8507 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE.BALL POINT PEN ONLY
BU LDI NG PROJECT I DENTI FICATI ON PERMIT NUMBER
I BUILDING APPLICATION & PERMIT
ADUR ESS
S TB}3�11 BUILDING - ELECTRICAL-PLUMBING-MECHANICAL 8507
..E s PLAN CHECK VALIDATION
I' NAME QTY. ELECTRIC PERMIT FEE
P o E i # X27
NAMEOUTLETSOUTLETS-SWITCHES-RECEP 10.00/1.00 O�
LIC No. LIGHTING FIXTURES 10.00/1.00
}' coNTRACTo APPLIANCES-RESIDENTIAL 4.00
rupertinn ADPREas ` 082e s3 Stevens -Crk B] vd
PRo- 252-2077 PANELS 10,00 DATE OF APPLICATION-
I( ORRCNITEC PANELS 200 AMP) 20.00 PLAN CHECK FEE P.C.NO.
FWNk"ARFK
* CRANDELLLN.. SIGNS TRANS. 3.00--.1
ARCH.
ENG. SPECIAL CIRCUIT 5.00 PERMIT VP
18008 SKYPARK CR. #200
Flo $ zas ,EMP.METER OR POLE INS. 20.00 {�
ADDLRC56 '2Q2rL#��en�A CrbSB11d MOTORS SEE FEE SCH. AUG .4U 198
2C I UPP SERVICE CHANGE 20.00
0 0 o LICENSED CONTRACTORS DECLARATION TEMP.POLE 30.00 City of Cupertino
¢ U I herrb atfinn that I am licensed under revisions of Cha pier 9
a Y P ) ISSUANCE DATE
Nw fcommenctng with Section 7000)of Division 3 of thr Business onA
Z PLG. MECH.
H BLD ELECT.
H >z Professions Code,and my license is in full force and effect ❑ ❑ ❑
z o w - Liccnsc Class�/�!�r{�y�- co Number
O N - G Datl' _G.T y.ly_COrlt JCtOr
¢ ¢ w tr
a OWNER-BUILDER DECLARATION BUILDING PERMIT
U INFORMATION
'xl ;u U. y I hereby affirm that I am exempt from the Contractor's License MISC.- REFER TO ORD 1'
O a Law for the following reason.(Sea 7031.5,Business and Professions
VALUATION S/FT.
� " PERMIT ISSUANCE 10.00
Code:Any city or county which requirese permit to construct., dS,
¢ improve,demolish,Or repair any structure,prior l0 its issuance,alp0 ELEC.CONTR. LIC.NO. ELEG.
u O ¢ requires the appliCunt for such permit to file a Sigurd statement Ihus TOTAL
aa m u he is licensed pursuant to the provisions of lite Contractor's License PERMIT TO
F Z i
Law(Chapter 9(commencingwith Section 7000)of Division 3 of the
14 o Business and Professions Code)or that he is exempt therefrom and QTY. PLUMBING PERMIT FEE tf
¢ I- o the basis for the alleged exemption,Any violation of Section 7031.5 STORIES TYP15CONSTR.
a ;x� byanyapplicanl for a permit subjects the applicant loa civil penalty ALTER-DRAIN -WATER IEA.) 5.00
of not more than five hundred dollars($500).):
O I,as owner of lite property.or my employees with wages as BACK FLOW PROTECT. DEVICE 4.00 OCC.G OP ES-UNITS
their sole compensation,wit)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
properly who builds or improves thereon,and who does such work FIXTURES-PER TRAP 5.00 sn.Fr.PLooR A EA To AL ACREAGE
• himself or through his own employees,Provided that such int Provo
m
mes 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, she owner- GAS EASYSTEM OVER 4 IEA) 200
builder will have lite burden of proving that Ile did not build or in - . - . .
III,. BUILDING USE
I R S IND CON PB 'Other
prove for OPnsr Ofsale.). INDUSTRIAL WASTE INTER. 30.00
❑ d as owner of the prof r construct
he exclusively contracting wish ❑ ❑ ❑ ❑
• I licensed contractors to a Contractor's
the project(Sec.7044,Business LAWN SPRINKLERS- 1 INC 5 V.B. 6.00 ASSESSORS PARCEL N0.
M Professions Code: ty Contractor's License Law Joos not apply
r. to contracts
owner of property who builds t r improves thereon.and who LAWN SPR INKLERS-OVER 5(EA.) 1.00 F
cher Contractors
Licenseetswith a contraaurfs)licensed purawnt in SEWER-SANITARY-STORM EA.200ft/10.00
the ContradoYs License Luw. TRACT N0. PARCEL N0.
❑ lain exempt under Sec.-,B.&P.C.tar this WATER HEATER W/VENT 6.00
reason
Owner - Dare WATER SYSTEM 5.00Act.DATE ACC.FILE NO.
'WORD FRS'COMPENSATION DECLARATION WATER TREATING EQUIP. 5.00
r I hereby affirm that 1 have a certificate of consent to self-insure. ZONING ENG.SITE N0.
I or a certificate of Workers'Compensation Insurance,or a certified
I copy thereof(Sec.3800,Lab.CJ.
Policy No. �N'(�I�'fy, -{��(���./�
0 Q Ccrtlt}fy1h1LT: u rod. "•r•` r ' D FIRE SPRINK ENERGY T-24
Z Z LSI Certified copy 's filed with theity inspection division.
Applicantpp ��(� to • � e - MISC.- REFER TO ORD.
Q Dn9�_C tlTLICI II'I 11- Y ❑ N❑ Y ❑ N❑
CC w PERMIT ISSUANCE 10.00
Lu - CERTIPICCOMPFNAXIOTINS FROMWORRI>RS' FLOOD ZONE A.L.UC.
W need not be completed
INSURANCE the PLG.CONTR. LIC.NO. PLG. Y❑ N❑ Y ❑ N❑
hundred
section need not be compldeA if lite pennis is for one TOTAL
hundred dollars IS 100)or less.)
U O I certify that in the performance of she work for which this per- OTY MECHANICAL PERMIT FEE FEE SUMMARY
LL H mit is issued,I shall not employ any Perron in any planner so as to
#
U w become subject to the Workers Compensation Laws of California. p
o, DateApplicantADD TO MECH. 5.00 BUILDING .I
} W NOTICE TO APPLICANT: If,after making this Certificate of fix- ALTER OR
f- Z emption,you should become subject to the Workers Conlpensasimt APPLIANCE 5.00 PLAN CHECK
proon
visis of the Labor Code, you umsl fofshwith comply with FEE
U such provisions or this permit shall he deemed revoked AIR HANDLING UNIT(TO 10=C.F.M.) 4,00
CONSTRUCT ION LENDING AGENCY AIR HANDLING UNIT(OVER 10,000C.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
Lender's Address H EATI NG UNIT(OVER 100,000 B.T.U.)9.50
\ r ELECTRIC
I certify Olaf I have read lid's application and state that the abovr VENTILATION FAN (SINGLE) 4.00
information is correct. I agree to comply with all city and county PLUMBING
ordinances and state laws relating to building construdfon, and BOILER-COMP(3 H.P.or 100,0009.7.11) 6.00
i bemby authorize roperty for ins inspection
this city Io color upon she BOILER-COMP IOve1100,000 BTU)SEE FEE SCH. MECHANICAL
I - above-mentioned property for .1 this
purposes.
(We) agree to save, indemnify and keep harmless Ote 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
granting of this permit. MECH.CONT, LIC.NO. MECH. If
TOTAL TOTAL j
a are of Applicant Contractor- Date
INSPECTOR COPY
w' I