8511 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
BUILDING PROJECT IDENTIFICATION PERMIT NUMBER
BUILDING APPLICATION & PERMIT
j /DDRE55 lir'
/ BUILDING -ELECTRICAL-PLUMBING-MECHANICAL 85
ow R' LLLTTTIII��' PLAN CHECK
VALIDATION
NAME QTY. ELECTRIC PERMIT FEE
•
CONTRACTOR'S
NAME OUTLETS-SWITCHES-RECEP 10.00/1.00
uc.No. LIGHTING FIXTURES 10.00/1.00
ADOREcorvraPA20823 Stevens Crk Blvd PPLIANCES-RESIDENTIAL 4.00
' ss
Cupertino
PHONE 2 PANELS 10.00 DATE OF APPLICATION
AROHITE PLAN CHECK FEE P.C.NO.
OR PANELS (OVER 200 AMP[ 20.00 ,4
ENGIN ER ' * IC.NO. C00917 5 SIGNS TRANS. 3.00
i
ARCH.OR ENG. PERMITP_
ADDRESS 18008 SKYPARK CR. N200 SPECIAL CIRCUIT 5.00 A`-,qS
RV I NE CA e,P .9571t TEMP. METER OR POLE INS. 20.00
t APPLICANT'$ MOTORS `SEE FEE SCH.
ADDRESS 2082er�L Rgen�ACr�581$d AUG ,2 p 1985
SERVICE CHANGE 20.00
.°u ¢
Foo
LICENSED CUN'I'RACTORS DECLARATION - TEMP.POLE 30.00 of
CUf�e
au v I hereby affirm that 1 am licensed under provisions of Chapter 9 ISSUANCE DATE
(commencing with Section 7000)of Division 3 of the Business and
a a BLD ERECT. PLG. MECH.
F D i Professions Code,and anlicense is in full force and effect. ❑ ❑ ❑
i o m - License Class Li c.Number
0 N _ [)are Contractor -@$--
a j n� r BUILDING PERMIT
¢ ¢ a OWNER-BUILDER DF;CLARATION
o a MISC.- REFER TO ORD INFORMATION
w 3 LL F I hereby ufl'irm that I :un exempt from the Comructor's License
fFu oa Law for the following reason.(Sec.7031.5„Business and Professions PERMIT ISSUANCE 10.00 vnLunTloN $/FT.
Code:Any city or county which requires a permit to construct,alter,
Qu, ¢ p Improve,demolish,of repair any structure.prior to Its issuance,also ELEC.CONTR. LIC.NO.ar ELEC.
4 i w m, requires the applicant for such permit to file a signed statement that TOTAL ERMIT TO /
he is licensed pursuant to the provisions of the )od Division License
F i
Law(ChapterProfessions
Codeng with Section is exempt
roofthe.
h i 4 as Business and Professions Code)or that he is exempt therefrom and OTY. PLUMBING PERMIT FEE
¢ F p the basis fur the alleged exemption.Any violation ofSecllon 7031.5 STORIES TYPE CONSTR.
Lu by any applicant for a permit subjects the applicant to a civil penalty ALTER-DRAIN -WATER IEA.) 5.00
of not more than five hundred dollar,($500).)'.
❑ 1,as owner of the property,or my employees with wages asBACK FLOW PROTECT. DEVICE 4.00 O .G P 5.DNIT$
their,sulc compensation,will do the work,and tru
On,stcture is not
intended or offered for sale (Sec. 7044, Business and Professions DRAINS-FLOOR,ROOF,AREA,COND. 5.00
Code T'he Contractor's License Law does not apply to an owner of
property who builds or improves thereon,and who dues such work FIXTURES-PER TRAP 5:00 SO.FT.r o AREA ror LACREAGE
. himself re through his own employees,provided that such improve- Li
hients mself a throuot gh
his or offered emor ployees,
provided
that r.such
building GAS-EA.SYSTEM-1INC.4OUTLETS 6.00
Of improvement is sold within one year of completion, the owner- GAS-EA.SYSTEM-OVER 4 IEA.) 2.00
builder will have the burden of proving that the did not build or im- -BUILDING USE
prove for purpose of sale.). INDUSTRIAL WASTE INTER. 3000 RS IND CON PB Omer
.
❑ 1,as owner of the property,am exclusively contracting with ❑ ❑ 0 ❑
licensed contractors to construct the project(Sec. 7044,[rosiness LAWN SPRINKLERS-1 INC 5 V.B. 6.00 'ASSESSORS PARCEL NO.
and Professions Code:The Contractor's License Law docs 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 it contractors)licensed pursuant to
the Contractor's License Law. SEWER-SANITARY-STORM EA.200ft/10.00 TRACT NO. PARCEL NO.
❑ lam exempt under Sec.-,BAP.C.for this WATER HEATER W/VENT 6.00 -
reason
Owner Date WATER SYSTEM 5.00
CC. ACC.FILE NO.
WORKERS'COMPENSATION DECLARATION WATER TREATING EQUIP. 5.00
I hereby affirm that I have a certificate of consent m v11-insure.
or a certificate of Workers Compensation Insurance,or a certified ZONING ENG.SITE NO
1 Copy there Sec.3800,Lah.C.).
Policy No. n - OW
_
1 O A Cert) le¢dcop i.ItIC a cd. r ! FIRE SPRINK ENERGYT T4'
Z 0 A�Ifcam �L/{ShF➢OIC-CF)P-Efuedwilh tRLTI{' - Tarop"HcityY
.Y ivision. MISC.- REFER TO ORD. Y ❑ N 'v ❑ No
~ rn PERMIT ISSUANCE 10.00
Lu - CER1'IFIQ\'fliPE SATION INS FROMW'ORKIiR$' FLDOD ZON A.L.U.C.
W COdIPotbe oro INSURANCE PLG.CONTR. LIC.NO. PLG. Y❑ NEl Y❑ NE]
� Z [This section need not be completed if the permit is for one TOTAL
hundred dollars($100)or less)
U O 1 certify that in the perfunmance of the work for which this per CITY. MECHANICAL PERMIT FEE FEE SUMMARY
LL I- mit is issued,I shall not employ any person in any....mner so as to
O U become subject to the Workers'Compensation Laws of California.
n Uatc Applicant BUILDING
} ALTER OR ADD TO MECH. 5.00
N NOTICE TO APPLICANT: If,after linking this Certificate of Ex_
F 2 mnpt on,you should beconm subject to the Workers'Connpensation APPLIANCE 5.00 PLAN CHECK
pro' of the Labor Code, you most forthwith Comply with
U
Suchprovisionsor this permit hs all be deemed revoked. AIR HANDLING UNIT(TO 10=C.F.M.) 4.00 FEE
CONSTRUCTION LENDING AGENCY AIR HANDLING UNIT(OVER 10=C.F.M.) 6.00 SEISMIC FEE 9
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 issue)(Sec. MICROFILM
f 3097.Civ.C.). HEATING UNIT(TO 100,000 B.T.U.) 8.00
,1 Lender's Name HEATING UNIT(OVER 100,000 B.T.U.)9.50 ELECTRIC
Lender's Address
p1 Ieertil'y that l have read this application and state that the above VENTILATION FAN (SINGLE) 4.00 -
ornntiun is correct. I agree to comply with all city and county PLUMBING
) '• ordinances and state laws relating to building construe ion, and BOILER-COMP(3 H.P.or 100,000 B.T.U.) 6.00
I hereby authorize representatives of this city to enter upon the BOILER-COMP [Over 100,IH)0 BTU[SEE FEE SCH. MECHANICAL
h• above-mentioned property for inspection purposes.
t (WO agree to save, indemnify and keep harmless the City of MISC.- REFER TO ORD.
Cupertino against liabilities,judgments, costs andexpenses which PERMIT ISSUANCE 10.00 CONST.TAX
may in any way accrue against said City in consequence of the
gmntingo [his permit. MECH.CONT. LIC.NO. MECH.
f TOTAL TOTAL �3S
EI ng ore of Applicant ollractur Date
INSPECTOR COPY
�s.
)( f