9252-FAPPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
BUILDING PROJECT IDENTIFICATION
APPLICATION &PERMIT
BUILDING - ELECTRICAL- PLUMBING - MECHANICAL
PERMIT NUMBER
5^
G
aDILDING
ADDRESS
/vc 2 r
OWNER'S
PLAN CHECK VALIDATION
NAME '/
CH '� vnoNE
OTY. ELECTRIC PERMIT FEE
NAME Acrona
1 UTLETS-SWITCHES -RECEP 10.00/1.00 (- -
LIGHTING FIXTURES 10.00/1.00 -.
^ Lac.
-40,
v- Y Ac oR -
ADDRESS �A ,
APPLIANCES -RESIDENTIAL 4.00
PANELS 10.00
`V
eRONe -�
DATE OF APPLICATION
A`RCPRT
on
PANELS (OVER 200 AMP) 20.00
PLAN CHECK FEE P.0 No.
ENGINEER
LIC. No,
SIGNS TRANS. 3.00
ADDRESS ENC'
SPECIAL CIRCUIT 5.00
PERMIT VALIDATION
EMP. METER OR POLE INS. 2Q.W
ZIP
�
APPLICANT 'S
ADDDRESS
MOTORS SEE FEE SCH.
SERVICE CHANGE 20.00
LICENSED CON 'I'RAC'FORS DECLARATION
' TEMP. POLE 30.00
I hereby affimh that 1 am licensed under provisions ol'Chapter 9
ISSUANCE DATE
(commencing with Seclion 7000) of Division 3 of (lac Business and
Professions Code,an m license isin lall lurcep deffect.
Licanv,Class Licm
. Nuburd
BLDG.
ELECT.
PLG.
MECH.
Datc ?, - Contractor I
BUILDING PERMIT
OWNERTUILDER DL'CLARP.TION
I hereby affirm ContraContractor'sMISC.
that I am exempt frothe Contractor's License
Law for the following reason. (Sec. 7031.5, Business and Professions
Code: Any city or county which requires a permit to construct, alter,
improve,demolish. or repair any structure. prior to its issuance. also
requires the applicant for smelt permit t0 file a signed statement that
he is licensed pursuant to the provisions of the Contractor's License
Law (Chapter 9 (commencing with Section 7000) of Division 3 of the
Business and 1'rol'cssions Code) or that he is exempt therefrom and
INFORMATION
- •' REFER TO ORD
VALUATION
S/FT.
PERMIT ISSUANCE -10,00
ELEC. CONTE. LIC. NO.
e
'
ELEC.
TOTAL / V-
PERMIT TO
L�G
CITY. PLUMBING PERMIT FEE
STORIES I
ItYPE CONSTR.
the basis for the alleged exemption. Any violation of Section 7031.5
by any applicant for d Recruit subjects the applicant to a civil penalty
of not more than five hundred dollars ($500)J:
ALTER -DRAIN -WATER (EA.) 5.00
❑ I, as owner of the properly, or my employees with wages as
their sole compensation, will do the work, and the structure Is not
BACK FLOW PROTECT. DEVICE 4.00
DCC. GROUP
RES. UNITS
DRAINS -FLOOR, ROOF, AREA,COND. 5.00
intended or offered for sale (Sec. 7044, Business and Professions
Code: The Contractor's License Law docs not apply to an owner of
property who builds or improves thereon, and who does such work
himself or through his own employees, provided that such improve-
mentsarenotintendedoroffered for sale. If, however, the building
FIXTURES - PER TRAP 5.00
SO. FT FLOOR AREA
TOTAL ACREAGE
GAS-EA.SYSTEM-I1NC.40UTLETS 6.00
or improvement is sold within one year of completion, the owner-
builder will have the burden o' proving that h e did not build or im-
prove for Purpose of sale.).
❑ I, as owner of the property, am exclusively contracting with
. ..
GAS - EASYSTEM -OVER 4 IEA) 200
BUILDING USE
RES IND CON PB Omer
❑ ❑ ❑ ❑ ❑
INDUSTRIAL WASTE INTER. 30.00
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
LAWN SPRINKLERS - 1 INC 5 V.B. 6.00
LAWN SPRINKLERS - OVER 5 (EA.) 1.00
ASSESSORS PARCEL NO.
contracts forsuch projects with a contractods) licensed pursuant to
the Contractors License Law. ..
SEWER -SANITARY -STORM EA. 200ft/10.00
TRACT NO.
PARCEL NO.
❑ I ani exempt under Sec. .B.&P.C. for this
lcaclon
WATER HEATER W/VENT 6.00
Owner Date
WATER SYSTEM 5.00
ACC. DATE
ACC. FILE No.
WATER TREATING EQUIP. 5.00
WORK ERS'COMPENSATION DECLARATION
I (hereby affirm that I have a certificate Of consent to self-iname.
or a certificate of Workers'ZONING Compensation Insurance, or a certified
ENG. SITE NO.
copy thereof (Sec. 3800. Lab.0 1. /'
Policy No. Company �ir�t. i••
FIRE BPRINK
Y❑ N❑
ENERGY T -Z4
Y❑ N❑
❑ CeRified copy is hereby' furmshed. �-
Certifi -d copy is file) ' wh th• cit inspect' h division.
t
MISC.- REFER TO ORD,
11
'IFICATEOF EXI'MPII0 M WORRIERS'
CIiR1� O
PERMIT ISSUANCE 10.00
FLOOD ZONE
AL.II.C.
PLG.CONTR. LIC. NO,
PLG,
TOTAL
C'OMPENSA'I' ION INSURANCE
PILE, welion need not be complcled it the Permit is for ane
v ❑ N❑
Y ❑ N❑
hundred dollars IS 100) or less.)
I certify that in the jmrOmnhaace, of um work for which this per-
not is issued 1 shall not employ any person in any manner so as to
QTY. MECHANICAL PERMIT FEE
FEE SUMMARY
"
BUILDING
become subject to the Workers' Compensation laws of California.
Dade 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 must forthwith comply with
such provisions or this permit shall be deemed revoked.
FEE
AIR HANDLING UNIT (TO 10MC.F.M.) 4.00
AIR HANDLING UNIT (OVER 10=C.F.M.)6.00
SEISMIC FEE
CONSTRUCTION LENDING AGENCY
I hereby affirm that there is a construfiun Icnding,agency for
EXHAUST HOOD (WITH DUCT) 5.00
0i performance of the work for which this permiPis issued (Sec.
MICROFILM
HEATING UNIT (TO 100,000 B.T.U.) 8.00
HEATING UNIT 100,000 B.T.U.)9.50
ELECTRIC
(JY
Lender's Name
Lenders Address
I certify that l have read this application and star, that the above
VENTILATION FAN (SINGLE) 4.00
Rfunnatinn is correct. I agree to comply with all city and county
ordinances and slate laws relining to building construction, and
PLUMBING
BOILER-COMP(3 H.P. or 100,000 B.T.U.) ,6.00
BOILER -COMP (Over 100.000 BTU) SEE FEE SCH. -
MECHANICAL
hereby authorize representatives of this city to enter upon the
above mentioned properly for inspection pupmhscs.
MISC. - REFER TO ORD.
(We) agree to save, indemnify and keep harmless the City of
Cupertino against liabilities, judgments, costs and expenses which
may in any waySecme Rest sai Gily in consequence of the
CONST. TAX
PERMIT ISSUANCE 10.00
grantin l this permit]
MECH. CONT. LIC. NO.MECH.
TOTAL
TOTAL
} [Cant nDac[ D t
INSPECTOR COPY
APPLICANT TO ;FILL IN INFORMATION WITHIN RED LINES - USE BA�A. POINT PEN ONLY
BUILDI PROJECT I DENTI FICATION
APPLICATION & PERMIT
BUILDING - ELECTRICAL- PLUMBING - MECHANICAL
PERMIT NUMBER
9252
BUILDING
ADORES
4�/"�;lk/p
0 NER'S
W
NAME
PHONE
7 777 777 77,
OR&
PLAN CHECK VALIDATION
DATE OF APPLICATION
CONTRACTORS
NAME
I No.
7 OUTLETS -SWITCHES- RECEP 10.00/1,00
LIGHTING FIXTURES 10.00/1.00
CONTRACTOR'S
ADDRESS
A PHONE
APPLIANCES - RESIDENTIAL 4.00
PANELS 10.00
ARCHITECT
08
ENGINEER
LIC, NO.
PANELS (OVER 200 AMP) 20.00
PLAN CHECK FEE
P.C. NO.
SIGNS TRANS. 3.00
ARCHO� ENG
ADDRESS
SPECIAL CIRCUIT 5.00
PERMIT VALIDATION
TEMP. METER OR POLE INS, 29-68
ZIP
APPLICANT'S
ADDRESS
MOTORS SEE FEE SCH.
(SERVICE CHANGE 20.00
L(CENSC ,I) CONTRACTORS DECLARATION
TEMP. POLE 1=0 00
I hereby affirin that I am licensed Linder provisions of Chapter 9
(commetwing, with $ection'7000) of'Diviswn 3 of the Business and
Professions license is in full to 0 't 0
Cod- a 11
License Lie. Number
Date Contractor -X�-
OWINER-BOILDER DECLARATION
I hereby affirm that I am exempt from the Contractor's License
Law for The following reasop, (Sec, 7031 5, Business and Professions
Code� A.ny (.fly or county which requires u permit to construct, alter,
improve, demolish, or repair any structure, prior to its issuance, also
requires itheapplicant for such permit to file a sign ed statement that
he is licensed pursuhrit to the provisions of the Contractor's License
Law (Chapter 9 (commencing with Section 7000) ofDjVi5iOn 3 of tete
Business and Professions C64e) or that fie is exempt therefrom and
the basis for the alleged exemption, Any violation ofSection 703 1.5
ISSUANCE DATE
JUL V-103
/7
BLDG. ELECT.
PLG. MECH.
0 El
City 01, CtIpertinc
MISC. REFER TO ORD
PERMIT ISSUANCE
VALUATION $/FT.
LEC. CON TH. ;LIC NO ELEC.
4 A
V, . . .... . / - TOT L
PERMIT TO
STORIES TYPE CONSTR.
by any applicant foi a permit subjects the applicant to a civil penalty
of not more than five hundred dollars 0500)-)�
0 1, as Owner1) the pioperty, or my employees, with wages as
their sole P11111" ion, will do the work, and the structure is not
ALTER -DRAIN & VENT -WATER (EA.) 5,00
BACK FLOW PROTECT. DEVICE 4.00
OCC. GROUP
RES. UNITS
DRAINS -FLOOR, ROOF, AREA, COND. 5,00
intended or ofterei, for sale (Sec, 7044, Business and Professions
Code: The Contractor's Li� J �cnse Law does not apply to an owner of
property 'who build'' improves Proves thereon, and who does such work
FIXTURES - PER TRAP 5.00
SO. FT, FLOOR AREA
TOTAL ACREAGE
himself or through his owo employees, provided that such improve-
ments are not intended or Offered for sale. It, however, the building
GAS - EA. SYSTEM -1 INC.4OUTLETS 6.00
I
or improvement is sold wAin one year of completion, the owner,
builder will have the burden ofproving that he did not build or un=
prove for purpose of I side.),,
0 1, as owner of the property, am exclusively contracting with
GAS - EA. SYSTEM -OVER 4 (EA.) 2.00
RES BUILDING USE
IND CON PB Other
0 D 11 D El
INDUSTRIAL WASTE INTER, 30.00
lie nsed contractorl" to construct the project (Sec. 7044, Business
e
and Professions Code, The Contractor's License Law does not apply
to in owner of pro�erty who builds or improves thereon, and who
contracts for such projects, with a contractor(s) licensed pursuant to
the Contractor's License Law.
LAWN SPR IN KLERS - 1 INC 5 V.B. 6.00
ASSESSORS PARCEL NO.
LAWN SPRINKLERS - OVER 5 (EA.) 1.00
SEWER -SANITARY -STORM EA, 200ft/1 0.00
TRACT NO.
PARCEL NO.
0 1 am exempt Under Sec........ ,134P.C. for this
WATER HEATER W/VENT 6.00
Owner Date
WATER SYSTEM 5.00
ACC. GATE
ACC. FILE NO.
WATER TREATING EQUIP. 5.00
WORKER�S'COM',PFNSATION DECLARATION
1 hereby affirm that I h4ve a certificate of consent to self -insure,
or a certificate of Workers,, Compensation Insurance, Or a cerfif`iQd
copy thereof (Sec, J800, Liitb . C.).
ZONING
ENG. SITE NO.
Po
Policy No, - ----------- --
FIRE SPRINK
Y [] No
ENERGY T-24
Y f❑ -1 NF�
EJ "Certified copy is hereby furnished.
"d copy is "Jed with th4� Citi/ inspqptf�on division,
I,�F OF f:XEMPTION FROM WORKERS'
MISC. - REFER TO ORD.
PERMIT ISSUANCE 10.00
FLOOD ZONE
A.L.U.C.
PLG. CCNTR. LIC. NO. JPLG.
TOTAL
COMPENATION INSURANCE
(This setineed not;he completed if the permit is for one
CanlO
Y ❑ N ❑
Y ❑ N ❑
F,
hundred dollars ($ 100) or less.)
I certify that in the pertormance of the work for which this per -
not is issued, I shall not employ any person in any manner sows to
become subject to the Workers' Compensa I ion Laws of California,
Date_ . . . . ...... ......
NOTICE FO APPLJCANT� If, after making this Certificate of Ex-
BUILDING
ALTER OR ADD TO MECH. 5.00
APPLIANCE 5.00
PLAN CHECK
emption, youshould become subject to the, Workers' Compensation
provisions of the, Labor Code, you trust forthwith comply with
such provisions or this permit shall be deemed revoked.
FEE
AIR HANDLING UNIT (TO 10MICY.M.) 4.00
AIR HANDLING UNIT (OVER 10=C.F.M.) 6.00
SEISMIC FEE
CON$ : TRUCTION LENDING AGENCY
I hereby affirm that them is a construction lending agency for
EXHAUST HOOD (WITH DUCT) 5.00
the performance of the work for which this permit is issued (Sec.
3097, Civ.C.).
MICROFILM
HEATING UNIT (TO 100,000 B.T.U.) 8.00
HEATING UN IT (OVER 100,000 B.T.U.) 9.50
ELECTRIC
Lender's Name
Lender's Address
I certify that I have read this application and state that the above
information is correct. I agree to comply with all city and county
ordinances and male laws, t(hating to building construction, and
VENTILATION FAN (SINGLE) 4.00
PLUMBING
BOILER - COMP (3 H.P. or 100,000 B.T.U.) 6.00
BOILER -COMP (over 100,000 BTU) SEE FEE SCH.
MECHANICAL
hereby authorize representatives of' this city to enter upon the
above-mentioned property frit inspection purposes.
(We) agree to s4ve, indemnify and keep harmless the City of
Cupertino against liabilities, judgments, costs and expenses which
may in any way accrue,,aiiinst saja,"E"ify in consequence of the
grant wf this perknit/,/ I I
J, /
a porn 44.
of
MISC.- REFER TO ORD,
CONST, TAX
PERMIT ISSUANCE 10.00
MECH. CONT. LIC. NO.
MECH.
TOTAL
OFFICE COPY
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