8426 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
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9 BUILDING PROJECT 1 DENT(FICATION PERMIT NUMBER
t =u BUILDING ��� -jAPPLICATION & PERMIT
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✓ .�. -.-���JJJ��f 3UILDING�� ELECTRICAL-PLUMBING-MECHANICAL - 4x,
i OWNER'S + I 4 '�* ]'f`I' PLAN CHECK VALIDATION
NAME 1 CITY. ELECTRIC PERMIT FEE
• ti ',z r< �t•TTP.ONE12CI 13A77
WAR 4w- %4 ^ .-.✓ �J a OUTLETS-SWITCHES-RECEP"10.00/1.00 1
$ r^ t•., sac.rvo LIGHTING'F IXTURES'- --' "' 10.00/1.00
,CON RACT R's- - - '- -ppLIANCES-RESIDENTIAL 4.00
A°DRESS 20823 Stevens Creek Blvd, .,, . - _,.. .,
CupertUoPHON 1t PANELS 10.00 DATE OF APPLICATION
T - " PLAN CHECK FEE P.C.NO.
OR PANELS (OVER 200 AMP)' 20.00
1 ENGINEER
sac.No. SIGNS TRANS. 3.00 IDA TrV
GRANDELLADDRESS 18008..SKY,PARK .CR.. XSPECIAL CIRCUIT 5.00 R (DATION
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>IhoP EMP. METER OR POLE INS. 20.00 'MOTORS SEE FEE SCH. AUG 2 0 1965
AooRE
ss 20823 �Stevens Creek Blvd,
#C2C. Cupertino CA 95 14 SERVICE CHANGE 20.00 City of Cupertino
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00 LICENSED CONTRACTORS DECLARATION TEMP.POLE 30.00
G u w I lerchy affirm [hat I am IiCcoscd under provisions of Chapter 9 ISSUANCE DATE
w c w (commencing with Section 7000)of Division 3 of tiro Business and SLOG ELECT. PLG. MECH.
Hoz Professions Code,and my license is in full force and effect ❑ ❑ ❑
i,z o - License Clas�s��y���1 Number
i o z F Date a Com'odw,b C.
" WN BUILDING PERMIT
.I to rt w a
OWNER-BUILDER R-BUILDER DECLARATION
A o A 0 INFORMATION
..'w ; a- I- I hereby affirm that I am exempt from the Contractor's License MISC.- REFER TO ORD'
.. o a Law for the following reason.(Sec.703 L5.Businessand Professions PERMIT ISSUANCE 10.00 VALUATION 8/FT.
- Code:Anycity orcounty which requires a permit to construct,
re G improve,demolish,or repair any Mnreture,prior to its issuance,also ELEC.CONTR. LIC.NO. ELEC.
U
iL ¢ requires the applicant for such peri[to file a signed statement that TOTAL RM TO
w he is licensed pursuant to the provisions of the Contractor's License /
w i Law(Chapter 9(commencing with Section 7000)of Division3ofthe
4o Business and Professions Code)or that he is exempt therefrom and QTY. PLUMBING PERMIT FEE i
iM tr: s- o the basis for the alleged exemption.Any violation of Section 703 L5 STORIESSJ VE TR.
n a- by any applicant fora permit subjects lheapplicant toacielpenally ALTER-DRAIN& VENT-WATER (EA.) 5.00
.fact more than five hundred dollars(55001.):
❑ Las owner of the property,or my employees with wages as BACK FLOW PROTECT. DEVICE 4.00 OCC.1G
their sole compensation,will do the work,and the structure is not
intended or offered for sale (Sea 7044, Business and Professions DRAINS-FLOOR,ROOF,AREA,COND. 5.00
Curie:The Contractor's License Law does not apply to an owner of
property.who builds or improves thereon,and who does such work FIXTURES-PER TRAP 5.00 SO.FT.FLO A TOTALACREAGE
. • himself or through his own employees.provided that such improve.
mems are not intended Or offered for sole.If,howeveq the building GAS-EA.SYSTEM-11NC.4OUTLETS 6.00
or intp,o,Cn,CUt is sold within one year of completion, the owner. GAS-EA.SYSTEM-OVER 4(EA.) 2.00 'leu ING USE
builder will have the burden of forcing that he did not build or him y
{rI prove for purpose ofsaleJ. - INDUSTRIAL WASTE INTER. 30.00 IND CON PB Omsr
O. I,as owner of[he properlyx?am exclusively comraging with ❑ ❑ ❑ Cl
licen'ed Contractors to construct the project(See 7044,Business LAWN SPRINKLERS-1 INC 5 V.B. 6.00 J ASSESSORS PARCEL NO.
and I'rol'ussmns Code:The,Conttuctor's License Law does not apply
to un owner of prolicrty who builds or improves thereon,andwho LAWN SPRINKLERS-OVER 5(EA.) 1.00
contracts for such projects with a contractions)licensed pursuant to;1 SEWER-SANITARY-STORM EA'.200ft/10.00 the Contractor's License Law. TRACT NO. PARCEL NO.
O lam exempt under Sec.-,B.&P.C,for this WATER HEATER W/VENT 6.00
reason
Owner Date WATER SYSTEM 5.00 c ace.FILE No.
WORK ERS'COMPENSAI DON DECLARATION", WATER TREATING EQUIP. 5.00
I hereby affirm that I have a Certificate of consent to self-insure,
or a certificate of Workers'Compensation Insurance,or a certified Sed ZONING ENG.SITE NO.
copy thereof(Sec.3800,Lab.C.L
I Policy No.,�j �1I� {jUff' II�
O [J Ccri Ri�dyla'm nishbf�nrE•V I�u +r - FIRE SPRINK ENERGY T 24
Z Z Q Certified copy is filed with the city,inspection division.
O Applicant e• MISC.- REFER TO ORD. Y ❑ N v ❑ No
F.- w �'AS-Q�tiPEllONF FROM
WOR -PERMIT ISSUANCE 10.00
` /� - f,ERTIF ICATIi OF FTSE}f I'I'ION PROsiM N'ONK ERS' FLOOD ZON A.L.u.C.
t L COMPENSATION INSURANCE. PLG.CONTR. - LIC.NO. PLG ❑
7. ❑(This sectioncsectionBeefno
Beef t be complded if the punnit is for one TOTAL YY❑ NEI2
hundred dollarsIn,the performance
„LL O I is issued,
I hall n performance of the work for which this per. OTY. MECHANICAL PERMIT FEE FEE SUMMARY
LL U •mit is issued,I shall not employ any person in any Banner so is to
i become subject to tire Workers'Compensation Laws of California.
0- Datc - Applicant ALTER OR ADD TO MECH. 5.00 BUILDING
} N NOT WE TO APPLICANT:.If,after making this Certificate of Ex
F
Z eniption,you should bemmC subject m the Work erF Cont pen suI ion APPLIANCE I 5.00 PLANCHECK
I
provisions the Labor Code, you most forthwith comply with
U°a such provisions or this permit shall be deemed revoked AIR HANDLING UNIT(TO 10,000 C.F.M.) 4.00 FEE
CONSTRUCTION LENDING AGENCY AIR HANDLING UNIT(OVER 10=C.F.M.) 6.00 SEISMIC FEE L
All hereby.affirm that there is a construction Icnding agency for .EXHAUST HOOD (WITH DUCT) 5.00
Ili i the performance of the work for which this PCnnit is issued(Sec MICROFILM
3097,CI,C). Y.. HEATING UNIT(TO 100,000 B.T.U.) 8.00
I
Lenders Name HEATING UNIT(OVER 100,000 B.T.U.)9.50' Lender's Address - ELECTRIC
4 I certify that l havereadthis application and state that the above VENTILATION PAN (SINGLE) x4.00
�.is information is correct.'( agree to comply with all city and emony PLUMBING
(.(L oohrome, and state laws relating to building construction. and BOILER-COMP(3 H.P.or 100,000 B.T.U.) 6.00
1 hereby authorise representatives n[ this City to enter upon the BOILER-COMP(Over 100,000 BTU)SEE FEE SCH. MECHANICAL
above-mentioned property for inspection purposes.
I (We) agree to cave,, indemnify and keep harmless the City of MISC.- REFER-TO ORD.
1 Cupertino against liabilitie¢,judgments, costs and expenses which PERMIT ISSUANCE 10.00 CONST.TAX
to may in any.way, accrue gainst said City in consequence of the ..
1,( I I granting of this permit. MECH.CONT. LIC.NO. MECH.
f �. TOTAL TOTAL 3
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pp icant/Contractor Uabli,
I
INSPECTOR COPY
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