8515 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
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BU LDI NG PROJECT I DENTI;FICATI ON , PERMIT NUMBER
BUDDING I APPLICATION & PERMIT
gooREss UDINGBIL -ELECTRICAL-PLUMBING-MECHANICAL
O SS irelill Ct � - 8515 --
PLAN
51 5
PLAN
CHECK VALIDATION
NAME CITY. ELECTRIC PERMIT FEE
NAME ACT s OUTLETS-SWITCHES-RECEP 10.00/1.00
IncLIc.No. LIGHTING FIXTURES 10.00/1.00
.o nc a 20823 Stevens Crk..Bl N PPLIANCES-RESIDENTIAL 4.00
ADDRESS
v
Cupertino PHONE _ PANELS 10.00 DATE OF APPLICATION I
"
PANELS (OVER 200 AMP) 20,00 PLAN CHECK FEE P.C.NO.
oR
ENGINEER
11! CrandplllhNG. - SIGNS TRANS. 3.00 I7/410
ARCH.OR RCHES N �, SPECIAL CIRCUIT 5.00 PERMIT VALIDATION
Irvine,ORES18eR8 Skypark Cr ., 42o AUG 2
ZIP 9571 EMP.METER OR POLE INS. 20.00 U 1985
APPLICANTS MOTORS SEE FEE SCH.
ADDRESS 20823 Stevens Crk B1 d Cit
7.
SERVICE CHANGE 20.00 y Of Cupertino
Foo LICENSED CON'[ TEMP.POLE 30.00 RACTORS DECLARATION 4 � T
¢ cwi o 1 hereby affirm that 1 ant IWEDA,d under provisions of Chapter9 ISSUANCE DATE
a a a (commvming with Section 7000)of Disi,wo 3 ol'the Bminess and BLD ELECT. PLG. MECH.
in w in Professions Code,and my license is in full forcpe a�nd�eQffe�ct. ❑ ❑ ❑
,00 m - Licenu CI ss Lic.Numbe--VGd-R
z r Lice Contractor
Q y E C
¢ ¢ a OWNER-BUILDER DECLARATION Y BUILDING PERMIT
o d " MISC.- REFER TO ORD INFORMATION
w ; H I hereby affirm that I am exempt from the Contractor's License
u VALUATION ppi $/FT.
Fu0 J Law for the following reason.(Sec.7031.5,Business and Professions PERMIT ISSUANCEa 10.00 Ar
wr Code.Any city or county which requires.permit to construct,alter,
Q ¢ QO Improve,demolish,Of repair any structure,prior to its issuance,also ELEC.CONTR. LIC.NO. ELEC.
O¢ reyuircs the applicant for such permit to file a signed statement(hal TOTAL P MI TO 1
A.
T m he is 11CCOsed pursuant to the provisions of the Contractor's License
Fz >
Law(Chapter 9(commencing with Section 7000)of Division 3 of the
a Business aDa Professions Code)or that he is exempt therefrom andCITY. PLUMBING PERMIT FEE
the basis for the alleged exemption.An
¢ Ff om g 1 Any violation ofSedion 7031.5 STORI TYPE CONSTR.
i 3 _
by an It licant for ennit subjects the applicant toacivil renals
+ f y pP p I penalty ALTER-DRAIN&VENT-WATER (EA.) 5.00
of not marc than live hundred property,
r my emp
❑ 1,as owner at the property,or my employees with wages as BACK F LOW PROTECT.DEV ICE 4.00 OCC.GROUP R S.UNITS
their sole compensation,will(S the work,and the structure is nal
ii Code:The offered for sale(Sec. 7044, Business and Professions DRAINS-FLOOR,ROOF,AR EA,CON D. 5.00
' Code:'fee Contramuh License Law docs not apply to un owner ul
property who builds or improves omreom,and who docs such work FIXTURES-PER TRAP 5.00 SD.FT.FLOG/ ARE TO AL ACREAGE
16
meats l re through his own employees,provided that such improve- /(p '
mems are through
intendeughhis or empld ees.or provided
that r.seel, building GAS-EA.SVSTEM-11NC.40UTLETS 6.00 �.
or improvement Is sold within one ycur of cent Plctlon,the owner- GAS-EA.SYSTEM-OVER 4 IEA.) 2.00 RuaolNc USE
builder will have the burden of proving that lie did not build or hit-
\ - R IND CON '-PB Other
prove for purpose of stheJ. INDUSTRIAL WASTE INTER. 30.00 ❑ i3- D 140
❑ I,as owner al'the property,um exclusively contracting with
i licensed contractors to construct the project(Sec 7044,Business LAWN SPRINKLERS- 1 INC 5 V.B. 6.00 A45ESSOHS PARCEL NU.
I and professions Codu:.ThecG%,IDfztor;ssLLicense Law does not apply
I to an.owner of property w0 builds or Improves thereon,and who LAWN SPRINKLERS-OVER 5(EA.) 1.00
contracts for such projocts with:Fcontmcind➢)licensed pursuant to
the Contractor's License Law. SEWER-SAN ITARY-STORM EA,200ft/10.00 TRACT NO. PARCEL NO.
'( ❑ 1 am exempt under Sec. `-'\,B.&PC.ter this WATER HEATER W/VENT 6.00
i '�.reason '
Owner- Dau WATER SYSTEM 5.00 1 AdC.DATE ACC.FILE NO.
I-
WORKERS"COMPENSATION DI:CI,ARA'f ION WATER TREATING EQUIP. W:t . 5.00
( I hereby affirm that I have a certificate of Consent to self-insure. ZONING ENG.SITE N0.
or a certificate of Workers'Compensation Insurance,or a certified
I copy ilureof(Sec 3800,Lab.C.f
Policy CerVIIM09f9p-hed. y,a-r
4 I y I'{I FIRE SPR IN ENEPGY T-29
z Z Cerifl--�tl d� py is fled with the city inspection division. MISC.- REFER TO ORD. i-]
O Applic_anFFli O C rl-dT--yam-PCRI-y 140 -11 Y N Y N
a: LO CIiR'1'IPICA'fl$UF EXEMPTION FROM WORKERS' PERMIT ISSUANCE 10.00 FLOOD zoN A.L.u.C.
L COMPENSATION'INSURANCE PLG.CONTR. LIC.NO. PLG, v ,/aY N
CL CI (This-section need not be completed if the permit is for one TOTAL El
hundred dollars I S I00)or las.)
U 0 1 certify that in the performance of the work for which this per- CITY. MECHANICAL PERMIT FEE FEE SUMMARY
LL H mit is issued;I shall not employ any person in any manner so as to !�
O U become subject tD the Work 'Compensation Laws of Cail'ornia.
u Cmc I Applicant ALTER OR ADD TO MECH. 5.00 BUILDING
} to NOTICE 10 APPLICANT. If,after making this Certificate of fix
F ? empfoo,you should become subject to the Workers'Compensation APPLIANCE 5.00 PLAN CHECK
provisions of the Labor Code„you must forthwith comply with
U such provisions or this permit shall be deemed revoked AIR HANDLING UNIT(TO 10=C.F.M.) 4.00 FEE
CONSTRUCTION LENDING AGENCY AIR HANDLING UNIT(OVER 10=C.EM.) 6.00 SEISMIC FEE
t 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. MICROFILM
3097,G'v.C.). ( HEATING UNIT(TO 100,000 B.T.U.) 8.00
Ixnder's Name I HEATING UNIT(OVER 100,000B.T-U.)9.50
1 1 Lender's Address ELECTRIC
1 certify that I have read Ibis application and state that Om above V ENTI LATIGN.F,AN-(SINGLE) 4.00
P 0information is correct. I agrec.to comply with all city and county - PLUMBING /!
ordinances and state laws relatin5 to building construction, and 601 -COW(3 H.P.or-100,000 B.T.U.) 6.00
hereby authorize representatives of this city to enter upon the 'g OILER-COMP (Over 10Q000 BTU)SEE FEE SCH. MECHANICAL e
above-mentioned property for inspection PmrpasCs,
(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 the
granting of this permit. MECH.CONT. _ LIC.NO. MECH.
OTAL TOTAL 7� O
i It alure Of pphcent/CRntractor I O
T• INSPECTOR COPY
• A ..