I,as owner of the property,am exclusively contracting with ❑ ❑ ❑ ❑
licensed contractors t0 construct the project(Sec. 7044,Business LAWN SPRINKLERS- 1 INC 5 V.B. 6.00 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 ILAWN SPRINKLERS-OVER 5(EA.) 1.00
contracts for such pmjeets with a contractons)licensed pursuant to
(he Contractor's License Law. SEWER-SANITARY-STORM EA.200ft/10.00 jTRACT NO. PARCEL NO.
❑ lam exempt under Sec. ,B.&P.C.(or this WATER.HEATER W/VENT 6.00
rea1(111
Owner Date WATER SYSTEM 5.00
ACC.DATE ACC.FILE N0.
WORK F.RS'COM PENSATION DECLARATION WATER TREATING EQUIP. 5.00
1 hereby affirm that I have a certificate ofemown(to self-insure. ZONING ENG.SITE NO.
or a certificate of Workers'Compensation Insurance.or a certifeJ
copy thereof(See.3800,Lab.C.). (f
Policy NoP UEz L§Company s3f='tt//L�zr
Q y CvUcd copy is hereby furnished. FIRE SPRINK ENERGY T 24
z p Applicant
copy is fled with the city inspection division. MISC.- REFER TO ORD. vN N
❑ ❑ v ❑ ❑
~ (n PERMIT ISSUANCE 10.00
� - CERTlfIGOMPI PSATION INSUROM1IN'ORKIiRS' FLOOD ZONE a.L.0 C.
W COMPENSATION INSURANCE tale PLG.CONTE. LIF NO. PL,
. Y❑ N❑ Y ❑ N❑
Z
hundred
sction need not be completed if the permit is for one TOTAL
hundreA dollars lS100)or lass)
U O 1 certify that in the performance of the work for which this per- OTY. MECHANICAL PERMIT FEE FEE SUMMARY
LL U mit is issued,I shall not employ any person in any manner so as to
become subject to the Workers'Compensation Laws of California.
a Datc Applicant ALTER OR ADD TO MECH. 5.00 BUILDING
} W NOCICIi'f0 APPLICANT: If,after making this CvHificum of Ex-
- I Z_ eruption,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 ycrmit shall be deemed revoked. AIR HANDLING UNIT(TO 10=C.F.M.) 4.00
CONSTRUCTION LENDING AGENCY AIR HANDLING UNIT(OVER 10=C.EM.) 6.00 SEISMIC FEE
I hereby nff in that there es a construction lending agency In, EXHAUST HOOD(WITH DUCT) 5.00
the performance of the work for which this permit is issued(Sce. MICROFILM
3097, am /0 x HEATING UNIT(TO 100,000 B.T.U.) 8.00
Lender's Name-/ r��'
Lender's Addre.; t_/�y_/-/gyp; g .tea gE HEATING UNIT(OVER 100,000 B.T.U.I9.50 ELECTRIC
I certify that 11,91 4utlhis"' lieuNOl'�'antSlshTc that the above VENTILATION FAN (SINGLE) 4.00
/r)
ielornmtion is correct. I agree to comply with all city and county PLUMBING
ordinances and state laws relating m 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 (h°
above-mentioned property for inspection purposes. BOILER-COMP (Over 100,000 BTU)SEE FEE SCH. MECHANICAL
(We) agree to save, indemnify and keep harmless the City of MISC.- REFER TO ORD.
Cupertino against liabilities,judgments, costs and expenses which PERMIT ISSUANCE 10.00 CONST.TAX
may in any way accrue against said City in consequence of the ry.qn
granting of this permit. MECH.CONT. LIC.NO. MECH.
TOTAL / 00 TOTAL
ig lure o Applicant/ ontrac[or� Date
INSPECTOR COPY
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APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
BUILDING PROJECT IDENTIFICATION
APPLICATION &PERMIT
BUILDING - ELECTRICAL -PLUMBING -MECHANICAL
PERMIT NUMBER
O
Gn
G
ADDRESS ADQRESS
p p/
OWNER'S
NAME
QTY. ELECTRIC PERMIT FEE
PLAN CHECK VALIDATION
CONTRACTOR'S
NAME NAME
A /3G' O 9
LIC. No. /
OUTLETS-SWITCHES-RECEP 10.0011.00
LIGHTING FIXTURES 10.0011.00
CONTRACTOR'S
ADDRESS PPLIANCES-RESIDENTIAL 4.00
PANELS 10.00pN .ff /5 9 _ DATE OF APPLICATION
ARCHITECT
ORENGINEER
LIC. NO.
PAN ELS (OVER 200 AMP) 20.00 PLAN CHECK FEE P.C. NO.
SIGNS TRANS. 3.00
ADDRESS ENG' SPECIAL CIRCUIT' 5.00 PER T ION
EMP. METER OR POLE INS. 20,00ZIP EPi7C 4 1985ADDRESS
City Of CU Ae)0
APPLICANT'S
f 9
MOTORS SEE FEE SCH.
SERVICE CHANGE 20,00
LICENSED CONTRACTORS DECLARATION TEMP. POLE 30.00
hereby affirm that 1 am licensed under provisions of Chapter 9
commencing with Section 7000) of Division 3 of the Business and
Professions Co e_and m license is in full force and effect.
Lice a Cl s G z E(c. Number
ISSUANCE DATE
BLDG. IELECT.1 PLG INC
ntractar
OWNER -BUILDER DECLARATION
1 hereby afrum that I am exempt from the Contractor's License
Law for the following reason. (Sec. 7031,5, Businessand 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 rde 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
BUILDING PERMIT
INFORMATION
MISC. - REFER TO ORD
VALUATION__
T
1FT.
PERMIT ISSUANCE 10.00
ELEC. CONTR. LIC. NO. ELEC.
TOTAL P MIT TO
D ,
vQTY. PLUMBING PERMIT FEE
TYPE CONSTR. the basis for the alleged exemption. Any violation of Section 7031.5STORIES
by any applicant for a permit subjects the applicant to a civil penalty
of not more than rive hundred dollars (S500).). 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, 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 does such work
himself or through his own employees, provided that such improve-
ments are not intended or offered forsale. If, however, the building
FIXTURES - PER TRAP 5.00 SOL FT. FLOOR AREA TOTAL ACREAG_ E
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 BUILDING USE
REA IND CON PS Other
INDUSTR IAL WASTE INTER. 30.00
licensed contractors to construct the project (Sec. 7044, Business'
and Professions Code: The Coritmctor's License Law does not apply
to an owner of property who builds or improves thereon, and who
ASSESSORS PARCEL NO. 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 -SAN ITARY STORM EA. 200ft/10.00 1 TRACT NO. PARCEL NO.
lam exempt under Sec. B.&P,C- for this
reason
WATER HEATER W/VENT 6.00
Owner Dale WATER SYSTEM 5.00 ACG. DATE ACC. FILE N0.
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 Ins ance, a certified
copy_rep[-38 0, Lab.C. .
Polie o ornpany
Certified copy is hereby famished.
Certified copy is filed with the city inspection division.
Applicant
ZONING ENG. 517E N0.
FIRE SPRINK
Y N
ENERGYT•24
Y NOMISC.- REFER TO ORD,
CERTIFICATE OF EXEMPTION FROM WORKERS' PERMIT ISSUANCE 10.00 FLOOD ZONE A.L.U.C.
COMPENSATION INSURANCE
This section need not be completed if the permit is for one
Y N Y N
PLG.CONTR. LIC. NO. ALG.
TOTAL
QTY. MECHANICAL PERMIT FEE FEE SUMMARY
hundred dollars (5 100) 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
become subject to the Workers' Compensation Laws of California.
Date Applicant
NOTICE TO APPLICANT: If, after making this Certificate or Ex-
BUILDING
ALTER OR ADD TO MECH. 5.00
APPLIANCE 5.00 PLAN CHECKemption, you should become subject to the workers' Compensation
provisions or the Labor Code, you must forthwith comply with
such provisions or this permit shall be deemed revoked.
FEEAIRHANDLINGUNIT (TO 10=C.F.M.) 4,00
AIRHANDLINGUNIT (OVER 10JODOGF.M.) 6.00 SEISMIC FEECONSTRUCTION -LIEN DING AGENCY
I hereby affirm that there is a construction lending agency for EXHAUST HOOD (WITH DUCT) 5.00 _4 -.pr)
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 8 .0
HEATING UNIT (OVER 100,900B.T.U.)9,50 ELECTRIC
Lender's Name
Lender's Addre
I certify that I have read tKis ppIcaa ion
andQ
state that the above VENTILATION FAN IS1NG1 E) 4.00 8.00
information is correct. 1 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.7 U.) 6.00
BOILER-COMP {pverlpD,00DHTl11 SEE FEESCl1. 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 in any way accrue against said City in consequence of the
CONST. TAX
PERMIT ISSUANCE 10.00 /D •00
grant!of this permit.
d
MECH. CONT. LIC. FSO, MECH.
TOTALa o., t TOTAL
Sign r f Applicant/Contracto Date
OFFICE COPY