09615 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
BU I LDING PROJECT IDENTIFICATION PERMIT NUMBER
BUILDINGAPPLICATION & PERMIT
A09615
ADDRESS
N/ BUILDING -ELECTRICAL-PLUMBING -MECHANICAL
OWNER'S -
NAME PLAN CHECK VALIDATION
OTV. ELECTRIC PERMIT FEE
eePHONE ! -
NOME cions UTLETS-SWITCHES-RECEP 10.00/1.00
qt' 2uc.NO - q n A LIGHTING FIXTURES 10.00/1.00
ADDRESS ions PPLIANCES-RESIDENTIAL 4.00
y P ONE PANELS 10.00 DATE OF APPLICATION
ORCHITECi
OR -G h`3^ � PANELS (OVER 200 AMP) 20.00 PLAN CHECK FEE
ENGINEER
LIC.NO. SIGNS TRANS. 3.00 P ►pP,C.NO.
AR. ENG. PERMIT VALIDATION
ADDRESS
ss / SPECIAL CIRCUIT 5.00 1f--pp ^
I ZIP EMP.METER OR POLE INS. 20.00 IEP 0 4 7985
APPLICANT
DORESl Ts MOTORS SEE FEE SCH.
// y,' SERVICE CHANGE 20.00 City Of Cupertino
o o LICF,NSIiU CO."TRACTORS DECIn RATION' TEMP.POLE 30.00
< o u I hereby affirm that 1 am licensed under provisions of Chapter 9
y¢ a (commencing with Section 7000)of Division 3 of the Business and. ISSUANCE DATE
0 y z Professions Code,and my license is in full forcean
d effect.
BLDG. ELECT. PLG.
o m o License ClassC!,2{.j.p�.{.Lia Numbr v f
H y r J Ddte`. 21,.0+x- Contracturees
¢ a, w a OWNER-BUILDER DECLARA'I'10,N BUILDING PERMIT
o
W 3 a U INFORMATION
u 1 hereby affirm m that 1 aexempt from the Contractor's License MISC.- REFER TO ORD
FLLog Luwforthe following ieus'an.(Sec.703 L5.Huxinessand Professions PERMIT ISSUANCE 10.00 VALUATION $/FT.
fw�4 Code:Any city orcounty which requiresapermil toconstruct,alter,
QQ ¢ 0 improve,demolish.or repair anv structure,prior to Its issuance,also ELEC.CONTR. LIC.NO. ELEC.
o I, requires the applicant for such permit to file a signed statement thatTOTAL
u w m be N licensed pursuant to the provisions of the Conhactor's Licensc PERMIT TO
� zr
Law(Chapter 9(co11m1mIv.C1 with Section 7000of Division 3ofthe
f x o Business and Professions Code)or thal he is exempt therefrom and OTY. PLUMBING PERMIT FEE
¢ m the basis for the alleged exemption.Any violation of Section 7031.5 STORIES TVP CONSTR.
a 3 _ by any upplicimI far a permit subjects the akgdi,anl toe civil penalty
of not muni than five hwulmd dollars($500).): ALTER-DRAIN& VENT-WATER (EA.) 6.00
❑ 1,as owner of the property,or my employees wihh 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,AREACON D. 5.00
Code:'File Co dractoi s License Law does not apply to ah ownerol , -
properly who builds or improves thereon,and who does such work F IXTUR ES-PER TRAP 5.00 50.FT.FLOOR AREA TOTAL ACREAGE
® himself or through his own employees.provided that such improve-
ments are not intended or offered for sale.If,however,the budding GAS-EA.SYSTEM-I INC.4 OUTLETS 6.00
or improvement is sold within one year of completion, the owner-
builder will have the burden of moving that he did not build or ire- GAS-EA.SYSTEM-OVER 4(EA.) 2.00 BUILDING USE
Prove property,
purpose of J' RES 1❑ ❑N ❑ 0❑
❑ I,as owner of the proPcr ,am exclusively contracting with INDUSTRIAL WASTE INTER. 30.00
licensed contractors to construct the project(Sec. 7044, Business LAWN SPRINKLERS- 1 INC 5 V.B. 6.00ASSESSORS PARCEL 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 contracmrto licensed pursuant to
the Contractor's License Luw, SEWER-SANITARY-STORM EA.200ft/10.00 k TRACT NO. PARCEL NO.
❑ lam exempt under See ,B.&P.C,for this
reason WATER HEATER W/VENT 6.00
Owner Date WATER SYSTEM 5.00 ACC.DATE ACC.FILE NO.
WORKERS'COMPENSAT ION DECLARAIION WATER TREATING EQUIP. 5.00
1 hereby affirm that I have a certificate of consent to self-insure,
or a certificate UI'Workers Compensation Insurance,or a certified ZONING ENG.SITE NO.
copy thereof(Sec 3800,Lab.C.1. J/
Policy o,/J}µpyCumpany
0 Certilfiieed cc-oh-iyy is
fwith th FIRE SPRINK ENERGY T 24
z Z ❑ Certified copy is Bled with the city inspection division.
FO .Applicant MISC.- REFER TO ORD. YE] N[] Y [] NE]
CC CERTIFICA'1'E OF EXEMPTION FROM WORKERS' PERMIT ISSUANCE 10.00 FLOOD ZONE A.L.U,O.
W > COMPI-NSAI'ION INSURANCE PLG.CONTR. LIC.rv0. PLG.
d (This section need not be completed if the permit is for one TOTAL Y❑ N V❑ IN
Z hundred dollar,($100)or Icss.)
U O 1 certify that in the performance of the workTor which this per- CITY
. MECHANICAL PERMIT FEE FEE SUMMARY
UE U mit is issued,1 shall not employ any person in any manner so as to
UJ become subject to the Workers'Compensation Laws of California.
U u Date nppllr nt ALTER OR ADD TO MECH. 5.00 BUILDING
>_ N NOlIC17 'TO APPLICANT: If,after making this Certificate of Ex-
F ? coalition,you should become subject to the Workers'Compensation APPLIANCE 5.00 PLAN CHECK
provisions of the Labor Code, you must forthwith comply with U FEE such provisions or this permit shall be deemed revoked. AIR HANDLING UNIT(TO 10,00DGF.M.) 4.00
CONSTRUCTION LENDING AGENCY AIRHANDLING UNIT(OVER I0OOOC.F.M.) 6.00 SEISMIC FEE
I hereby affirm that there is a construction lending agency for EXHAUST HOOD (WITH DUCT) 5.00
the perl'unnance of the work for which this permit is issued(Sec. MICROFILM
3097,Civ.C.f HEATING UNIT(TO 100,000 B.T.U.) 8.00
Lender's Name
Lender's Addres HEATING UNIT(OVER 10Q000 B,T.0-)9,50 ELECTRIC
I certify that 1�rL r�aV lhis$ptMctirlAnd state that theabove VENTILATION FAN (SINGLE) 4.00
information is correct I agree to comply with all city and county PLUMBING
ordinances and star, laws relating to building construction. and BOILER-OOMP(3 H.P.or 100,000 B.T.U.) 6.00
hereby authorize representatives of this city to enter upon the BOILER-COMP (Over 100,000 BTU)SEE FEE SCH. MECHANICAL
hereby enhance Property forinsm ofth i puny to
(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 in any way accrue against said City in consequence of the PERMIT ISSUANCE 10.00 T
granting f this Permit' MECH.CONT. LIC.NO. MECH. )
aTOTAL
.
�/ 00
w �a. '�
Sgnature of pplmanl�Co�ntraclor �� ate TOTAL
INSPECTOR COPY