09613 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
BUILDING PROJECT I DENT[FICATION PERMIT NUMBER
BUILDING APPLICATION & PERMIT
ADDRESS
BUILDING -ELECTRICAL-PLUMBING-MECHANICAL
09613
OWNER'S - _ PLAN CHECK VALIDATION
NAME
/p QTY. ELECTRIC PERMIT FEE
,yam/ f_p PHONEaAn
NOMERAcions OUTLETS-SWITCHES-RECEP 10.00/1.00
rDoRs LIC.NO. LIGHTING FIXTURES 10.00/1.00
ADDRESS APPLIANCES-RESIDENTIAL 4.00
REs
B P OrvE AA PANELS 10.00 DATE OF APPLICATION
OPCRIi ECT q , al �� PANELS (OVER 200 AMP) 20,06 PLAN CHECK FEE D.C.NO. /
ENGINEER -C/ _l
LIC.NO. SIGNS TRANS. 3.00
ARCH.OR ADDRESS ENG. SPECIALCIRCUIT 5,00 P DATION
ZIP EMP.METER OR POLE INS. 20.00 pen A f�p
ADDRESS MOTORS SEE FEE SCH. SEP o 4 1J05
ADDRESS
.� �✓ _-j- P SERVICE CHANGE 20.00
City of Cu
F D o LICENSED CON'T'RACTORS DECLARATION TEMP.POLE 30.00 Cupertino
a i w I hereby affirm that 1 am licensed under provisions of Chapter
(commencing with Section 7000)of Division 3 of the Business and ELECT.
CE DATE
Ci Q A BLDG. ELECT. PLG.
F w i Professions Cole,and my license is in full force and effect. ) ❑ ❑ ❑
z o u, - License Glossa ^..-a a-9r Lic.Number - ❑
g - o DatD-�I-*Q-`n_--a-Contractor 119
Qy5 � 30- 9- 3-.� '
¢ ¢ w Q OWAIiR-B LDER Dt:CLARA'I'ION BUILDING PERMIT
A o A o INFORMATION
X ; y I hereby affirm that 1 am exempt from lite Contractor's License MISC.- REFER TO ORD
LL o J Law for the following reason,(Sec.7031.5.Business and Professions VALUATION g/FT.
_ PERMIT ISSUANCE 10.00
E
;;.w f Code: e.d city or county whiny reqstructure,s a
permit o its isstruct,alter,
uance.also
¢ ¢'¢ O improve.demolish,or repair any structure,prior to its issuance,also ELEC.CONTR. LIG NO. ELEC.
o¢ requires the applicant for such permit to file a signed statement that TOTAL
n w m he is licensed pursuant to the provisions of the Contractors License PER IT TO
His, Last(Chapter 9(commencing with Section 7000)of Division 3 ofthe
Q Business and Professions Cole)or that he is exempt therefrom and QTY. PLUMBING PERMIT FEE
¢ I m the basis for the alleged exemption.Any violation of$ection 7031.5 STORMS TYPE CONSTR.
Ate _ by any applicant fora permitllar,tire applicant toacivil penalty
doars
of not more than I'Ivc hundred doll ($5001.1: ALTER-DRAIN& VENT-WATER (EA.) 5.00 -
❑ 1,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 structure is not OCC.GROUP ' RES.UNITS
msa
intended or offered for sale (Sec. 7044, Business and Professions DRAINS-FLOOR,ROOF,AREA,CON D. 5.00
Code:The Contractor's License Law docs not apply to an owner of.
property who builds or improves thereon,and who docs such work FIXTURES-PER TRAP 5.00 SQ.FT.FLOOR AREA TOTALACREAGE
himself re through his own employers,provided that such improve-
ments or throot ugh
Offered for reoyeesale.Iided that such
emprovg GAS-EA.SYSTEM-11NC.4OUTLETS 6.00
or improvement is sold within one year of completion,the owner- GAS EASYSTEM OVER 4 IEA) 200
builder will have the burden of proving that he did not huild or int - . - . .
- BUILDING USE
prove for purpose ofsaleJ. INDUSTRIAL WASTE INTER. 30.00 RES IND CON PS Other
❑ I,as owner of the property',am exclusively contracting with ❑ 11 ❑ 0
licensed contractors to construct the project(Sea 7044, Business LAWN SPRINKLERS- 1 INC 5 V.B. 6.00 ASSESSORS PARCEL N0.
and Professions Coda:The Contractor's License Law does not apply
to an owner of property who builds or improves thereon.and who LAWN SPRINKLERS-OVER 5 IEA.I 1.00
contracts for such projects with a contractogs)licensed pursuant to SEWER-SANITARY-STORM EA.200ft/10.00
the Contractor's License Law. ' TRACT NO. PARCEL NO.
❑ 1 an exempt under Sec. ,B.&P.C.for Bi is WATER HEATER W/VENT 6.00
reason
Owner Date WATER SYSTEM 5.00 ACGDATE ACC,FILE NO.
4
WORKERS'COMPENSATION DECLARATION WATER TREATING EQUIP. 5.00
1 hereby affirm that 1 have a certificate of consent to self-insure. ZONING ENG.SITE NO.
or a certificate of Workers'Compensation Insurance,or a certified
copy thcreof(See.3800,Lah.C.)--a /
Policy NaQa0p, .eompanY /�b Z�
O VCe lifted copy is hereby'furnished. -67 FIRE SPRINK ENERGY T 24
z Z ❑ Certified copy is filed with the city inspection division.
i- O Applicant MISC.- REFER TO ORD. Y❑ N❑ Y ❑ NE]
= CERTI FICA'1'E OF 8XEMPf10N FROM WORKERS' PERMIT ISSUANCE 10.00 FLOOD ZONE A.L.UD.
LU ? COMPENSATION INSURANCE PLG.CONTR. LIC,NO. PLG. V N� Y N�
CL o This Section need not be completed if the permit is for One TOTAL
::) Z hundred dollars IS 100)nr less.)
U O I certify that in fire performance of the work for which this per- QTY. MECHANICAL PERMIT FEE FEE SUMMARY
LL I- mit is'issued.I shall not employ any person in any manner so as to
O w become subjectAo the Workers Compensation Laws of California.
u Date Applicant ALTER OR ADD TO MECH.- 5.00 BUILDING
- to NOTICE TO APPLICAN"T': If,after making this Certificate of lis.
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 pennit shall he deemed revoked. AIR HANDLING UNIT(TO 10=C.F.M.) 4.00
CONSTRUCTION LENDING AGENCY AIR HANDLING UNITIOVER 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 T T
the performance of the work for which this permit is issued(Sec. MICROFILM
3097,Civ.C.), HEATING UNIT(TO 100,000 B.T.U.) 8.00 Is
Lender's Name HE UNIT(OVER 100,000 B.T.U.)0.50
Lender's Name
ELECTRIC
I certify that I have read ihi alipliiahon n` a tbYh3tthe above p VENTILATION FAN (SINGLE) 4.00 J -
• information is correct. I agree to comply with all city and county PLUMBING
ordinances and state laws relating to building construction, and BOILER-DOW(3 H.P.or 100,000 B.T.U.) 6.00
hereby authorise representatives of this city 10 enter upon the BOILER-COMP (Over 100,000 BTU)SEE FEE SCM.
above mentioned property I'nr inspection purposes, 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
w
may in any ay accrue against said City in consequence of lire
granting of this permit. MECH.CONT. LIC.NO. MECH.
/�S 7N J G D TOTAL TOTAL
Signa u�,pphcant/Contactor .,Date 3- O(]
INSPECTOR COPY
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APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
BUI L'131 NG PROJECT I DENTI FICATION
APPLICATION &PERMIT
BUILDING - ELECTRICAL- PLUMBING - MECHANICAL
PERMIT NUMBER
09613
a •' ING
A r/RES5
OWNER'S
NAME
vim a J PHON 7 J 8
QTY,, ELECTRIC PERMIT FEE
PLAN CHECK VALIDATION
CONTRACTOR'S
NAME OUTLETS - SW ITCHES - R ECEP 10.0011.00
LIGHTING FIXTURES 10.0011.00LIC, NO. p5
ArDR's
ADDRESSDREss PPLIANCES- RESIDENTIAL 4.00
10.003AONEf/ 7FAPANELS DATE OF APPLICATION
ARCHITECT'
a{
ORENGINEER
LIC. No,
PANELS (OVER 200 AMP) 20,00 PLAN.CHECK FEE P.C. NO.
SIGNS TRANS. 3.00
ARCH, OR ENG.SPECIALADDRESS CIRCUIT 5.00 PER 2lTJi( TION
i^
TEMP. METER OR POLE INS. 20.00ZIP
At ry o
7+ Q •x 1985
iii 0 Cupertino
APPLICANT'S
ADDRESS
MOTORS SEE FEE SCH.
SERVICE CHANGE 20.00
LICENSED CONTRACTORS DECLARATION TEMP. POLE 30,00
I hereby affirm that 1 am licensed under provisions of Chapter 9
commencing with Section 7000) of Division 3 of the Business and
Professions Co a and m Ii nse is in full force and effect.
Lic se CIaSS Ge. Number
D O Contractor 60
ISSUANCE DATE
BLDG. ELECT.
11
PLG. EC .
BUILDING PERMIT
INFORM ATION
IV _3
OWNER -BUILDER DECLARATION
hereby affirm that 1 am exempt from the Contractor's License
Law for the following reason. (Sec. 703 1.5, 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. ELEC.
TOTAL E IT TO
CITY. PLUMBING PERMIT FEE
Law (Chapter 9 (commencing with Section 7000) of -Division 3 of the
Business and Professions Code) or that he is exempt therefrom and
the basis for the alleged exemption. Any violation ofSection 7031,5 STORIES TYPE CONSTR,
by any applicant for a permit subjects the applicant to a civil penalty
of not more than five hundred dollars (S500).): ALTER-DRAIN-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 for sale. Ir, however, the building
F IXTUR ES - PER TRAP 5.00 SO FT. FLOOR AREA TOTAL ACREAGE
GAS - EA. SYSTEM -1 INC.4 OUTLETS 6.00
or improvement is sold within one year or completion, the owner-
builder will have the burden of proving that he did not build or (m•
prove for purpose ofsale.).
1, as owner of the property, am exclusively contracting with
GAS EASYSTEM -OVER 4 IEA.) 2.00 BUILDING USE
R IND CON PB other
INDUSTRIAL WASTE INTER. 30.00
LAWN SPRINKLERS -1i INC 5 V.B. 6.00licensedcontractorstoconstructtheproject (Sec. 7044, Business
and Professions Code: The Contractor's License Law docs 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-SANITARYSTORM EA. 200ft/i0.00 TRACT NO. PARCEL NO.
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 N0.
WATER TREATING EQUIP, 5.00WORKER5'COMPENSATION DECLARATION
I hereby affirm that - I have a certificate of consent to self -insure,
or a certificate or Workers' Compensation Insurance, or a certified ZONING- ENG. SITE NO.
COPY there ec. 3800; Lab.C.)
Polk o_rr ompany
FIRE SPRINK
Y N
ENERGY T•24
Y N
Certified copy is hereby furnished.
Certified copy is filed with the city inspection division.
Applicant IMISC. - 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
CITY. MECHANICAL PERMIT FEE FEE SUMMARY
hundred dollars ($100) or less.)
I certify that in the performance of [be work for which this per-
mit is issued, I shall not employ any person in any manner so as to
BUILDING
become subject to Elie Workers' Compensation Laws or California,
Data 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 forthwith comply with
such provisions or this permit shall be deemed revoked.
FEEAIRHANDLINGUNITITO10)000 C.F.M.) 4.00
AIR HANDLING UNIT (OVER 10MO C.F.M.) 6.00 SEISMIC FEECONSTRUCTIONLENDINGAGENCY
I hereby affirm that there is a construction lending agency for
the 7cC q Once of the work for which this permit is issued (Sec.
309
EXHAUST HOOD (WITH DUCT) 5.00
MICROFILM
HEATING UNIT ITO 100,000 B.T.U.) 8.00 .dd
HEATING UNIT (OVER 100,000 B.T.U.0.50 ELECTRIC
Lender's Name
Lender's Address
certify that I have read thisapp Icatfon an s atb9f1at -the above
information is correct. I agree to comply with all city and county
ordinances and state laws relating to building construction, and
3 VENTILATION FAN (SINGLE) 4.00 1A a&
PLUMBING
BOILER - COMP {3 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.
CONST. TAX
We) agree to save, indemnify and keep harmless the City of
Cupertino against liabilities, judgments, costs and expersses which
may in any way accrue against said City in consequence of the PERMIT ISSUANCE 10.00
granng this permit. MECH, CONT. LIC. NO. MECH.
TOTAL
35
470TOTAL
Signat pplicant/Contractor Date
OFFICE COPY