09529 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
BU LDI NG PROJECT I DENTI FICATI ON PERMIT NUMBER
ADAPPLICATION & PERMIT ^��^�
ED
ADDRESS J
BUILDING-ELECTRICAL-PLUMBING -MECHANICAL
O ry PLAN CHECK VALIDATION
"A QTY. ELECTRIC PERMIT FEE
PHON[
NOMERA T s OUTLETS-SWITCHES-RECEP 10.00/1.00
.No. LIGHTING FIXTURES 10.00/1.00
r, ACTOR's
ADDRESS PPLIANCES-RESIDENTIAL 4.00
04- vHONE ,S PANELS 10.00 DATE OF APPLICATION
RC rtE� PANELS fOVER 200 AMP) 20,00 PLAN CHECK FEE P.C.NO.
OR
ENGINEER
Llc,No. SIGNS TRANS. 3.00
ARCH.ORENG. PERMI ALIDATION
ADDRESS SPECIALCIRCUIT 5.00 PAID
ZIP rFEMP.METER OR POLE INS. 20.00
APPLICANT
Ess RESS 3AP MOTORS SEE FEE SCH. AUG 2 '1980
J
SERVICECHANGE 20.00 p
M o LICENSED CONTRACTORS DECLARATION TEMP.POLE 30.00 laity Of Cu
Dart,
{a nertino
Ix o u I hereby affirm that I am licensed under provisions of Chapter 9 ISSUANCE DATE y
< "' (commencing with Section 7000)of Division 3 o(th'Business and
N BLDG. ELECT. P G MECH.
0 w z Professions Code,and my license is in full for;•and ff cl. ❑ ❑ ❑
0 o m - Liccnsc Cpl.ls 1 Lie.Contract.; 7r)
Q F Ualu l9Cwrtractor
P x f BUILDING ERMIT
it IS i OWNER-BUILDER DECLARA'r10N INFORMATION
I hereby affirm that I am exempt from the Contractor's License MISC.- REFER TO ORD
uoas Law for the following reason.(Sec.7031.5,Rusinessand Professions PERMIT ISSUANCE 10.00 VALUATION $/FT.
� - 0 Code:Any city or county which requiresa permit tomnstrvt,altv,,
KR ¢ improve,demolish,or repair any structure,prior to its issuance,also ELEC.CONTE. LIC.NO. ELEC.
n cu requires the applicant for such permit to file a signed statement that TOTAL PERMIT TO
n is m m he is licensed pursuant to the provisions of the Contractor's License
F z ve Law(Chapter9(commencingwith Section 7000)of Division 3 of the
Business and Professions Code)or that Ile is exempt therefrom and GTY. PLUMBING PERMIT FEE
r o the basis for the alleged exemption.Any violation of Section 7031.5 STO in E CONSTR.
a ; m by any applicant for a permit subjects the applicant to a civil penalty ALTER-DRAIN& VENT-WATER (EA.) 5.00
of not more than fivohundred Aollars[55001.):
❑ h 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:'rhe Contractors License Law does not apply to an owner of /'y�
property who builds or improves thereon,and who does such work FIXTURES-PER TRAP 5.00 Bay SO.FT.FLOOR AREA TOTAL ACREAGE
himself or through his own employees,provided that such improve-
mentsare not intended oroffered for sale.If.however,the building GAS-EA.SYSTEM-I INC.4 OUTLETS 6.00 QU
or improvement is sold within one year of completion,tileowner- GAS-EA.SYSTEM-OVER 4 IEA.) 2.00 BUILDING USE
builder will have the burden of proving that he did not build(if im-
prove bar purpose ofsale')' INDUSTRIAL WASTE INTER. 30.00 RE IND CON PR Omar
. ❑ I,as owner of the property,am exclusively'contracting with ❑ ❑ ❑ ❑
licensed contractors to construct the project(Sec.7144,Business LAWN SPRINKLERS- 1 INC 5 V.B. 6.00ASSESSORS PAECEL NO.
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-OVER 5(EA.) 1.00
contracts for such projects with a contraclons)licensed pursuant to SEWER-SANITARY-STORM EA.200ft/10.00 00
the Con tractor's Li;s•nse Law. TRACT NO, PARCEL NO.
❑ lam exempt under Sec ,B.&P.C.tix this 11.10, WATER HEATER W/VENT 6.00 $O
Owner.' Date WATER SYSTEM 5.00 Acc.DATE ACC.FILE NO,
WORKERS'COMPENSAT ION DECLARATION WATER TREATING EQUIP. 5.00
1 hereby affirm that 1 have a c'criflecale of consent to sell insure, ZONING ENG.SITE NO.
or a certificate of Workers Compensation Insumnce,or a certified
copy lhereof(Sec.3800,Lab CA
Policy No. Company
O ❑ Certified copy is hereby furnished. FIRE SPRINK ENERGY T-24
Z Z 1.1.G'ter[i led yupy is Filed with the city inspection division.
H O' App c:ml_Fn:_L� .A Z s MISC.- REFER TO ORD. Y ❑ N❑ Y ❑ No
fr N CF:RTIFIICA�'II'E OF EXEMPTION FROM WORKERSPERMIT ISSUANCE 10.00 FLOOD ZONE A.L.U9. '
L COMPENSATION INSURANCE PLG.CONTE. LIC.NO. I.G.PCL
OV N Y❑ E] Y❑ r N❑
O IThis section neral not be completed if the permit is for One. TOTAL
Z huodmddldlars(SIOo)Orless.)
U O 1 certify that in the performance of the work for which this per- CITY. MECHANICAL PERMIT FEE FEE SUMMARY
LL F mit is issued,1 shall not employ any person in any manner,so as to
O w become subject to the Workers'Compensation Laws of California. BUILDING
n Date - Applicant ALTER OR ADD TO MECH. 5.00
} N NOTICE TO APPLICANT: If,after making this Certificate of Ex-
F 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 permit shall be deemed revoked. AIR HANDLING UNIT(TO 1Q000CF.M.) 4.00
CONSTRUCTION LIiNDING AGENCY AIR HANDLING UNIT(OVER IOMC.F.M.) 6.00 SEISMIC FEE
I hereby affirm that there is a construction lending agency for EXHAUST HOOD(WITH DUCT) 5.00
the performmnee of the work for which this permit is issued(Sec. MICROFILM
3097,Cie C.). I HEATING UNIT(TO 100,000 B.T.U.) 8.00
Lender's Name HEATING UNIT(OVER 100,000 B.T.U.)9.50
Lender's Address ELECTRIC
I certify that I have read this application and"at'"a'the above
VENTILATION FAN (SINGLE) 4.00
• information is correct. ] agree m;omply with all city and counly PLUMBING Qp
ordinances and stale laws relating to building-construction and BOILER-COMP(3H.P.or100,000B.T.U.) 6.00
hereby authorize representatives of 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 harmless the City of MISC.- REFER TO ORD.
Cupertino against liabilities,judgments, costs and expenses which CONST.TAX
may 'n any way accrue against said City in consequence of the PERMIT ISSUANCE 10.00
s gronti 11'Ill permit. MECH,CONT. LIC.NO. - MECH.
TOTAL TOTAL
INSPECTOR COPY
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APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
BUI CD! NG PROJECT I DENTI FICATION
APPLICATION &PERMIT
PERMIT NUMBER
09529S , ADRESs
BUILDING — ELECTRICAL— PLUMBING —MECHANICAL G
ow NtEER
NA/ 1 logmoi}
OTY. ELECTRIC PERMIT FEE
PLAN CHECK VALIDATION
PHONE
NNTRACTaR s
NAME UTLETS - SW ITCH ES - R ECEP 10.0011.00
FIXTURES 10,0011.00No. rLIGHTING
CONTRACTOR'S
ADDRESS ADDRESS APPLIANCES- RESIDENTIAL 4,00
10.00t
PHONEPANELS DATE OF APPLICATION
ARCHITECT
OR
ENGINEER
LIC. No.
PANELS (OVER 200 AMP) 20.00
PLAN CHECK FEE
A
P.C. NO.
111111% SIGNS TRANS. 3.00
AA
C14 ORDOR55 ENG SPECIAL CIRCUIT 5,00 PERMIT
TEMP. METER OR POLE INS. 20,00ZIP
VAUG APPLICANT'S
ADDRESS
MOTORS SEE FEE SCH,
SERVICE CHANGE 20.00
City of Cupertino
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 and license is in full torcSapaL ffpgt7LicenseLic. Number -- ttno [VJ
ISSUANCE DATE
BLDG, ELECT. MECH.
Date Contractor
BUIL
INFORMATION
ERMIT
OWNER -BUILDER DECLARATION
1 hereby affirm that 1 am exempt from the Contractor's License
Law ror the following reason. (See, 7031.5, Business and Professions
Code: Any city or county which requires a permit to construct, aller,
improve, demolish, or repair any structure, prior to its issuance, also
requ--ares the applicant for such permit to rite a signed statement that
he is licensed pursuant to the provisions of the Contractor's License
MISC. — REFER TO ORD
VALUATION SJF7.
PERMIT ISSUANCE 10.00
ELEC. CONTR, LIC. NO. ELEC.
TOTAL p R 1T TO
QTY. PLUMBING PERMIT FEE
Law (Chapter 9 (commencing with Section 7000) of Division 3 of the
Business and Professions Code) or that Ire is exempt therefrom and
ST RIES PE CONSTR. the basis for the alleged exemption. Any violation of5ection 7031.5
by any applicant for a permit subjects the applicant to a civil penalty
or not more than five hundred dollars (5500).): ALTER -DRAIN & VENT -WATER (EA.) 5,00
13I, as owner of the property, or my employees with wages asBACK
their sole compensation, will do the work, and the structure is not
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 or'
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 sate. 1 f, however, the building
FIXTURES -PER TRAP 5.0 0, SO. FT. FLOOR AREA TOTALACREAGE
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
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
R IND CDN P8 Other
PARCEL NO.
INDUSTRIAL WASTE INTER. 30,00
LAWN SPRINKLERS - 1 INC 5 V.B. 6.00ASSESSORS
LAWN SPRINKLERS -OVER 5 (EA.) 1.00
contracts for such projects with a coniractor(s) licensed pursuant to
the Contractor's License Law. SEWER -SANITARY -STORM EA.200ft1i0.00 TRACT NO. PARCEL NO.
am exempt under Sec. ,B.&P.C. for this WATER HEATER W/VENT 6.00 ('00
reason
Owner Date WATER SYSTEM 5.00 SV ACC. DATE ACC. FILE NO.
WATER TREATING EQUIP. 5.00WORKERS'COhIPENSATION DECLARATION
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 (Scc. 3800, Lab.C.).
Policy No. Company
FIRE SPRINK
Y N
ENERGY T•24
Y N
Certified copy is hereby furnished,
Certified po y is de w rtlyahe city inspection division.
App cant_h jQ MISC. REFER TO ORD,
CERTIFICATE OF EXEMPTION FROM WORKERS' PERMIT ISSUANCE 10,00 Q FLOOD ZONE A.L.U,C.
PLG. CONTR. LIC. NO. ------[PLC aU
TOTAL
C04lPENSATION INSURANCE
This section need not be completed it 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
become subject to the Workers' Compensation Laws of California.
8U1DateApplicantBUILDINGALTERORADDTOMECH. 5.00
NOTICE TO APPLICANT: jr, after making this Certificate of Ex-
APPLIANCE 5.00 PLAN CHECKemplion, 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 000C F.M.) 4.00
AIR HANDLING UNIT(OVER10=C.FM.) 6.00 SEISMIC FEECONSTRUCTIONLENDINGAGENCY
1 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
1 certify that t have read this application and state that the above
information is correct. 1 agree to comply with all city and county
ordinances and stale laws relating to building construction, and
VENTILATION FAN (SINGLE) 4.00
PLUMBING 0o
BOILER COMP(3 H.P, Dr 100 000 B.T.U.} 6.00
801 LER-COMP (Over 100,000 BTU) SEE FEE SCH, hereby authorize representatives of this city to enter upon the
above-menlioned property for inspection purposes. MECHANICAL
M)SC. - REFER TO ORD. We) agree to save, indemnify and keep harmless the City or
Cupertino against liabilities, judgments, costs and expenses which
may in any ay accrue against said City in consequence of the
grant of t permit.
CONST. TAX
PERMIT ISSUANCE 10,00
MEC". CONT, LIC. NO. MECH.
TOTAL
TOTAL
Signitur a 17Applicant! o tractor Date
OFFICE COPY