09530 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
BU LD1 NG PROJECT IDENTIFICATION PERMIT NUMBER
BUILDINGAPPLICATION & PERMIT
ADDRESS
1 BUILDING-ELECTRICAL-PLUMBING -MECHANICAL 09530
D,Rs
I- PLAN CHECK VALIDATION
NAMElf�s- QTY. ELECTRIC PERMIT FEE
PHONE
NAMEnA ro s OUTLETS-SWITCHES-RECEP 10.00/1.00
f c.N LIGHTING FIXTURES 10.00/1.00
ADDDRERESSS R'S
AD -APPLIANCES-RESIDENTIAL 4.00
n ✓`% PHONE PANELS 10.00 DATE OF APPLICATION
AOn HIT CT PANELS (OVER 200 AMP) 20.00 PLAN CHECK FEE P.C.NO,
ENGINEER
LIC,NO. SIGNS TRANS. 3.00
ARC..
eo ESS E"G' SPECIAL CIRCUIT 5.00 PERµ�TXryI ATION
ZIP EMP. METER OR POLE INS. 20.00 I�HFLJ
APPLICANT MOTORS SEE FEE SCH. 1AUG 2 3 1995
ADDRESS
SERVICE CHANGE 20.00
w o o LICENSED CONTRACTORS DECLARATION TEMP.POLE 30.00 City of Cupertino
H Z W I fourth,Afire,that I am licensed under provisions of Chapter 9 ISSUANCE DATE
(commencing with Section 7000)of Division 3 of the Business and
w Q w BLDG. ELECT. P G. MECH.
D z Professions Cod• and m license is in full forc;,Y=")d off cJ.
' 00 o License Cla s Lia Numbera .(,1.ZCZ ❑ ❑ i1
Date-Contractor
a m J, BUILDING PERMIT
a as OWNER-BUILDER DECLARATION
A o au uINFORMATION
w LL y I hereby allirm that I am exempt from the Contractor's License MISC.- REFER TO ORD
FLLoj Law for the following reason. 7031.5.Businessand Professions 'PERMIT ISSUANCE VALUATION $/FT.
Code:An cit n count - 10.00
Y Y< county requires permit construct,Ate"
IS ,al Q improve,demolish,or repair any structure,prior to its issuance,also ELEC.CONTE. LIC.NO. ELEC.
u w m u requires the applicant for such permit to file a Signed statement that TOTAL P R T TO
he is licensed pursuant to the provisions of the Contractor's License
H z a
Law(Chapter 9(commencing with Section 7000)of Division 3 ofthe
24 o Business and Professions Code)or that he is exempt therefrom and OTY. PLUMBING PERMIT FEE
¢r-� the basis for the alleged exmnption.Any violation of Section 7031.5 S RI CONSTR.
uby any applicant her a permit subjects the applicant tea civil penalty ALTER-DRAIN -WATER (EA.) 5.00
of nol more than five hundred dolla¢(S500.):
❑ I,as owner of the property,or my employees with wages as BACK FLOW PROTECT. DEVICE 4.00 OCC.GROUP ES.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:The Contractor's License Law does not apply to an owner of
property who builds or improves thereon,and who docs such workFIXTURES-PER TRAP 5.00 ()O SO.FT.FLOOR AREA TOTAL ACREAGE
himself or through his own employees,provided that such improve-
Tentsarenotintendedorofferedforsale.If,however,the building GAS-EA.SYSTEM-I INC.4 OUTLETS 6.00
or improvement is sold within one year of ivcompletion,Ore owner- GAS EASYSTEM OVER 4 (EA) 200
builder will he the burden of proving that be did nil tire
ar - . - . .
Ira- BUILDING USE
prove for purpose ofsale.l. INDUSTRIAL WASTE INTER. 30.00 E
NO CON PB Omer
C11,as owner of the property,am exclusively contracting with ❑ ❑ ❑ ❑
licensed contractors to construct the project(Sec. 7044,Business LAWN SPRINKLERS- 1 INC 5 V.B. 6.00g55E55oRS PARCEL NO.
and Professions Code:The Contractor's License Law does not apply
to un owner of property who builds or improves thereon,and who LAWN SPRINKLERS-OVER 5(EA.) 1.00
contracts for such projects with a contructor(s)licensed pursuant to SEWER-SAN EA.200ft/10.00 C70
the Contractors License Law. 'TRACT NO. PARCEL NO.
❑ 1amexempt under Sec. ,B.&P.C.for this WATER HEATER W/VENT 6.00 GO
reason
Owner Date WATER SYSTEM 5.00 "47 ACC.DATE ACC.FILE No.
WORKERS'COMPENSATION DECLARATION WATER TREATING EQUIP. 5.00
1 hereby affirm that I have a certificate efcoPscnt msel Ginsne.
or a certificate of Workers'Compensation Insurance or a certifni ZONING ENG.SITE NO,
copy thereof(Sec.3800,Lah.CJ.
Policy No. Company
O ❑ Certified copy is herehy famished. FIRE SPRINK ENERGY TQ4
Z Z � Certilled c py is filed with the city inspection division. MISC. REFER TO ORD.
F O AXV an . . C1�C><fj S Y❑ IN E] Y ❑ No
ITN CERTIFICATr 017 EXEMPTION I7ROM WORK ERSPERMIT ISSUANCE 10.00 00 FLOOD ZONE A,LU.C.
LU > COMPEN5A'I'ION INSURANCE PLG.CONTE. LIC.NO. PLG,
CL o
O. (This section need not be completed if the permit is for ne TOTAL �D Y❑ N❑ Y❑ N❑
::I` Z hundred dollars IS 100)or IessJ
U O 1 certify that in the performance of the work for which this per- OTV. MECHANICAL PERMIT FEE FEE SUMMARY
LL F mit is issued,1 shall not employ any person in any manner so as m
0w become subject to the Worker'Compensut ion Laws of California.
Date Applicant - ALTER OR ADD TO MECH. 5.00 BUILDING
>_ w NOTICE TO APPLICAN'T': IL after making this Certificate of Ei -
(_. Z emption,you should become subject to lire Workers'Compensation APPLIANCE 5.00 PLAN CHECK
provisions of the Labor Code, you must forthwith comply with FEE
U such provisions or this permit shallme
be deed revoked. AIR HANDLING UNIT(TO 10=C.F.M.) 4.00
CONSTRUCT ION LENDING AGENCY AIR HANDLING UNIT(OVER I0=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 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
Lender's Name HEATING UNIT(OV ER 100,000 B.T.U.)Lender's Address ELECTRIC
1 certify that I have read this application and state that the above VENTILATION FAN (SINGLE) 4.00
• information is correct. 1 agree to comply with all city and county PLUMBING 00
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
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 Om -
gmnt of i s permit. MECH.CONT. LIQ NO. MECH.
slgf o� Q�Q1 � /4� -_ GTAL TOTAL
�ii 1�1-A mant ontractor
INSPECTOR COPY
lf
APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
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BUILDING PROJECT IDENTIFICATION
APPLICATION &PERMIT
BUILDING - ELECTRICAL- PLUMBING - MECHANICAL
PERMIT NUMBER
09530BUILDINGADDRESS
I f D
O NER's ` + r
NA i! Q•1•Y. ELECTRIC PERMIT FEE
PLAN CHECK VALIDATION
PHONE 0L Jya
CONTRACTORS
NAME OUTLETS -SWITCHES - RECEP 10,0011.00
LIGHTING FIXTURES 10,0011.00joEc,N
ADDRESS
CONTRACTOR'S PPLIANCES- RESIDENTIAL 4.00
PANELS 10.00t
PHONE 7/ DATE OF APPLICATION
A CHITEC7
OR
ENGINEER
LIC. No.
PANELS LOVER 200 AMP) 20,00
PLAN CHECK FEE P.C. NO.
SIGNS TRANS, 3.00
ARCH. RCEss ENG' SPi±CIAL CIRCUIT S,OQ PERMIT VALIDATION
PAID
EMP, METER OR POLE INS, 20,0021P
AUG Baa
APPLICANT'S
ADDRESS
MOTORS SEE FEE SCR.
SERVICE CHANGE 20.00
city of CupertinoLICENSEDCONTRACTORSDECLARATIONTEMP. 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 Co an license is in full force td f c
License s Lic. Number )20
Dale Contactor
ISSUANCE DATE
BLDG. ELECT. P G. MECH,
BUILDING RMIT
IORM TIONOWNER -BUILDER DECLARATION
hereby affirm that 1 am exempt from the Contractor's License
Law for the following reason, (See. 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, alto
requires the applicant for such permit to file a signed statement [hat
he is licensed pursuant to the provisions or the Contmclor's License
MISC. - REFER TO ORD
vALUZTIA710N SIFT.
PERMIT ISSUANCE 10.00
ELEC. CONTR. LIC, NO, ELEC.
TOTAL ITTO
QTY. PERMIT FEEthebasis
Law (Chapter 9 (commencing with Section 7000) of Division 3 of the
Business and Professions Code) or that he is exempt therefrom and 4".pfortheallegedexemption. Any violation ofSectian 7031.5
PLUMBING
T E CONSTR.
by any applicant for a permit subjects the applicant to a civil penalty
of not more than five hundred dollars ($500).): 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 GCC. GROUP RES.UNI7S
DRAINS -FLOOR, ROOF, AREA, CON D. 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-
mcnts are not intended or offered forsale. If, however, the building
FIXTURES - PER TRAP 5.00 000 SBFT, FLOORAREA TOTALACAEAce
GAS - EA, SYSTEM -1 I N C. 4 OUTLETS 6.00
or improvement is sold within one year of completion, the owner
builder will have the burden or proving that he did not build or im-
prove for purpose or sale.).
as owner or the property, am exclusively contracting with
GAS - EA. SYSTEM -OVER 4 (EA.) 2.00 BUILDING USE
f IND CON PB Other
INDUSTRIAL WASTE INTER. 30,00
LAWN SPRINKLERS - 1 INC 5 V.B. 6.00ASSESSORS PARCEL NO. licensed contractors to construct the project (Sec. 7044, Business
and Professions Code: The Contractors 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 contractor(s) licensed pursuant to
the Contractor's License Law. RSA EA, 200ft110.00SEWER TRACT N0. PARCEL NO,
1 am exempt undcTSec. B.&P.C. for thisWATER HEATER WIVENT 6.00IJV
reason
Owner Date WATER SYSTEM 5.00 LL7
ACC. DATE ACC. FILE NO,
WATER TREATING EQUIP. 5.00WORKERS'COMPENSATION DECLARATION
I hereby affirm that I have a certificate ofconsent 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.
tified iapy is file witp,. he city inspection division. A
Certified
PP f - L . S MISC. - REFER TO ORD.
CERTIFICATE OF EXEMPTION FROM WORKERS' PERMIT ISSUANCE 10.01) FLOOD ZONE A.L,u.C,
PLG. CONTR. LIC. NO, PLG, - 00
TOTAL
COMPENSATION INSURANCE
This seetidn need not be completed if the permil is for one
N V [D HE]
QTY. MECHANICAL PERMIT FEEI FEE SUMMARY
hundred dollars (S 100) or less.)
I certify that in the performance or 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 orcalifomia.
Date Applicant IALTER OR ADD TO MECH. 5.00
NOTICE TO APPLICANT: If, after making this Certificate of Ex-
emption, you should become subject to the Workers' Compensation APPLIANCE 5.00 PLAN CHECK
provisions of the Labor Code, you must forthwith comply with
such provisions or this permit shall be deemed revoked.
FEEAIRHANDLINGUNIT (TO 10,000GF.M.) 4.00
AIRHANDLINGUNIT(OVERIQAOOC.i.M.) 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, ClY.C.),
MICROFILM
HEATING UNIT (TO 100,000 B.T.U.) 8.00
H EATI NG UN IT (OV ER 100,000 B.T.U.) 9,50 ELECTRIC
Lender's Name
Lender's Address
1 certify that I have read this application and state that the above
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
PLUMBING 00
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, 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 CI in consequence of the
CONST. TAX
PERMIT ISSUANCE 10.00
gra n of permit. MECH. CONT. LIC. NO, MECH.
JA '- TOTAL
TOTAL
Si at reo AppGcantJ ontractor ate
OFFICE COPY