C8521APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
BU I LDING PROJECT I DENTIF I CATION
! i
APPLICATION & PERMIT
.BUILDING - ELECTRICAL- PLUMBING - MECHANICAL
PERMIT NUMBER
BDILD,NG
ADDRESS (qui to 2Co
10201 Torre AveIIue "C Cupertino- •
OWNER'S ^ / �-- (41
NAME ? 5 )
Lineoln Property CoI�Siny 571-L20
-
DTV. ELECTRIC PERMIT FEE
NCHECK VALIDATION
NAMERAc*ors
OUTLETS - SWITCHES -RECEP 10.00/1.00
WIICI uc. No. 377579 -,
LIGHTING FIXTURES 10.00/1,00
TORS (415 328 -OBS
ADDRESS
PPLIAN_CE_S-_R_ES_I_D_E_NTIAL 4.00
1011.Hamilton Ct. , McX11O k§rtC..CA•,
. , PANELS;_ .... ..... 110.00
DATE OF APPLICATION
ARCHITECT
OR
ENGINEER
LIC. NO, 377579
PANELS (OVER 200 AMP) 20.00
PLAN CHECK FEE P.C. NO.
SIGNS TRANS. 3.00
ARCHHE R ENG.. ^-- --
" SPECIACCIRCUIT 5.00 ML
PERMIT VALIDATION
�.
EMP. METER OR POLE INS. 20..
••' MOTORS "` - SEE FEE SCH
!QftMenle
ADDRESS T `-
_ • J
\/U,�j `�/✓/
SERVICE CHANGE 20.00
_
LICENSED CONTRACTORS DECLARATIO1,T
TEMP, POLE 30.00
1 hereby allirin that I ant licensed under provisiotisrof Chapter 9
[commencing with Section 7000) of Division 3 of the Business and
Professions Code, and my license is in full force and effect.
License Class Lie. Furber
ISSUANCE DATE
BLDG-
ELECT.
❑
PLG. MECH.
❑ ❑
/q ..........
Dates -/p -Ips. B Contractor -V
5",o,OWNER-BUILDER
... ...... �.,.- ....^..-, ... .
BUILDING PERMIT
INFORMATION
4i.�9
DGCLARA'I'ION«w.-«+.�
hereby affirm that I ant exempt from the Contractor's License
Law for the following reason. (Scc.oinesO,ermit t0cndt'rofessions
Code: Any mulish county
to cansuance, heq
improve, demolish, or repair any structure. prior to its issuance, also
pair any structur e p prior
requires the applicant for such permit to file a signed statement that
he is licensed pursuant to the provisions of the Contractor's License
MISC.- REFER TO ORD
VALUATION
/,/ Sv'f7
$/FT.
PERMIT ISSUANCE 10.00
ELEC. CONTR. LIC. NO.
ELEC.
TOTAL
PERMIT TO
OTV PLUMBING PERMIT FEE
Law (Chapter 9 (commencing with Section 7000) of Division 3 sit the
Business and Professions Code) or that he is exempt therefrom and
/N %FJZw
STORIES
TYPE CONSTR.
the basis for the alleged exemption. Any violation oftiection 7031.5
by any applicant for a permit subjects the applicant o a civil penalty
of not more than five hundred dollars (S500).):
ALTER -DRAIN -WATER (EA.) 5.00
❑ I, as owner of the property, or my employees with wages as
their sole compensation, will do file work, and the structure is not
BACK F LOW PROTECT. DEV ICE 4.00 t
OCC. GROUP
RES. UNITS
DRAINS -FLOOR, ROOF, AREA, COND. 5.00
intended or offered for sale (Sec. 7044, Business and Professions
Code: Tire Contractor's License Law floes not apply to an owner of
property who builds or improves thereon, and who does such work
himself or though his own employees, provided that such improve.
ments are not intended Or offered for sale. If. however, the budding
,
_
FIXTURES - PER TRAP 5.00
SO. FT. FLOOR AREA
TOTAL ACREAGE
GAS - EA. SYSTEM - I INC.4 OUTLETS 6.00
or improvement is sold within one year of completion, the owner-
builder will leave lire harden of proving that he did not build or iIll.
prove for purpose Olsale.).INDUSTRIAL
❑ I, as owner of'tire property', am exclusively contracting with
licensed contractors to construct the project (Sec. 7044, Business
and Professions Code: The Contractor's License Law does not apply
to an owner of property who builds or improves thereon. and who
GAS - EA. SYSTEM - OVER 4 (EA.) 2.00
_
BUILDING USE
RES IND CON PB other
❑ ❑ ❑ ❑ ❑
WASTE INTER. 3000
:
LAWN SPRINKLERS- 1 INC 5 V.B. ' 6.00
LAWN SPR INKLERS - OVER 5 (EA.) 1.00
ASSESSORS PARCEL NO.
contracts lot such projects with a con,art.00 licensed pursuant In
the Con fleeters License Law.
SEWER-SANITAR V -STORM EA. 200ft/10.00
TRACT NO.
PARCEL NO.-
❑ 1 am exempt under Scc. .B,&P. C. for Dl is
reason
WATER HEATER W/VENT 6.00
Owner Date
WATER SYSTEM 5.00
ACC.OATE
ACC. FILE NO.
,WATER TREATING EQUIP. 5.00
WORKERS' COMPENSA'I' ION DECLARATION
I hereby affirm that I have a certificate of consent to rel Ginslo,.
or a certificate of Workers' Compensation Insurance, or a cvinifi,d
I
ZONING
ENG, ITE NO.
copy thereof (Sec. 3800, Lab.C.).
Policy No.' ef.ub,,y
ElCtrl Y byfu )Ind.D�„D
IQ Certified �opy is Ole r'ith the, city inspection divisions
Al icnt
_
a iea.._
FIRE SPRINK
IY❑ N❑
ENERGY T 24
Y❑ N❑
MISC,- REFER TO ORD.
CFRTIFICATI EXEhtfTIh�ON 17ROM WORKERS'
PERMIT ISSUANCE 10.00
FLOOD ZONE
A.L.uc.
PILO, CONTR. LIC. NO.
PLG.
TOTAL
COMPENSATION INSURANCE
(This section need not be Completed if the permit is for one
Y ❑ N
Y ❑ N❑
hundred dollars ($100) or less.)
I certify that in the performance of the work for which this per
]Ili[ is issued, 1 shall not employ any person in any Inunner so os ❑a
QTY. MECHANICAL PERMIT FEE
FEE SUMMARY
BUILDING
become subject to the Workers' Compensation Laws o(Cali(omia.
Date Applicant
ALTER OR ADD TO MECH. 5.00
NOTICE TO APPLICANT: If, after making this Certificate of Ex-
emption, you should become subject to the Workers Compensation
APPLIANCE 5.00
PLAN CHECK
Provisions of the Labor Code, you most forthwith comply with
such provisions or this permit shall be deemed revoked.
-
AIR HANDLING UNIT (TO 10.000CF.M.) 4.00
FEE
AIR HANDLING UNIT (OVER 10p00C.F.M.) 6.00
SEISMIC FEE
K/(
CONSTRUCTION LEN DI NG AGENCY
I hereby affirm that there is a construction lending agency for
EXHAUST HOOD (WITH DUCT) 5.00
the perforirtancet of clic work for which this permit is issued (Sec.MICROFILM
3097, Civ.C,1.
Lender's Name PBS mortgage Cem lin-r--
Lender', Acidic ss
HEATING UNIT (TO 100,000 B.T.U.) 8.00
HEATING UNIT (OVER 100,000 B.T.U.19.50
ELECTRIC
^-
1 certify that I ha-TLMspp tion UI al t e move
- 'VENTILATION FAN (SINGLE) 4.00
information is correct. I agree to comply with all city and county
Ordinances and state laws relating to building construction, and
PLUMBING
80ILER-COMP(3H.P.or100,000B.T.U.1 6.00
BOILER -COMP (Over 100,000 RTU15EE FEE SCH.
MECHANICAL
hereby authorize representatives of this city to enter upon the
above mentioned property for inspection purposes.
MISC. - REFER TO ORD.
CONST. TAX
(We) agree to save, indemnify and keep hmrnles the City of
Cupertino against liabilities, judgments, costs and expenses which
may in any way accrue against said City in consequence of the
PERMIT ISSUANCE 10.00
grantingohhis PerriL `
Sig c t/Cit r
MECH. CONT. LIC. NO. MECH.
TOTAL
TOTAL
1 INSPECTOR COPY