4533 4534 4535 4536 4537 4538 4539 4540 4542 4543 4544 5202 20644 THRU 20651 CELESTE
CIR
4533, 4534, 4535, 4536, 4537,
4538, 4539, 4540, 4542, 4543,
4544, 5202
F/P
DE ANZA FORGE
SCANNED BOX # 783
APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
BUILDING PROJECT IDENTIFICATION PERMIT NUMBER
aooaENNG �,;�d-� tt/ APPLICATION & PERMIT 4533
BUILDING-ELECTRICAL-PLUMBING-MECHANICAL
eele-6yZ
OWNER'S PLAN CHECK VALIDATION
NAME OTY. ELECTRIC PERMIT FEE
• /-�'JJ PHONE
NAMERFCTDR$ UTLETS-SWITCHES-RECEP 5.00/1.00
LIC.NO. LIGHTING FIXTURES 5.00/1.00
CONTRAC
ADDRESS TOWS PPLIANCES-RESIDENTIAL 4.00
PHONE PANELS 5.00 DATE OF APPLICATION
ARRCHITECT SIGNS 6.00 PLAN CHECK FEE P.C.NO.
ENGINEER
LIC.N044 SIGNS TRANS. 3.00
ADDRESS END' SPECIAL CIRCUIT 5.00 PERMIT VALIDATION
ZIP EMP.METER OR POLE INS. 15.00 [�
A
ADDRIESNi'S oREss IMOTORS SEE FEE SCH.
SERVICE CHANGE 10.00
woo LICENSED CONTRACTORS DECLARATION O
a v I hereby affirm that I am licensed under provisions of Chapter 9
Z w ISSUANCE DATE
(commencing with Section 7Wi rt
of Division 3 of ler Business and
0 i Professions Code.and my licenses in full foe and effect. BL❑OG. ELECT. PL❑G. MECH.
a o`� License Class Lia Number
0 w 0 Date Contracmr
c "a a OWNER-BUILDER DECLARATION BUILDING PERMIT
°n" MISC. - REFER TO ORD INFORMATION
0 H I hereby affirm that I am exempt from the Contractor's License
a. o¢ Law for the following reason.(Sec.7031.5,Businessand Professions VALUATION $/FT.
-N PERMIT ISSUANCE 6,00
y> I Code:Any city or county which to
x a¢O improve,demolish,or repair any strdclure,prior to its issuance,also ELEC.CONTR. LIC.NO. ELEC.
uE 0,
requires the applicant for such permit to file a signed statement that TOTAL
X.8 w he is licensed pursuant to the provisions Of the Contractor's License PERMIT TO
F z Q Law(Chapter 9(commencingwith Section 7000)of Division 3 ofthe /y, ,
f 4 O Business and Professions Code)or that he is exempt therc0om and OTY. PLUMBING PERMIT FEE /-f�•' �
M F $ the basis for the alleged exemption.Any violation Of Section 7031.5 STORIES TYPE CONSTR.
i ;- by any applicant for a permit subjects the applicant to a civil penalty
ofoot more than five hundred dotlars(5500).): ALTER-DRAIN&VENT-WATER IEA.) 4.00
❑ I,as owner of the property,or my employees with wages as BACK FLOW PROTECT. DEVICE 2.00
their sole compensation,will do the work,and the structure is not OCC.GROUP RES.UNITS
intended or offered for sale(Sec 7044. Business and ProfessionsDRAINS-FLOORROOFAREACOND. 4.00
Code:The Contractor's License Law does not apply to an owner of , , ,
property who builds or improves thereon,and who docs such work F IXTUR ES-PER TRAP 4.00• SO FT.FLOOR AREA TOTAL ACREAGE himself or through his own employees,provided that such improve-
mentsarenolintendedoroffered for sale.If.however,the building GAS-EA.SYSTEM-I INC.4 OUTLETS 4.00
or improvement is sold within one year of completion,the owner- GAS EA.SYSTEM-OVER 4 (EA.) 1.00
builder will have the burden of proving that he did not build or im- - BUILDING USE
Prove for purpose of sale.). INDUSTRIAL WASTE INTERRES IND tory PB omen
❑ 1,as owner of the properly,am exclusively contracting with . 20.00 El Cl ❑ ❑ ❑
licensed contractors to construct the project(Sec.7044,Business LAWN SPRINKLERS-1 INC 5 5.00 ASSESSORS PARCEL NO.
and Professions Code:The Contractor's License Law does not apply V.B.
to an owner of property who builds or improves thereon.and who LAWN SPRINKLERS-OVER 5(EA.) 1,00
contracts for such projects with a contractions)licensed pursuant to
the Conlructor's License Law. SEWER-SANITARY-STORM EA.200ft/8.00 TRACT NO, PARCEL NO.
❑ I am ex plural
T_,B.&PC.I.,this
Baso WATER HEATER W/VENT 4.00
�w�r WATER SYSTEM 4,00
ACC.DATE ACC.FILE NO.
WORKF:RS'COMPF.NSATION DECLARATI WATER TREATING EQUIP. 4.00 -
1 hereby affirm that I have a certificate of consent to self-insure.
or a certificate Of Workers•Compensation Insurance,or a certified ZONING ENG.SITE NO,
copy thereof(Sec.3800.Lab.C.).
Policy No. Company
O ❑ Certified copy is hereby furnished.
Z Z ❑ Certified copy is filed with the city inspection division. FIRE SPRINK ENERGY T-34
O Applicant MISC.- REFER TO ORD. Y rv� v N�
� LO CERTIFICATE OF EXEMPTION FROM WORKERS' PERMIT ISSUANCE 6.00 FLOOD ZONE A.L.U.C.
LU > COMPENSATION INSURANCE PLG.CONTR. LIC.NO. PLG.
d (This section need not be completed if the permit is for one TOTAL YE] N I Y n NE]
7 Z hundred dollars(SI00)Oiless.)
V O 1 certify that in the performance of the work for which this per- OT
LL FW y MECHANICAL PERMIT FEE FEE SUMMARY
mit is issued,1 shall not employ any person in any Insurer so as to
O become subject to the Worked Compensation Laws of Callfomia.
Q.} NOT Applicant ALTER OR ADD TO MECH. 4.00 BUILDING 2 NOTICE TO APPLICANT: If,after making this Certificate of Iix-
F _ emption,you should become subject to the Workers'Compensaliun APPLIANCE 4.00
provisions of the Labor Code, you must forthwith comply with PLAN CHECK
U such provisions or this permit shall be deemed revoked. AIR HANDLING UNIT(TO 10,000C.F.M.) 3.00 FEE
CONSTRUCTION LENDING AGENCY AIR HANDLING UNIT(OVER 10 5.00 SEISMIC FEE
I hereby affirm that there is a construction lending agency for EXHAUST HOOD(WITH CT) 2.00
the performance of the work for which this permit is issued(Sec.
3097,Civ-C)L HEATING UNIT ITO 10 B. MICROFILM
Lender's Name
Lender's Address HEATING UNIT(0 1 0000B.T.U.P.50 ELECTRIC
1 Certify that I have read this application and state that the above VENTILATION FAN ISI E Upe
information is correct.i agree to comply with all city and cranny PLUMBING
henna au and state laws relining to building construction, and BOILER-COMP I3 H.P.or 100,000 B.T.U.) 4.00
hereby authorize representatives for ins Of this city to enter upon the 801 LER-COMP(Over 100,000 BTU)SEE FEE SCH. 1 C
above-mentioned sale. indemnify
inspection keepposes. MECHANICAL ��
(We) agree to save, indemnify end keep harmless Inc City of MISC.- y REFER TO ORD -
Cupertino against liabilities,judgments, costs and expenses which CONST.TAX
may in any way accrue against said City in consequence of the PERMIT ISSUANCE 3.00
eating this
MECH.CONT. LIC.NO. MECH, y
SigrtaturcofA plica t)Contmalor ' Dutr TOTAL°t / rl, TOTA`•
OFFICE COPY
APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALI. POINT PEN ONLY
BU I LD1 NG PROJECT IDENTIFICATION PERMIT NUMBER
* BUILDING �I APPLICATION & PERMIT fl
ADDRESS 3N��d� J `T
_ BUILDING-ELECTRICAL-PLUMBING-MECHANICAL
Z-;,z le
OWNER'S PLAN CHECK VALIDATION
NAME QTY,
NAMEELECTRIC PERMIT FEE
RACTORS UTLETS-SWITCHES-RECEP 5.00/1.00
LID.No, LIGHTING FIXTURES 5.00/1.00
CONTRACTORS
ADDRESSPPLIANCES-RESIDENTIAL 4.00
ADDRESS
PHONE PANELS 5.00 DATE OF APPLICATION
ORRLAN CHECK FEE CHITECT SIGNS 6.00 PP.C.NO.
ENGINEER
LIC.No. SIGNS TRANS. 3.00
AARCH.OR DDRESS ENG. SPECIAL CIRCUIT 5.00 PERMIT VALIDATION
ZIP TEMP.METER OR POLE INS. 15.00
APPLICANrs
ADDORERSDRESS MOTORS SEE FEE SCH. J-
SERVICE CHANGE 10.00
Foo LICENSED CONTRACTORS DECLARATION J
a u w I herebyaffirm that I am licensed under provisions of Chaptcr 9 ISSUANCE DATE
HT (commencing with Section 7000)of Division 3 of the Business and
i Professions Code,and my license is in full force and effect. BLDG. ELECT. PLG. MECH.
z 013 - License Class Lie.Number ❑ 19
oh I-w Date Contractor
M ¢¢ 4 OWNER-BUILDER DECLARATION BUILDING PERMIT
s Ori D INFORMATION
W ; w I hereby affirm that I am exempt from the Contractors License MISC.- REFER TO ORD
n0¢ Law for the following reason.(Sec.7031.5,Business and Professions PERMIT ISSUANCE VALUATION $/FT.
- 0 � Coder Anycity orcounty which mquiresa permit to construct,alter, 6.00
S, improve,demolish,or repair any structure,prior to its issuance.also ELEC.CONTR. LIC,NO. ELEC,
y 'O LL requires the applicant for such permit to file a signed statement that TOTAL
w w he is licensed pursuant to the provisions of the Contractors License PERMIT TO
Fz >
Law(Chapter 9(commencing with Section 7000)of Division 3 of the
f 4 o Business and Professions Code)or that Ile is exempt therefrom and CITY. PLUMBING PERMIT FEE
zw
2 H $ the basis for the alleged exemption.Any violation of Section 7031.5 STORIES TYPE CONSTR.
La by any applicant for a permit subjects the applicant to a civil penally
of not more than five hundred dollars(5500).): ALTER-DRAIN&VENT-WATER (EA.) 4.00
❑ I,as owner of the property,or my employees with wages us BACK FLOW PROTECT.DEVICE
their s01e compensation,will do the work,and the structure is not 2.00 OCC.GROUP RES.UNITS
intended or offered for sale(Sec 7044. Business and Professions DRAINS-FLOOR,ROOF,AREA,COND. 4.00
Code:The Contractor's License Law docs not apply to an owner of
property who builds or improves thereon,and who does such work F IXTUR ES-PER TRAP 4.00 SO.FT.FLOOR AREA TOTAL ACREAGE
• himself or through his own employees,provided that such improve-
memsamnotintendedoroffcrcd for sale.If,however,the building GAS-EA.SYSTEM-11NC.4OUTLETS 4.00
or improvement is sold within one year of completion,the owner-
builder will have the burden of proving that he did not build or im. GAS-EA.SYSTEM-OVER 4 IEA.) 1.00 BUILDING USE
prove for purpose of sale.). INDUSTRIA-WASTE INTER. 20.00 RES IOr
❑ as owner of the property, exclusively.7044 ❑ El ❑ ❑
contracting with
licensedd contractors to construct thehe project ISrc7044.Business LAWN SPRINKLERS-1 INC 5 V.B. 5.00 ASSESSORS PARCEL NO.
and Promsions Code:The Conlmam's License Law does 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 a contractods)licensed pursuant to
the Contractors License Law. SEWER-SANITARY-STORM EA.200ft/8.00 TRACT NO. PARCELING.
reason)am axe t under }. .B.&P.C.for this WATER HEATER W/VENT 4.00
sv"e // WATER SYSTEM 4.00
'WORKER ACC.DATE ACC.FILE NO.
WATER TREATING EQUIP. 4.00
I hereby ate ol-that I have a certificateCompensation
In consent m s certiurc.
or a certificate of Workers'Compensation Insuronsc.or a certifiCd ZONING ENG.SITE N0.
copy thereof fSec.3800,Lab.
Policy N Companyy
❑ Certified copy is hereby furnished.
Z Z ❑ Certified copy is filed with the Clly inspection division. FIRE$PRINK ENERGY T 29
F O Applicant MISC.- REFER TO ORD. Y❑ N[] Y ❑ No
0: y CERTIFICATE OF EXEMPTION FROM WORKERSPERMIT ISSUANCE 6.00
W > COMPENSATION INSURANCE PLG.COFLOOD ZONE A.L.U.C.
NTR. LIC.NO. PLG
� Z e Sectionidn need not be completed if the pennil i5 for one TOTAL Y[] N[] Y❑ N�
CJ O hundred dollars(4 1001 err less.)
I certify that in the performance of the work for which this per- QTY MECHANICAla FEE SUMMARY
IL h mit is issued,I shall not employ any person in any inanner so as to ,/ T FEE
O W become subject to the Workers Compensation Laws of California.
CL Date ApplN,sot ALTER OR ADD TO MECH. 4.00 BUILDING
>- to NOTICE TO APPLICAICANC If,after making This Certificate of Ex-
F ? emption,you should become subject to the Workers'Compensation APPLIANCE
provisions of the Labor Code, you must forthwith comply with 4.00 PLAN CHECK
V such provisions or this permit shall be deemed revoked. AIR HANDLING UNIT(TO 10=C.F.IA) 3.00 FEE
CONSTRUCTION LENDING AGENCY AIR HANDLING UNIT 5.00 SEISMIC FEE
I hereby affirm that there is a construction lending agency for EXHAUST HOOD(WITH DUCT) 2.00
the performance of the work for which this permit is issued(Sec.
3097,Civ.C.), HEATING UNIT(TO 100,000 B.T.U.) MICROFILM
4.00
Lender's Name
Lenders Address HEATI NG UN IT DIV ER 100,000 B.T.U.)7.50 ELECTRIC
I Certify that I have read this application and slate that the above VENTILATION FAN (SINGLE) 3.00
. information is correct. I agree to Comply with all city and county BOILER-COMP 13 H.P. LUMBING
ordinances and state laws relating to building construction. and .P.or 100,000 B.T.U.) 4.00
hereby authorize representatives of this City to enter upon the 801 LER-COMP(Over 100,000 BTU)SEE FEE SCH.
above-mentioned properly for inspection purposes. MECHANICAL
(we) agree to save, indemnify and keep harmless the City of MISC.- REFER TO ORD.
Cupertino against liabilities,judgments, casts and expenses which
MAY in any, Way accrue against said City in conscqucnoe of the PERMIT ISSUANCE 300 3 CONST.TAX
ranting (this pe 't' MECH.CONT. LIC.NO. MECH.
/o TOTAL a�7 .ti TOTAL
gn tum o A IwngContnc�lor Dale
OFFICE COPY
l
APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
BUILDING PROJECT IDENTIFICATION PERMIT NUMBER
3
APPLICATION & PERMIT 4535
• ADDRESS !�N/a✓/a�j
G/' L BUILDING— ELECTRICAL—PLUMBING—MECHANICAL
OWNER'S PLAN CHECK VALIDATION
NAME QTY. ELECTRIC PERMIT FEE
• 4r_An A PHonE —Y57
Ninure ACTORS UTLETS-SWITCHES-RECEP 5.0011.00
LIC.No. LIGHTING FIXTURES 5.00/1.00
ADDRs
ADDRESSRESS PPLIANCES-RESIDENTIAL 4.00
PHONE PANELS 5.00 DATE OF APPLICATION
ARCHITECT SIGNS S.00 PLAN CHECK FEE .C.NO.
ENGINEER
LIC.xo. SIGNS TRANS. 3.00
ARCH.OR END' SPECIALCIRCUIT 55,00 PER MIT VALIDATION
SS
ZIP TEMP.METER OR POLE INS. 15.00
AMOTORS SEE FEE SCH.
ADDDRESSDRESS
SERVICE CHANGE 10.00
wZ.
.00 LICENSED CONTRACTORS DECLARATION
<u U I hereby affirm that I am licensed under provisions of Chapter 9 ISSUANCE DATE
<$I (Commencing with Section 7000)of Division 3 of the Business and BLDG. ELECT, PLG. MECH.
f as Z Professions Code,and my license is in full force and effect. ❑ ❑ ❑
o 0 8 W License Class Lie.Number
IUY�1
Date Contractor
x f
a BUILDING PERMIT
(CMOWNER-BUILDER DECLARATION
a aINFORMATION
Is ; n I hereby affirm that 1 am exempt from the Contractor's License MISC.— REFER TO ORD
a.
ulaw for the following reason.(Sec.7031.5,Business and Professions PERMIT ISSUANCE VALUATION SIFT.
im> Code:Any city or county which requiresa permit to cpnshucL aheq 5•�
a: ¢¢0 improve,demolish,or repair any structure,prior to its issuance.also ELEC.CONTR. LIC.NO. ELEC.
w DLL requires the applicant for such permit to file a signed statement that
n m m rA he is licensed pursuant to the provisions of the Contractor's License TOTAL Meal.RMIT TO
rz> Iaw(Chapter 9(commencing with Section 7000)of Division 3 of the
s 4 o Business and Professions Cade)or that he is exempt therefrom and OTY. PLUMBING PERMIT FEE
so 1- the basis for the alleged exemption.Any violation of Scctio.7031.5 STORIES TYPE CONSTR.
ou by any applicant for a permit subjects the applicant too civil penalty
of not more than five hundred dollars(5500).1: ALTER-DRAIN&VENT-WATER (EA.) 4.00
❑ 1,as owner of the properly,or my employees with wages es BACK FLOW PROTECT.DEVICE 2.00
their Sole compensation,will do the work,and the slmCDlre is net OCC.GROUP RES.UNITS
intended or offered for to(Sec. 70.4, Business and Professions DRAINS-FLOOR,ROOF,AR EA,CON D. 4.00
Code:The Contractor's License law docs not apply to an owner of
property who builds or improves thereon,and who does such work FIXTURES-PER TRAP 4.00 So.FT.FLOOR AREA TOTAL ACREAGE
• merits re not hrough
ownemployees.fors.provided that howevsuch improve.g GAS-EA.SYSTEM-1 4,00
merits are not intended or offered for sale.If,however the building
or improvement is sold within one year of completion,the owner, GAS-EA.SYSTEM-OVER 4(EA.) 1.00 BUILDING USE
builder will have the burden of proving that he did not build or on-
prove for purpose of sale.). INDUSTRIAL WASTE INTER. RES IND CON PB Omer
❑ 1.as owner of theproperty. 20.00
he exclusively.7044.contracting with
licensed contractors to construct the project Ise[,7044,BusinessLAWN SPRINKLERS-1 INC 5 V,B. 5.00 ASSESSORS PARCEL NO.
and Professions Code:The Contractor's License Law duns net apply
to antr owner of properly who builds t r improves need PLL and who LAWN SPRINKLERS-OVER 5(EA.) 9.00
the lmet5 such cprojects L with a conmuaoH sl licensed pursuonl to
the Contractor'sLxcLicense Law. SEWER-SANITARY-STORM EA.200ft/8:00 TRACT NO, PARCEL NO.
ID
am exam t riders .B.SP.C.for,his WATER HEATER W/VENT 4.00
Uul Owne{ �� WATER SYSTEM 4,00 ACC,DATE ACC.FILE NO.
WORKERS'C MPENSAT ON DF,CLARAO/N� WATER TREATING EQUIP. 4.00
I hereby affirm that I have a certificate ofconsent no self-insure.
or a certifieme of Workers'Compensation Insurance,or a certified ZONING ENG.SITE NO.
copy thereof(See.3800,Lab.C.).
Policy No. Company
O ❑ Certified copy is hereby furnished. FIRE SPRINK ENERGY R24
Z Z ❑ Certified copy is riled with the city inspection division.
f-" O Applicant MISC.- REFER TO ORD. Y❑ No Y ❑ ND
K LO CERTIFICATE:OF EXEMPTION FROM WORKERS' PERMIT ISSUANCE 8.00FLOOD ZONE A.L.u.c.
LU > COMPENSATION INSURANCE PLG.CONTR. LIC.NO, PLG,
1 O (This section raced not be completed if the permit is for one TOTAL Y N Y N
Z hundredd.1hos(SI000°,less.)
U O 1 certify that in the performance of the work for which this per QTY MECHANICAL PERMIT FEE FEE SUMMARY
LL 1- mit is issued,1 shall not employ any person in any manner w as to
0 W become subject to the Workers'Compensation Laws of California.
y
Date—Applicant ALTER OR ADD TO MECH. 4,00 BUILDING
} 2 NOTICE TO APPLICANT: If,after making this Certificate of Ex-
F emption,you should became subject to the Workers'Compensation APPLIANCE 4.00 PLAN CHECK
provisions of the Labor Code, you must forthwith comply with FEE
U such provisions or this permit shall be deemed revoked. AIR HANDLING UNIT(TO 10,O7DGF.M.) 3.00
CONSTRUCTION LENDING AGENCY AIR HANDLING UNIT(OV ,F.M) 5.00 SEISMIC FEE
I hereby affirm that there is a construction lending agency for EXHAUST HOOD(WITH DUCT) 2.00
the performance of the work for which this permit is issued(Sec.
3097,Civ.C.L HEATING UNIT(T ,0 4.00 MICROFILM
Lender's Name
Lender's Address HEATINGUNIT(OV R100, 0 .!1.)7.50 ELECTRIC
I certify that I have read thisapplication and state ilia,the above VENTILATION FA• 3.00 information is correct. I agree to comply with all city and county PLUMBING
ordinances and stale laws relating to building construction, and BOILER-COW(3 H.P.Or 100,000 B.T.U.) 4.00
hereby authorize representatives of this city to enter upon the BOILER-COMP(Over 100,000 BTU)BEE FEE SCH.
above-mcmioned property for inspection purposes. MECHANICAL OZ `-
(We)'agree to Save, indemnify and keep hornless the City of MISC.. REFER TO ORD.
Cupertino against liabilities,judgments. costs and expenses which CONST.TAX
may in any way acem against Said City in consequence of the PERMIT ISSUANCE 3.00
cling. MECH.CONT. LIC.NO. MECH.
�p TOTAL rsL.2 dW TOTAL
ignamre of pp cant/Contractor Date
OFFICE COPY
APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
BUILDING PROJECT I DENTIFICATION - PERMIT NUMBER
ADDRESS pHe• :-,y APPLICATION & PERMIT 4536
BUILDING -ELECTRICAL-PLUMBING-MECHANICAL
OWNER' PLAN CHECK VALIDATION
NAME /_//� CIn. ELECTRIC PERMIT FEE
QQ PHONE lJ /7
NANTRAcroRs
NAME UTLETS-SWITCHES-RECEP 5.00/1.00
LIC.No. LIGHTING FIXTURES 5.00/1.00
CONTRACTOR'S PPLIANCES-RESIDENTIAL 4.DO
ADDRESS
PHONE PANELS 5.00 DATE OF APPLICATION
ARCHITECT SIGNS 6.00 PLAN CHECK FEE P.C.NO.
OR
ENGINEER
LIC.NO. SIGNS TRANS. 3.00
ARCH,OR ENG. SPECIAL CIRCUIT 5.00 PERMIT VALIDATION
ADDRESS
EZIP EMP.METER OR POLE INS, 15.00
ADDRESS AMOTORS SEE FEE SCH.
SERVICE CHANGE 10.00 /0/y�/� ?
woo LICENSED CONTRACTORS DECLARATION �J
<u u I hereby affirm that I am licensed under provisions of Chapter 9 ISSUANCE DATE
y Q n (Commencing with Section 7000)of Division 3 of the Business and BLDG. ELECT. PLG. MECH.
F-O i Professions Code,and my license is in full force and effect. ❑ ❑ ❑
z0r%- License Class Lic.Number
z w Date Contractor
1- �~J
¢ o w OWNER-BUILDER DECLARATION BUILDING PERMIT
x ; w I- 1 hereby affirm that 1 am exempt from the Contractor's License MISC.- REFER TO ORD INFORMATION
F y y Law for the following reason(Sec.703 1.5,Business and Pml'essions —PERMIT ISSUANCE 600 VALUATION g/FT.
Code:Any city or county which requires a permit to construct,alter. .
a a< improve,demolish,or repair any structure,prior to its issuance,also ELEC.CONTR. LIC.NO ELEC.
- O e requires the applicant for such pernil to file a signed statement that TOTAL
e w m w he is licensed pursuant to the provisions of the Contractor's License PERMIT TO
HIi Law(Chapter 9(commencing with Section 7000)ofDivision3ofthe MFc-,f
i c Business and Professions Code)or that he is exempt therefrom and CITY. PLUMBING PERMIT FEE
M F m the basis for the alleged exemption.Any violation of Section 7031.5 STORIES TYPE CONSTR.
i3 - by any applicant for a permit subjects the applicant to a civil penally gLTER-DRAIN -WATER IEA.) q,00
of not more than five hundred dollars(8500).):
❑ Las owner the property,or my employees with wages as BACK FLOW PROTECT.DEVICE 2.00 OCC.GROUP RES.UNITS
.their sole compensation,will do the work,and the structure is not
intended or offered for sale (Sec. 7044• Business and Professions DRAINS-FLOOR,ROOF,AREA,COND. 4.00
Code: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 4.00 SO.FT.FLOOR AREA TOTAL ACREAGE
• himself or through his own employees•provided that such improve-
mentsarenetintended or of farad for sale.If,however,the building GAS-EA.SYSTEM-1 INC.4 OUTLETS 4.00
or improvement is sold within one year of completion.the owner- GAS-EA.SYSTEM-OVER 4(EA.)
builder will have the burden of proving that Ire did not build or im 1.00 BUILDING USE
prove for purpose of sale.). INDUSTRIAL WASTE INTER. RES IND CON PB Omer
❑ I,as owner of the properly am exclusively contracting with 20.00 1:1 El El 1:1 1:1licensed contractors to construct the project(Sec.7044,Business LAWN SPRINKLERS-1 INC 5 5.00 ASSESSORS PARCEL NO.
and Professions Code:The Contractor's License Law does not apply V.B.
to an owner of property who builds or improves thereon.and who LAWN SPRINKLERS-OVER 61EA.) 1,p0
contracts for such projects with a conlractogs)licensed pursuant to
the Contractor's License Law. SEWER-SANITARY-STORM EA.200ft/8.00 TRACT NO. PARCEL NO.
reason exc rand• ec. ��27;
.for thisWATER HEATER W/VENT 4,00
WATER SYSTEM 4.00 ACC.DATE ACC.FILE No.
DWORKER COMPENSATION U ' WATER TREATING EQUIP. 4.00
1 hereby affirm that I have a certificate of Consent to wif-insure.
or a certificate of Workers'Compensation Insurance,or a certified ZONING ENG.SITE NO.
Copy thereof(Sec.3800,Lab.C.).
Policy No. Company
O ❑ Certified copy ishereby furnished. FIRE SPRINK ENERGY T-24
Z Z O Certified copy is filed with the city inspection division.
� O Applicant MISC.- REFER TO ORD. Y❑ N Y ❑ N❑
2N CERTIFICATE OF EXEMPTION FROM WORKERS' PERMIT ISSUANCE 6.00 FLOOD ZONE A.L.u.C.
W COMPENSATION INSURANCE PLG.CONTR. sec.NO. Pt.G.
1 (This section need not be completed if the permit is for one TOTAL Y❑ N❑ Y ❑ N❑
0 Z hundred dollars(SI00)or less.)
U O I certify that in the performance of the work for which this per- Oar FEE SUMMARY
U. U mit is issued,I shall not employ any person in any manner so as to MECHANICAL PERMIT FEE
O W become subject to the Workers'Compensation Laws of California.
0. Date Applicant ALTER OR ADD TO MECH. ,pp BUILDING
>_ m NOTICE TO APPLICANT: If,after making this Certificate of Ex-
F.. Z emplion,you should become subject to the Workers Compenvlion APPLIANCE 4.00
provisions of the Labor Code, you must forthwith comply with PLAN CHECK
U such provisions or this permit shall be deemed revoked. AIR HANDLING UNIT(TO 1 FEE
CONSTRUCTION LENDING AGENCY AIR HANDLING UNIT(OVER I C.F,M.) 5.00 SEISMIC FEE
1 hereby affirm that them is a construction lending agency for EXHAUST HOOD(WITH D
the performance of the work for which this permit is issued(Sec. MICROFILM
3097,Civ.C.). HEATING UNIT(TO 100,000 B.T.U.) 4.00
Lender.Name
Lender's Address HEATINGUNIT(OVER100,000B.T.U.)7.50 ELECTRIC
1 certify that I have read thisappllcathm and state Thal the above VENTILATION FAN (SINGLE) 3.00
• information is correct. I agree to comply with all city and county PLUMBING
ordinances and stale laws relating to building construction. and BOILER-COMP(3 H.P.Or 100,000 B.T.U,) 4.00
hereby authorize representatives Of this city to erne upon the BOILER-COMP tOver 100,000 BTU)SEE FEE SCH. dis
above-mentioned properly I'or inspection purports. MECHANICAL
(We) agree to save, indemnify and keep harmless the City of MISC.- REFER TO ORD.
Cupertino against liabilities,judgments. costs and expenses which _ CONST.TAX
may in any way aceme against said City in c,nsequemce of the PERMIT ISSUANCE
g Of it. MECH.CONT. LIC.NO. MECH.
,o TOTAL d da TOTAL
Signature of Ap jea /Contract,, Date �`-
OFFICE COPY
APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
BUILDING PROJECT IDENTIFICATION PERMITNUMSER
UILDI' ADDRESS �N:/d:,� ,� APPLICATION & PERMIT 53"J
I
' G , BUILDING-ELECTRICAL-PLUMBING-MECHANICAL
OWNER'S PLAN CHECK VALIDATION
NAME OTV. ELECTRIC PERMIT FEE
RAcroRs
. PHorvE
NAMEUTLETS-SWITCHES-RECEP 5.00/1.00
LIC.No, LIGHTING FIXTURES 5.00/1.00
DNTR DRESS oRs
ADDRESS PPLIANCES-RESIDENTIAL 4.00
PHONE PANELS 5.00 DATE OF APPLICATION
ARCHITECT SIGNS 6.00 PLAN CHECK FEE P.C.NO.
ENGINEER
uc.No. SIGNS TRANS. 3.00
ADORESS ENc' SPECIALCIRCUIT 5.00 PERMIT VALIDATION
ZIP TEMP.METER OR POLE INS. 15.00 / `
ADDRESS MOTORS SEE FEE SCH. �d `a
APPLICANT
SERVICE CHANGE 10.003
'09 LICENSED CONTRACTORS DECLARATIONso
<U u 1 hereby affirm that 1 am licensed under provisions of Chapter 9
ISSUANCE DATE
i (commencing with Section 7000)of Division 3 of the Business and
w
Z.y BLDG. ELECT. PLG. MECH.
H D z Professions Code,and my license is in full(Deet and effect. ❑ ❑ ❑ ❑
0 i y W License Class Lin.Number
Date Contractor
A,s BUILDING PERMIT
a a`w a OWNER-BUILDER DECLARATION
D MISC.- REFER TO ORD INFORMATION
'x O w y I hereby affirm that I am exempt from the Contractor's License
w VALUATION SIFT.
LL o Law for the following reason.(Sec.7031.5.Business and Professions
g PERMIT ISSUANCE .6.00
2 m 2 Code:Any city or county which structure permit toconstruct.alter,
M Q Q Q ImplOVe,demolish,Or repair any alNe[Um,prior t0 IB Ir50aDC0,also ELEC.CONTR. LIC.NO. ELEC.
so S D a requires the applicant for such permit to file a signed statement that TOTAL
X he is licensed pursuant to the provisions of the Contractor's License PERMITTU
r2i
Law(Chapter 9(commencing with Section 7000)of Division 3 ofthe
g 4 o Business and Professions Code)or that he is exempt therefrom and OTY. PLUMBING PERMIT FEE
a I-e the basis for the alleged exemption.Any violation of Section 7031.5
a. ;m by any applicant for a permit subjects Ute applicant W acivil penally STORIES TYPE CONSTR.
of not more than file hundred dollars(5500).1: ALTER-DRAIN&VENT-WATER (EA.) 4.00
❑ 1;as owner of the property,or my employees with wages as BACK FLOW PROTECTDEVICE 2.00
their sole compensation,will do the work,and the structure is not . OCC.GROUP RES.UNITS
intended or offered for sale(Sec. 7004. Business and Professions DRAINS-FLOOR,ROOF,AREA,COND. 4.00
Code: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 4.00 SO.FT.FLOOR AREA TOTAL ACREAGE
• himself or through his own employees.provided that such improvo-
ments are not intended or offered for sale.If.however,Die building GAS-EA.SYSTEM-11NC.40UTLETS 4.00
or improvement is sold within one year of completion,the owner-
builder will have the burden of proving that he did not build or im. GAS,EA.SYSTEM-OVER 4(EA.) 1.00 BUILDING USE
prove for purpose of rale.). RES IND CON PIS Other
❑ 1,as owner of the property,am.exclus'ively contracting with INDUSTRIAL WASTE INTER. 20,00 11 O ❑ ❑ 1:1licensed contractors to construct the project(See.7044,Business LAWN SPRINKLERS-1 INC 5 V.B. 5.00 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 project with o contmetons)licensed pursuant to
the Contractor's License Law. SEWER-SANITARY-STORM EA.200ft/8.00 TRACT NO. PARCEL NO.
❑ I am exer,; uRder Sec. I ,BAP.C.for this WATER HEATER W/VENT 4.00
son
0�'n WATER SYSTEM 4.00 ACC.DATE ACC.FILE N0.
w0 KERS'COMPENSATION E AR O.'ff
WATER TREATING EQUIP. 4.00
1 hereby affirm that I have a certi0nm ofconwnl to elf-insure,
or a certificate of Workers'Compensation Insurance.or a certified ZONING ENG.SITE NO.
copy thereof(See.3900.Lab.C.).
Policy No. Company
0 ❑ Certified copy is hereby furnished.
Z Z ❑ Certified Copy Is filed with the city inspection division. FIRE SPRINK ENERGY T.24
F O Applicant MISC.- REFER TO ORD, Y C] NY ❑ NE]
(Y T CERTIFICATE OF EXEMPTION FROM WORKERS' PERMIT ISSUANCE 6.00
FLOOD ZONE A.L.U.C.
Lu 2 COMPENSATION INSURANCE PLG.CONTR. LIC.NO. PLG,
1 O (This vection need not be completed if the permit is for one TOTAL YE] NE] Y❑ IN
:3Z hundred dollars 1 S 100)or lc.,)
U O I certify that in the performance of the work I'or which this per. OTV FEE SUMMARY
LL F- mit is issued,I shall not employ oily person in any manner seas m MECHANICAL PERMIT FEE
0 W become subject to the Workers'Compensation Laws of California.
a• Date Applicant ALTER OR ADD TO MECH , BUILDING
>_
W NOTICE TO APPLICANT: If,after making this Certificate of Ex-
. qQQ
F. Z emption,you should become subject to the Worken'Compensation APPLIANCE 4.00 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 116gor.F.IA) 3.00 FEE
CONSTRUCTION LENDING AGENCY AIR HANDLING UNIT(OVER 10=C.F.M.) 5.00 SEISMIC FEE
I hereby affirm that there is a construction lending agency for EXHAUST HOOD(WITH DUCT) 2.00
the performance of the work I'or which this permit b issued(Sec.
3097,Civ.C.). HEATING UNIT(TO 100,000 B.T.U.) 400 MICROFILM
Lender's Name .
Lenders Address HEATING UNIT(OVER 100,000 B.T.U.)7.50 ELECTRIC
I certify that I have read this application and state tloo the above VENTILATION FAN (SINGLE) 3.00
Information I, correct.I agree to comply with all city and county PLUMBING
ordinances and state laws relating to building construction, and BO Camp OO,000B.LU.) 4.00
hereby authorize representatives of this city to enter upon the
above-mentioned property for inspection puToss. BOILER-COMP ver ,0100 BTU)SEE FEE SCH. MECHANICAL p2�
(We) agree to save, indemnify and keep harmlcsr the City of MISC.- ER TO ORD.
Caper rum against liabilities,judgments,casts and expenses which
may in any way aceruc agaigst said City in consequence of the PERMIT I 3.00 CONST.TAX
Ing a MECH.CONT. LIC,NO. MECH.
Sign/0-
i nature of �� City Ot Cupertino TOTALsap 7 // TOTAL
g p mant/Contractor Date s
OFFICE COPY
APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
BUILDING PROJECT IDENTIFICATION PERMIT NUMBER
BU'oAess B /dl-Ag # =BUILDING APPLICATION 4538
ram ��C rc G�� CTRICAL-PLUMBING-MECHANICAL
PLAN CHECK VALIDATION
OWNER'S
NAME - QTY. ELECTRIC PERMIT FEE
0 ) PHONE -v-VOW
NAME croRs OUTLETS-SWITCHES-RECEP 5.00/1.00
NAME
LIC.No. LIGHTING FIXTURES 5.00/1.00
CNTRDDAEacrofls
AAPPLIANCES-RESIDENTIAL 4.00
PHONE PANELS 5.00 DATE OF APPLICATION
ARRCHITECT SIGNS 6.00 PLAN CHECK FEE P.C.NO.
ENGINEER
LIc.No. SIGNS TRANS. 3.00
ADDRESS ENG' SPECIAL CIRCUIT 5.00 PERMIT VALIDATION
zip TEMP.METER OR POLE INS. 15.00
ADDRESSESS
NTS Dxij
ADDRESS MOTORS SEE FEE SCH,
SERVICE CHANGE 10.00
woo LICENSED CONTRACTORS DECLARATION 0/41A'3
a it u I hereby affirm that 1 am licensed under provisions of Chapter 9 ISSUANCE DATE
a r (commencing with Section 7000)of Division 3 of the BuRnessanJ e< BLDG. ELECT. PLG. MECH.
H.i Professions Code,end my license is in full force and effect. El ❑ ❑
' 0.
i C License Class Lic.Number21
Date Contractor
Y g BUILDING PERMIT
¢ ¢w OWNER-BUILDER DECLARATION INFORMATION
X ;a. I hereby affirm that I am exempt from the Contractors License MISC.- REFER TO ORD
r a-o J Law for the following reason.(Sec.7031.5.Businessand Prolessious PERMIT ISSUANCE 6.00 VALUATION $/FT.
w Code:Any city or county which requires permit loconstrum.alter.
> ELEC.CONTR. LIC.NO.
z a o improve,demolish,or repair any structure,prior to its issuance,oho ELEC.
ILO n requires the applicant for such permit to file a signed statement that TOTAL PERMIT TO
w$m he is licensed pursuant to the provisions of the Contractor's License ICC U
Fi> Law(Chapter 9(commencingwith Section 7000)of Division 3 of the 144 /7
i c Business and Professions Code)or that he is exempt therefrom and QTY. PLUMBING PERMIT FEE
¢ F p the bests for the alleged exemption:Any violation of Section 7031.5 STORIES TYPE CONSTR.
i ;m by any applicant for a permit subjects the applicant to civil Penalty
of not more than five h and red dollars 15500).): ALTER-DRAIN&VENT-WATER (EA.) 4,00
❑ I,as owner the property,a wor employees with wail sas
not BACK FLOW PROTECT.DEVICE 2.00 OCC.GROUP RES.UNITS
their sole compensation,will do the work,and the structure a not
intended or offered for Sale (Sec. 7044, Business and Professions DRAINS-FLOOR,ROOF,AREA,COND. 4.00
Code:Tile 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 4.00 SO.FT.FLOOR AREA TOTAL ACREAGE
• himself or through his own employees,provided that such improve-
mentsara not intended or offered for side.I L however,the building GAS-EA.SYSTEM-I INC.4 OUTLETS 4.00
or improvement is sold within one year of completion.the owner- GAS-EA.SYSTEM-OVER 4 IEA.) 1.00
builder will have the burden of proving that he did not build or im- BUILDING USE
prove for purpose of sale.). RES IND CON Pe 011ie,
❑ 1,as owner of the property,am exclusively contracting with INDUSTRIAL WASTE INTER. 20.00
licensed Contractors to construct the project(Sec.7044,Business -SPRINKLERS- 1 INC 5 VB. 5.00 ASSESSORS PARCEL N0.
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-OVER 5(EA.) 1.00
Contracts for such projects with a contractors)licensed pursuant to
the Contractor's License Law. SEWER-SANITARY-STORM EA.200ft/8.00 TRACT NO. PARCEL NO.
❑ lam exempt under Sec.-,B.&P.C.for this WATER HEATER W/VENT 4.00
e
ale ne WATER SYSTEM 4,00 ACC,DATE ACC.FILE NO.
/O/J9
WORKERS` OM PENSA"PION UECL ATION WATER TREATING EQUIP. 4.00
I hereby affirm that I have a certificate of consent to self-inwm,
or a certificate of Workers'Compensation Insurance,or a certified ZONING ENG SITE NO.
copy thereof(Sec.3800,Lab.CA
Policy No. Company
O ❑ Certified copy is hereby famished. FIRE SPRINK ENERGY T-Z4
Z Z 13 Certified copy is filed with the city inspection division.
FO Applicant MISC.- REFER TO ORD. YE] N[] Y NL]
CC to CERTIFICATE OF EXEMPTION FROM WORKERS* PERMIT ISSUANCE 6.00 FLOODZONE A.L.U.C.
LU 2 COMPENSATION INSURANCE PLG CONTR. LIC.NO. PLG.
a Cl (This Section need not be Completed if [lie permit is for one TOTAL Y NY [] NC]
Z hundred dollars IS 100)or less.)
U O 1 certify that in the performance of the work for which this per- Qom. MECHANICAL PERMIT FEE FEE SUMMARY
IL f mil is issued.I shall not employ any person in any manner so as to
O W become subject to the Workers'Compensation Laws of California.
S Date Applicant ALTER OR ADD TO MECH. 4.00 BUILDING
} w NOTICE TO APPLICANT: If,after making this Certificate of Ex-
F_ 2 emotion.you should become subject to the workers Compenvtion APPLIANCE
4.00 PLAN CHECK
provisions of the Labor Coda, you must (orrhwi[h comply with U FEE
such provisions or this permit shall be deemed revoked. AIR HANDLING UNIT(TO iQ000GF.
CONSTRUCTION LENDING AGENCY AIR HANDLING UNfT(OVERIOPMQF.M,) 5.00 SEISMIC FEE
I hereby affirm that (here is a construction lending agency for EXHAUST HOOD(WITH DU ';
the performance of the work for which this permit is issued(Sec. MICROFILM
3097,Civ.C.). HEATING UNIT(TO 100,000 . .U.) 4.00
Lender's Name
Lender%Address H EATI NG UN IT(OV ER 100,00 )
IIID ELECTRIC
I certify that 1 have read this application and state that the above VENTILATION FAN (SINGLE) 3.00
. '"formation n correct. I agree to comply with all city and county BOILER-COMP PLUMBING
ordinances and slate Taws relating to building construction, and (3 H.P.or 100,0008.T.U.) 4.00
hereby authorize representatives of this city to enter upon the 801 LER-COMP low,1OQ00o BTU)SEE FEE SCH.
shove-mentioned property for inspection purposes. MECHANICAL � 1Z
(We) agree to save, indemnify and keep harmless the City of MISC.- �Y REFER TO ORD
Cupertino against liabilities,judgments, costs and expenses which PERMIT ISSUANCE CONST.TAX
may in any way accrue against mid City in consequence of the 3.00
g sag Of I arms , MECH.CONT. LIC.NO. MECH.
TOTAL �7 J
/ TOTAL
Signnlure ol'A is t/Contruaor Uate
OFFICE COPY
APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
BUILDING PROJECT IDENTIFICATION PERMIT NUMBER
BUILDING eBH,w".
ADDRESS 7 APPLICATION & PERMIT 4539
BUILDING - ELECTRICAL-PLUMBING-MECHANICAL
OWNER'S PLAN CHECK VALIDATION
NAME OTY. ELECTRIC PERMIT FEE
RacroR's
. PHONE -
NAMEUTLETSG-SWITCHES-RECEP 5.00/1.00
LIC.NO. LIGHTI NF IXTURES 5.00/1.00
CONTRACTOR'S
oR's PPLIANCES-RESIDENTIAL 4.00
CONTRAS
PHONE PANELS 5.00 DATE OF APPLICATION
ARRCHITECT SIGNS 6.00 PLAN CHECK FEE P.L.NO,
ENGINEER
LIC.No. SIGNS TRANS. 3.00
AARCH.OR DDRESS ENG. SPECIAL CIRCUIT 5,00 PERMIT VALIDATION
ZIP TEMP.METER OR POLE INS. 15.00
APPLICANT'S MOTORS SEE FEE SCH. or J
AOORFSa
SERVICE CHANGE 10.00 0
woo LICENSED CONTRACTORS DECLARATION
<U W I hereby affirm that I am licensed under provisions of Chapter 9 ISSUANCE DATE
(commencing with Section 7000)of Division 3 of the Business and
w< y SLOG. ELECT. PLG. MECH.
O Z Professions Code,and my license is in full force and effect. ❑ ❑ ❑ ❑
O i Littre Class Lic.Number
w j Dale Contractor
i¢a OWNER-BUILDER DECLARATION BUILDING PERMIT
E: o w U INFORMATION
X; u w I hereby affirm that I am exempt from the Contractor's License MISC.- REFER TO ORD
�.o as Law for the following reason.(Sec.7031.5,Business and Professions VALUATION SIFT,
Fw�e Code:Any city or county which requimsa permit[oconstma.1teq
PERMIT ISSUANCE 6,00
le ce Q O improve,demolish,or repair any Structure,prior to Its issuance,also ELEC.CONTR. LIC. O. ELEC.
DLL requires the applicant for such permit to file a signed statement that
EL
he is licensed pursuant to the provisions TOTAL of the Contractor's License PERMIT TO
FiQLaw(Chapter 9(Commenctngwith Section 7000)ofDivision 3 oflhe /✓��-
s 4 o Business and Professions Code)or that he is exempt therefrom and OTY. PLUMBING PERMIT FEE
H$ the basis for the alleged exemption.Any violation GfSlciion 7031.5 STORIES TYPE CONSTR.
c 3 - by any applicant fora permit subjects the applicant loo civil penalty
Grant more than five hundred dollars(S500).): ALTER-DRAIN&VENT-WATER (EA.) 4.00
❑ I,as owner of the properly,or my employees with wages as BACK FLOW PROTECT.DEVICE 2.00
their sale compensation,will do the work,and the structure is not OCC.GROUP RES.UNITS
intended or offered for Sale (Sec. 7046, Business and Professions DRAINS-FLOOR,ROOF,AREA,COND. 4.00
Code:The Contractors License Law does not apply to an owner of
properly who builds or improves thereon,and who does such work FIXTURES-PER TRAP 4.00 SO.FT.FLOOR AREA TOTAL ACREAGE
• himself or through his own employees,provided that such improve-
menis arc not intended or offered for sale.If.however.the building GAS-EA.SYSTEM-1 INC.4 OUTLETS 4.00
or improvement is sold within one year of completion,the owner- GAS-EA.SYSTEM-OVER 4(EA.) 1.00
builder will have the burden of proving that Ile did not build or im- BUILDING USE
prove for purpose ofsale.). RES IND CON PIS Other
❑ I.as owner of the ro ert am exclusive) contracting with INDUSTRIAL WASTE INTER. 20.00
p p Y. Y, 7044, in
licensed contractors od to construct the project(Sec. 7044,Business LAWN SPR INKLERS-1 INC 5 V.B. 5,00 ASSESSORS PARCEL NO.
and Professions Code:The who
builds
Littre Law docs net apply
to tr owner of property who builds tr improves thereon,and who LAWN SPRINKLERS-OVER 5(EA.) 1.00
contracts lot such projects with a mntraclodsl licensed pursuant to
the Contractor's License Law. SEWER-SANITARY-STORM EA.200ft/6.00 TRACT NO, PARCEL NO.
exempt ul ei Sec. Cn — WATER
for this WATER HEATER W/VENT 4.00nonDate SYSTEM 4.00 ALG DATE ACC.FILE NO.
WORKERS'COk PENSATION DErWATER TREATING EQUIP. 4.00
1 hereby affirm that I have a certificate of Consent to weir sum.
or a certificate of Workers'Compensation Insurance,or a certified ZONING ENG.SITE NO.
copy thereof(Sec 3800,Lab.C.).
Policy No. Company
O ❑ Certified copy is hereby furnished.
Z Z ❑ Certified copy is fled with the city Inspection division. FIRE SPRINK ENERGY T 24
F O Applicant MISC.- REFER TO ORD. Y ❑ N❑ Y ❑ IN
to CERTIFICATE.OF EXEMPTION FROM WORKERS' PERMIT ISSUANCE- 6.00 FLOOD ZONE A.L.U.C.
LU COMPENSATION INSURANCE: PLG.CONTR, LIC.NO. PLG
OL O (This section need not be completed if[lie permit is for one TOTAL Y N Y ry
� Z hundred dollars(S 100)or less.)
U O 1 certify that in the performance of the work for which this per- Oar FEE SUMMARY
LL I- mit is issued,1 shall nm employ any person in any manner so as to MECHANICAL PERMIT FEE
U W become subject to the Workeri Compensation Laws of California.
y
Date—Applicant ALTER OR ADD TO MECH. 4,00 BUILDING
} 2NOTICE TO APPLICANT: If.after making this Certificate of Ex-
F.- emplion,you should become subject to the Workers'Compensation APPLIANCE 4.00 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 1 NL) 3.00 FEE
CONSTRUCTION LENDING AGENCY AIR HANDLING UNIT(OVER1 . ,M.) 5.00 SEISMIC FEE
I hereby affirm that there is a construction lending agency for EXHAUST HOOD( 2,00
the performance of the work for which this permit is issued(Sec.
3097,Civ.C.). HEATING UNIT IT ,0 .T. 4.00 MICROFILM
Leader's Name
Lender's Address HEATING UNIT(0 1 OB.T.U.)7.50 ELECTRIC
1 certify that 1 have read this application and state that the above VENTILATION FAN 1 L 3.00
information is correct.1 agree to comply with all city and county PLUMBING
ordinances and state laws relating to building construction. and 130ILER-COMP(3H.P.or100,000B.T.U.) 4.00
hereby authorize representatives of this city to enter upon the BOILER-COMP IOver 100,000 BTU)SEE FEE SCH. ev
above-mentioned properly for inspection purposes. MECHANICAL _
(We) agree ID stave, indemnity and keep harmless the City of MISC.- REFER TO ORD. ,0
Cupertino against liabilities,judgments, costs and expenses which
may in any way accrue against said City in consequence of the PERMIT ISSUA CCONST.TAXE 3.00�t
granting of this pen 'r /� ' MECH.CONT. LIC,NO. MECH
pL
Aps
ignature of icanljContractor a9 ate 7 S TOTAL
OFFICE COPY
APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALI- POINT PEN ONLY
BUI LDI NG PROJECT I DENTI FICATI ON PERMIT NUMBER
Boot ass W%/..%_4 �p APPLICATION & PERMIT 4540
y0 BUILDING—ELECTRICAL—PLUMBING—MECHANICAL
OwNER'S PLAN CHECK VALIDATION
NAME QTY. ELECTRIC PERMIT FEE
• ONE - 'rte/
NAMERACTORS UTLETS-SWITCHES-RECEP 5.00/1.00
LIC.Na. LIGHTING FIXTURES 5.00/1.00
CONTRAAcrOR's
ADDRESS PPLIANCES-RESIDENTIAL 4.00
PHONE PANELS 5.00 DATE OF APPLICATION
ARCHITECT SIGNS 6.00 PLAN CHECK FEE P.C.NO.
ENGINEER
uc.No. SIGNS TRANS. 3.00
ARCH,OR ENG SPECIAL CIRCUIT 5.00 PERMIT VALIDATION
zip TEMP.METER OR POLE INS. 15.00
AMOTORS SEE FEE SCH.
ADDRESS j
SERVICE CHANGE 10.00
w 0 0 LICENSED CONTRACTORS DECLARATION G
Q u U I hereby affirm that I am licensed under provisions of Chapter 9 ISSUANCE DATE
4 y
es (commencing with Section 7000)of Division 3 of the Business and BLDG. ELECT. PLG. MECH.
s- N i Professions Code,and my license is in full force and effect ❑ El 11 11o 0 m W Lie...Class Lie.Number
Date Contractor
Y -J' BUILDING PERMIT
M IC w 4 OWNER-BUILDER DECLARATION INFORMATION
X ;u s- I hereby affirm that I am exempt from the Contractor,License MISC.— REFER TO ORD
LL 0¢ Law for the following reason.(Sec.7031.5,Businessand Professions VALUATION SIFT.
I- - PERMIT ISSUANCE 8,00
vr� Code: e.demolish,
counpair any requircsapermittoconsuace,alsr,
improve,demolish,or repair any structure,prior to its issuance,also ELEC,CONTR. LIG.NO. ELEC.
i A D LL requires the applicant for such permit to file a signed statement thatTOTAL PERMIT TO
w$N he is licensed pursuant io'the provisions of the Contractor's License
� Z > Low(Chapter 9(commencing with Section 7000)ofDivisian 3 ofthe
i c Business and Professions Code)or That he is exempt therefrom andCITY. PLUMBING PERMIT FEE
e I-o the basis for the alleged exemption.Any violation of Section 7031.5
i 3 m STORIES TYPE CONSTR.
by any applicant for a permit subjects the applicant to a Civil penalty
of net more than five hundred dollars(5500).1: ALTER-DRAIN& VENT-WATER (EA.) 4.00
❑ I,as owner of the property,or my employees with wages as BACK FLOW PROTECT. DEVICE
their sole compensation,will do the work,and the structure is not 2.00 OCC.GROUP RES.UNITS
intended or offered for sale (Sec. 7044, Business and Professions DRAINS-FLOOR,ROOF,AREA,COND. 4.00
Code:The Contractors License Law does not apply to an owner of
pruperty who builds or improves thereon,and who docs such work FIXTURES-PER TRAP 4.00 50.FT.FLOOR AREA TOTAL ACREAGE
• himself or through his own employees,provided that such tmProve-
mentsare not intended oroffeyed for sale.IL however.the building GAS-EA.SYSTEM-1 INC.4 OUTLETS 4.00
or improvement is sold within one year of completion,the owner- GAS-EA.SYSTEM-OVER 4(EA.)
builder will have the burden of proving that he did not build or im- 1.00 BUILDING USE
Prove for purpose of sale.). INDUSTRIAL WASTE INTER. RES IND CON PB Other
❑ 1,as owner of the ro n 20.00
p tr y,he exclusively contracting with
licensed contractors to construct the project(Sec. 7044,Business LAWN SPRINKLERS- i INC 5 V.B. 6.00 ASSESSORS PARCEL NO.
and Professions Code:The who
build,Contractors License Law dues no apply
to tr owner of property who builds or improves thereon,and who LAWN SPRINKLERS-OVER 5(EA.) 1.00
me Cont for such projects with a contnaor(s)licensed pursuant In
the Contractor's exe License Law. SEWER-SANITARY-STORM EA.200ft/5.00 TRACT NO. PARCEL NO.
❑ lam exam funder Sec. .B.&P.C.lar this WATER HEATER W/VENT 4,00
ate )w'nur{, WATER SYSTEM
/ a�/� 4.00 ACC.DATE ACC.FILE NO.
WORKER COMP.ENSATION UECI.ARATI N WATER TREATING EQUIP, 4.00
1 hereby affirm that I have a certificate of consent to self-insum.
or a certificate of Workers'Compensation Insurance.or a certified ZONING ENG.SITE NO.
copy thereof(Sec.3800,Lab.C.7.
Policy No. Company
0 ❑ Certified copy is hereby famished.
Z Z ❑ Certified copy is filed with the city inspection divisimL FIRE SPRINK ENERGY T-24
p O Applicant MISC.- REFER TO ORD, Y❑ N[] Y ❑ N[3
try CERTIFICATE OF EXEMPTION FROM WORKERS' PERMIT ISSUANCE 6.00 FLOOD ZONE A.L.U.C.
W 2: COMPENSATION INSURANCE PLG.CONTR. LIC.NO. PLG
CL o (This section need not be completed if the permit is for one TOTAL Y N� Y N❑
Z hundred dollars AS 100)or Ins,,
U 0 1 certify that In the Performance of the work for which this per.RHANDLING
ECHANICAL PERMIT FEE SUMMARY
UL U mit is issued,I shall not employ any person in any manner so as to FEE
O W become subject to the Workers'Compensation Laws of California.
As. NOT Applicant ADD TO MECH, 4,00 BUILDING
} to NOTICE TO APPLICANT: If,alter making this Certificate of bx
Z emption,you should become subject to the Workers'Compensation 4.00 PLAN CHECK
provisions of the Labor Code. you most forthwith comply with FEE
U such provisions or this permit shall be deemed revoked. - NG UNIT(TO 10,000 .00CONSTRUCTION LENDING AGENCY NG UNIT(OVE ) SEISMIC FEE
I hereby affirm that there is a construction lending agency forHOOD(W ITH )the performance of the work for which this permit is issued(See. NIT(TO 100,
3097,CN.C.). ) 490 MICROFILM
Lender's Name
Lender's Address HEATING UNIT(OVER 100, ELECTRIC
I certify that I have read this application and state[flat the above VENTILATION FAN (SINGLE) 3.00
information is correct.I agree to Comply with all city and coolly PLUMBING
ordinances and state laws relating to building construction, and BOILER-COMP(3 H.P.Dr 100,000B.T.U.) 4.00
hereby 'Auenti oed roperty For
of this city to enter upon the BOILER-COMP (Oval 100,000 BTU)SEE FEE SCH. GFO
above-mentioned property for inspection purposes. MECHANICAL _
(We) agree to save, indemnify and keep harmless the City of MISC.- REFER TO ORD.Cupertino .
against liabilities,judgments, costs and expenses which
may in any way accrue against said City in consryuence of the PERMIT ISSUANCE 3.00 CONST.TAX
g of All permit. MECH,CONT. LIC.NO. MECH.
e OTAL � 7 ✓° TOTAL
Ignatum of Applica /Contractor Uare
OFFICE COPY
APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
BUILDING PROJECT IDENTIFICATION PERMIT NUMBER
BUILDING
a9.%/d/.A� st/o APPLICATION & PERMIT _ 4542
Irr Oyer L, BUILDING—ELECTRICAL—PLUMBING—MECHANICAL
OWNER'S PLAN CHECK VALIDATION
NAME QTY. ELECTRIC PERMIT FEE.
. RACTOP's P PHGNyy —
NAMEUTLETS-SWITCHES-RECEP 5.0011.00
Lm.No, LIGHTING FIXTURES 5.00/1.00
ATOP'S
ADDRESS PPLIANCES-RESIDENTIAL 4.00
ADDRESS
PHONE PANELS 5.00 DATE OF APPLICATION
ARCHITECT SIGNS 6.00 PLAN CHECK FEE P.C.N0.
ENGINEER
I.M.No. SIGNS TRANS. 3.00
ARCH.OR ENG. SPECIAL CIRCUIT 5.00 PERMIT VALIDATION
ZIP TEMP.METER OR POLE INS. 15.00
ADRESrvT's
ADDRESS MOTORS SEE FEE SCH.
SERVICE CHANGE 10.00 /C
w o o LICENSED CONTRACTORS DECLARATION
<u v I hereby affirm that I am licensed under provisions of Chapter q ISSUANCE DATE
y Q N (commencing with Section 7000)of Division 3 ofthe BYsineSsand BLDG. ELECT. PLG. MECH.
F o z Professions Code,and my license is in full force and effect.
0 License
1:1 E3 1:1 O
o 0 .Chun Lie.Number
y F i Date Contractor
c w a OWNER-BUILDER DECLARATION BUILDING PERMIT
s U INFORMATION
x ' se I hereby affirm that 1 am exempt from the Contractors License MISC.— REFER TO ORD
w u o c Law for the fallowing reason.(Sec.7031.5,Business and Professions VALUATION $/FT.
N rn PERMIT ISSUANCE 6,00
Code:Any city or county which requiresa permit to construct,alter,
c ¢4.0 improve,demolish,or repair any Structure,prior to Its issuance,also ELEC.CONTR. LIC.NO. ELEC.
y LL KQGIRc the dp pursuant
for such revisit 10 filet a signed statement i that TOTAL PERM X $x he is licensed pursuant to the provisions of the Conm¢ision License
Fir
Low(Chapter 9(commencing with Section 7000)of Division3ol'the (Q
4 et Business and Professions Code)or that he is exempt therefrom and
F�s the basis for the alleged exemption.Any violation of Section 7031.5 QTY. PLUMBING PERMIT FEE STORIES TYPE CONSTR.
n; _ by any applicant for a permit subjects the applicant ton civil penalty
of not more titan five hundred dollars($500).): ALTER-DRAIN&VENT-WATER (EA.) 4.00
❑ 1,as owner of the properly.or my employees with wages as BACK FLOW PROTECT.DEVICE
their sole compensation,will do the work,and the structure is not 2.00 DCC.GROUP RES.UNITS
intended or offered for sale (Sec. 7044, Business and Professions DRAINS-FLOOR,ROOF,AREA,COND. 4,00
Code:The Contractor's License Law does not apply to an owner of
property who builds or improves thereon,and who doss such work FIXTURES-PER TRAP 4.00 SOL FT._FLOOR AREA TOTAL ACREAGE
. himself or Ihrough his own employees,provided that such improve-
meIts are not intended or offered for sole.If,however,the building GAS-EA.SYSTEM-11NC.40UTLETS 4-00
or improvement is sold within one year of completion. the owner. GAS-EA.SYSTEM-OVER 4(EA.) 1.00 BUILDING USE
builder will have the burden of proving that he did not build or im-
prove for purpose of soled: INDUSTRIAL WASTE INTER. 20.00 RES IND CON PB Other
❑ 1,as owner of the property,am exclusively contracting with13 C3 ❑ El 1:1licensed contractors to construct the project(Sec.7044,Business LAWN SPRINKLERS- 1 INC 5 V.B. 5.00
and Professions Code:The Contractors License Law does not apply ASSESSORS PARCEL NO.
to an owner of property who builds or improves thereon,and who LAWN SPRINKLERS-OVER 5(EA.) 1.00
contracts for such projects with a contractors)licensed pursuant to
the Contractor's License Law. SEWER-SANITARY-STORM EA.200ft/8.00 TRACT NO. PARCEL NO.
re❑ lam exempt under Sec. ,B.&P.C.Ibr this WATER HEATER W/VENT 4.00
D e WORKERS' OOy�tJrWATER SYSTEM 4.00 ACC,DATE ACG FILE NO.
OMPENSATIO I�CLARAT Oh WATER TREATING EQUIP. 4.00
I hereby affirm that I?lave a certificate of consent to self-insure,
or a certificate of Workers'Compensation Insurance.or a certified ZONING ENG.SITE NO.
copy thereof(Sec.3800,Lab.C.).
Policy No. Company
O ❑ Certified copy is hereby furnished.
Z Z ❑ Certified copy is filed with the City inspection division. FIRE SPRINK ENERGY T-24
F O Applicant MISC.- REFER TO ORD. Y[] A Y LJ N[:)
CCT CERTIFICATE OF EXEMPTION FROM WORKERS' PERMIT ISSUANCE 6.00 FLOOD ZONE A.L.U.C..
W it COMPENSATION INSURANCE PLG.CONTR. LIC.N0. PLG
? Z (This section need not be completed if the permit is for one TOTAL Y N� Y N[]hundred dollars IS 100)i or less.)
U O 1 certify that in the performance of the work for which this per- OTV MECHANICAL PERMIT FEE FEE SUMMARY
LL mil is issued.I shall not employ any person in any manner so as to
Q W become subject to the Workeri Compensation Laws of California.
y Date Applicant ALTER OR ADD TO MECH. 4,00 BUILDING
>_ Cal NOTICE TO APPLICANT: If,attar making this Certificate of Hx
F Z emplion.you should become subject to the Workers'Compensation APPLIANCE 4.00
provisions of the Labor Cade, you must forthwith comply with PLAN CHECK
U such provisions or this permit shall be deemed revoked. AIR HANDLING UNIT(TO 10 ) 3.00 FEE
CONSTRUCTION LENDING AGENCY AIR HANDLING UNIT(OVER 10 F. 0 SEISMIC FEE
1 hereby affirm that there is a construction lending agency for EXHAUST HOOD(WI
the performance of the work for which this permit is issued(Sec. MICROFILM
3097,Civ.C.). HEATING UNIT(TO 100,000 B.T.U.) ,4 p
lender's Name
Lender's Address H EATI NG UN IT(OV E ELECTRIC
I certify that l have read this application and stale that the above VENTILATION FAN (SINGLE) 3.00
• information is correct. 1 agree to comply with all city and county PLUMBING
ordinances and state laws relating to building construction, and BOILER-COMP(3H.P.or 100,000B.T.U.) 4.00
hereby authorize ropertyfor insles of This city to enter upon the BOI LER-COMP(Over 100,000 BTU))SEE FEE SCH.
above-mentioned properly for inspection purposes. MECHANICAL
(We) agree to Save. Indemnify and keep harmless the City of MISC.-
Cupertino against liabilities,judgments, costs and expenses which CONST.TAX
may in any way accrue against Said City in consequence of the PERMIT ISSUANCE 3.00
granting of lh' per , / MECH.CONT. LIC.NO. MECH
OTAL�- 7
N
aturc of Ap 1' ant/Contactor ate
TOTAL
OFFICE COPY
APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
BUILDING PROJECT IDENTIFICATION APPLICATION & PERMIT PERMIT NUMBER
BUILDING
.B.Vr/d/.af ¢/� 4543
Zt L' BUILDING-ELECTRICAL-PLUMBING-MECHANICAL 4 5 4 3
OWNEITS I -2�7 PLAN CHECK VALIDATION
NAME OTY. ELECTRIC PERMIT FEE
/,Vj P NONE
Nnree"AOTORs UTLETS-SWITCHES-RECEP 5.00/1.00
LIC.NO. LIGHTING FIXTURES 5.00/1.00
CONTRACTOR'S
RES PPLIANCES-RESIDENTIAL 4.00
PHONE PANELS 5.00 DATE OF APPLICATION
ARRCHITECT SIGNS Q.QQ PLAN CHECK FEE P.C.NO.
ENGINEER
LIC No. SIGNS TRANS. 3.00
ADDRESS ENc' SPECIAL CIRCUIT 5.0Q PERMIT VALIDATION
ZIP TEMP.METER OR POLE INS. 15.00
AEMOTORS SEE FEE SCH. S
ADDRESS
SERVICE CHANGE 10.00
o o LICENSED CONTRACTORS DECLARATION
a z I hereby affiml that I am licensed under provisions of Chapter 9 ISSUANCE DATE
(commenemg with Section 7000)of Division 3 of the Business and
3 i Professions Code.and my license is in full force and effect. BLDG. ELECT. PLG. MECH.
oi ve D License Class Lie.Number
Z.r J Date Contractor El El El El
c¢ a OWNER-BUILDER DECLARATION BUILDING PERMIT
O a Dw MISC.- REFER TO ORD INFORMATION R: s- I hereby affirm that 1 am exempt Gmn the Contractor's License
I.O Law for the following reason.(Sec.7031.5.Businessand Professions VALUATION $)FT.
w >2 iCode e.dem y or demolish,
pair any reqstructure.es a
prior to consuance,alter,
PERMIT ISSUANCE 6.00
Q It at O improve.demolish,or repair any sl NclnR,pr10r t0It5155uancf,also ELEC.CONTR. LIC.N0. ELEC.
u O u requires the applicant for such permit to file a signed statement that TOTAL
X w he is licensed pursuant to the provisions of the Contractors License PERMIT TO
ri>
Law(Chapter 9(commencingwilh Section 7000)ofDivision 3 ofthe
a Business and Professions Code)or that he is exempt therefrom and OTY. PLUMBING PERMIT FEE V
¢ r the basis for the alleged exemption.Any violation of Section 7031.5
y; by any applicant for a permit subjects the applicant to a civil penalty STORIES TYPE CONSTR.
of not mon than five hundred doll..0500).): ALTER-DRAIN&VENT-WATER (EA.) 4.00
❑ I.as owner of the property,or my employees with wages as BACK FLOW PROTECT.DEVICE
their Sole compensation,will do the work,and the structure is not 2.00 OCC.GROUP RES_UNITS
intended or offered for sale(Sec. 7044. Business and Professions DRAINS-FLOOR,ROOF,AREA,CON D. 4.00
Code: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 4.00 SO.FT.FLOOR AREA TOTAL ACREAGE
himself or through his own employees,provided that such improve-
mentsamnotintendedorofferedforsale,IL however.the building GAS-EA.SYSTEM-11NC.40UTLETS 4.00
or improvement is Said within one year of completion,the owner GAS-EA.SYSTEM-OVER 4(EA.) 1,00
builder will have the burden of proving that he did not build or im- BUILDING USE
prove for purpose of Sale.). RES IND CON PB Gina,
❑ 1,as owner of the property,am exclusively contraclingwith INDUSTRIAL WASTE INTER. 20.00
licensed contractors to construct the projectISec. 7044.Business LAWN SPRINKLERS-1 INC 5 V.B. 5.00 A55ESSORS PARCELNO,
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-OVER 5(EA,) 1.QO
contracts for such projects with a contractorts)licensed pulsumu to
the Contractors License Law. SEWER-SANITARY-STORM EA.200ft/8.00 TRACT NO. PARCEL NO.
❑ I I Iexeml under Sec. ,B.&P.C.for Ibis 400
rc n WATER HEATER W/VENT
Ow"' WATER SYSTEM 4.00 ACC.DATE ACC.FILE NO.
WORKERS' Me,cF ATION DECLA;el'"-> WATER TREATING EQUIP. 4.00
I hereby affirm that I have a certificate.1 consent mselLinsum,
or a certificate or Workers'Compensation Insurance,or a certified ZONING ENG.SITE NO.
copy thereof(See.3800.Lab.C.).
Policy No. Company ,
O ❑ Certified copy is hereby fumisheJ.
Z Z ❑ Certified copy is filed with the city inspection division, FIRE SPRINK ENERGY T.24
F O Applicant MISC.- REFER TO ORD. Y[:] N❑ Y ❑ N�
T CERTIFICATE OF EXEMPTION FROM WORKERS' PERMIT ISSUANCE 6.00 FLOOD ZONE A.L.U.C.
W > COMPENSATION INSURANCE PLG.CONrp. LIC.NO. PLG
CL O (This section need not be completed if the permit is fur one TOTAL Y N� Y IN E]
Z hundred doBafs(SIOO)or less.)
V O 1 certify that in the performance of the work for which this per. OTY MECHANICAL PERMIT FEE SUMMARY
LL F mit 6 issued,I shall not employ any person in any manner sn as to FEE
O U become subject to the Workers Compensation Laws of California.
a Data Applicant ALTER OR ADD TO MECHBUILDING
>_ 2 NOTICE TO APPLICANT: If,after making this Certificate of Ex-
. q•QQ
F _ aption,you should become subject to the Workers Compensation APPLIANCE AIR H4.00
provisions of the Labor Code. you must forthwith comply with PLAN CHECK
U such provisions or this permit shall be deemed revoked. HANDLING UNIT(TO 1Q000CF.M.) 3.00 FEE
CONSTRUCTION LENDING AGENCY AIR HANDLING UNIT(OVER 10pODC.EM.15.00 SEISMIC FEE
I hereby affirm that there is a construction lending ugency for EXHAUST HOOD(WITH DUC .00
the performance of the work for which this permit is issued(Sec.
3097•Civ.C.). HEATING UNIT(TO 100,000 B.T.U. 4.00 MICROFILM
Lender's Name
Lender's Address HEATINGUNIT(OVER T . 0 ELECTRIC
1 certify that I have read this application and stale that the above VENTILATION FAN (SINGLE)
winformation is correct. I agree to comply with all city and county PLUMBING
ordinances and state laws relating to building construction.and BOILER-COMP(3 H.P.or 1� ,00
hereby authorizerepresentativesof this cit to enter upon the BOILER-COMP IDVe,100,000 BTUI SEE EE �j
above-mentioned property for inspection purposes. MECHANICAL Oe
(We) agree to save, indemnify and keep harmless the City of MISC.- REFER TO ORD
Cupertino against liabilities,judgments. costs and expenses which
may in any way accrue against said City in consequence of the PERMIT ISSUANCE 3.00 CONST.TAX
ting of is n F MECH.CONT. LIC.NO.,
MECH.
TOTAL oo TOTAL
Signature of p mens/Comraclor a[c 7�
OFFICE COPY
APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
BUILDING PROJECT I DENT(FICATION PERMIT NUMBER
BUILDING #�� APPLICATION & PERMIT 4544
Ir
An
/3Ni /CE/tiq
07 OCG / t BUILDING—ELECTRICAL—PLUMBING—MECHANICAL
OWNER'$
PLAN CHECK VALIDATION
rvnmE QTY. ELECTRIC PERMIT FEE
NAMERACTORB UTLETS-SWITCHES-RECEP 5.00/1.00
LIC.NO, LIGHTING FIXTURES 5.00/1.00
ADDRESS row's PPLIANCES-RESIDENTIAL 4.00
PHONE PANELS 5.00 DATE OF APPLICATION
OORCRITECT SIGNSPLAN CHECK FEE P.C.NO,
ENGINEER 6'DD
LIC.NO. SIGNS TRANS. 3.00
ADDRESSENA.
ADDRESS
SPECIAL CIRCUIT 5.00
PERMIT VALIDATION
ZIP EMP.METER OR POLE INS. 15.00
AnPLICAT'$ MOTORS I
SEE FEE BCH. vr/
SERVICE CHANGE 10.00
Woo LICENSED CONTRACTORS DECLARATION Id/ZG/j
<u V I hereby affimh that 1 am licensed under provisions of Chapter 9
w< ca (commencing with Section 7000)or Division 3 of the Business and ISSUANCE GATE
us y i Professions Code,and my license is in full force and effect. BLDG. I ELECT.I PLG. I MECH.
o 0 m W License Class Lic.Number ❑ 1:1 ❑ C-1Far J Date Contractor
a Sc m a OWNER-BUILDER DECLARATION BUILDING PERMIT
Xu,,;LL H I hereby affirm thus I am exempt from the Contractor's License MISC.— REFER TO ORD
INFORMATION
u. O a taw for the following reason ISec.7031.5,Business and Protissiuns VALUATION
t —H PERMIT ISSUANCE $jFT'
Code:Any city or cou my which req ones a permit to conanmt.alteq 6.00
ELEC
¢¢0 improve,demolish,or repair any structure,priorto i[s issuance,also ELEC.CONTR. LIC.NO.
requires the applicant for such permit to file a signed statement,hal To"
ca$m he is licensed pursuant 10 the provisions of the Co.
License TOTAL PERMIT TO
riQ 1)aw(Chapter9(commencing With Sect ion 7000)of Division Sof the M �,�,[
z O Business and Professions Code)or,
he is exempt therefrom and QTY. PLUMBING PERMIT FEE / e CT /4
(cF $ the basis for the Or
exemption.Any vidlalion of Section 7031.$ STORIES TYPE CONSTR.
by any applicantfora permit subjectsthe applicant loocivil penally ALTER-DRAIN&VENT-WATER
of Rat more than five hundred dollars(3500).): , (EA.) 4,00
❑ I,as owner of the property or my employees with wages as BACK FLOW PROTECT. DEVICE
their sole compensation,will do[he work,and the stivctllrc is Rat 2.DD OCC.GROUP RES.UNITS
intended or offered for sale(Sec. 7044, Business and Professions DRAINS-FLOOR,ROOF,AREA,COND. 4.00
Code: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
• himself or through his own employees,provided that such improve+ 4'� SO.FT.FLOOR AREA TOTAL ACREAGE
ments are not intended or offered far sale.If.however.the building GAS-EA.SYSTEM•11NC.4OUTLETS 4.00
or improvement is sold within one year of completion,the owner-
builder will have the burden of proving That he did no,build or im. GAS-EA.SYSTEM-OVER 4(EA.) 1.00 BUILDING USE
prove for purpose of sale.), INDUSTRIAL WASTE INTER. 20.00 RES IND CON PB Omar
❑ I,as owner of The property,am exclusively contracting with ❑ ❑11 ❑ ❑
licensed contractors To construct the project(Sec. 7044.Business LAWN SPRINKLERS- I INC 5 V.B. 5.00
and Professions Code:The Contractor's License Law does not apply ASSESSORS PARCEL NO.
to an owner of property who builds or improves tlsareon,unit who LAWN SPRINKLERS-OVER 5(EA,) 1.00
contracts for such projects with a contraclodsl licensed pu Ramit to
the Contractor's License Law. SEWER-SANITARY-STORM EA.200ft/8.00 TRACT NO. PARCELNO.
rc❑n l am exempt under Sec. .BAP.C.In,this WATER HEATER W/VENT
4.00
ata �ghher /�� WATER SYSTEM
0 v id"3 4-� ACG.DATE ACC,FILE NO.
WORK ' 'CO PENSATION DECLARA I WATER TREATING EQUIP. 4,00
I hereby affirm That I have a certificate of consent to sell.inure.
or a certificate of Workers Compensation Insurance,Of a eellified ZONING ENG.SITE NO.
copy thereof(Sec.3800,Lab.C.).
Policy No. Company
O ❑ Certitcd copy is hereby furnished.
Z Z ❑ Certified copy is riled with the city inspection division. FIRE SPRINK ENERGY T-24
O Applicant MISC.- REFER TO ORD. Y No v (] NN[3~ PERMIT ISSUANCE
N CERTIFICATE OF EXEMPTION FROM WORKERS' 6.00 FLOOD ZONE A.L.U,C.
W > COMPENSATION INSURANCE PLO.CONTR. LIC.NO.
d PLO.
o
(This section need not he completed if the pemhi, is Ira one �
� 2 hundred dollars IS 100)or less.) TOTAL Y❑ NY[:] NC]
0 O I certify that in the performance of the work for which this per-
F mit is issued,I shall not employ an QTY' MECHANICAL PERMIT FEE FEE SUMMARY
LL p y Y person I.any manner Sons to
Q w become subject to the Workers'Compens:.Ition Laws o(Calilomin.
Q. Date Applicant g ALTER OR ADD TO MECH. q,00 BUILDING
} m NOTICE TO APPLICANT: If,after making this Certificate of Ex-
I— Z emption,you should become subject to the Workers'Compensation APPLIANCE
provisions of the Labor Code, you must forthwith comply with q•00 PLAN CHECK
V such provisions or this permit shall be deemed revoked. AIR HANDLING UNIT(TO 10,Ailix 3.00 FEE
CONSTRUCTION LENDING AGENCY AIR HANDLING UNIT(OVErt 10p00C.FM,15.00 SEISMIC FEE
I hereby affirm that there is a construction lending agency for EXHAUST HOOD(WI ) 0
the performance of the work for which this permit is issued(Sec.
3097,Civ.C.). HEATING UNIT 10100,000 B.T.U.) 4.00 MICROFILM
Lender's Name
Lender's Address HEATING UNIT(OVEIL` 0 ELECTRIC
I certify that 1 have read this application and state that the above VENTILATION FAN (SINGLE) 3.00
• information is Correct.1 agree 10 comply with all city and county
L
ances and state laws relating to building construction, and BOILER-COMP(3 H.P.Or 100,000 B.T.U.) 4,00 PLUMBING
y authorize representatives of this city to enmr upon the
-mentioned property for inspection purposesBOILER-COMP(Over 100,000 BTU(SEEFEEBCH. Qye) MECHANICALagree to save, indemnify and keep hernal s the Ciry or MISC.- REFER TO ORD.
tino against liabilities,judgments, costs'and expenses whichn any way accrue against said City in consequence of the PERMIT ISSUANCE 3.00CONST.TAX
ng of is crMECH.CONTLIC.NO. MECH.
TOTALqTOTAL
ure ofA pl" anllCommclar Uae QC/
OFFICE COPY
APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
WNN
BUILDING PROJECT IDENTIFICATION PERMIT NUMBER
,r' OING ICATION & PERMIT
5ctelBUILDING—ELECTRICAL—PLUMBING—MECHANICALER'sPLAN CHECK VALIDATION
E O ELECTRIC PERMIT FEE
!I_i �.i�1 CONTRACTOR'S
NAME UTLETS-SWITCHES-RECEP 5.00!1.00
Lie.NO. LIGHTING FIXTURES 5.00/1.00
NTRgciofls
ADDRESS
PPLIANCES-RESIDENTIAL 4.00
CONTRACTORS
PANELS 5.00 DATE OF APPLICATION
ARCHITECT PLAN CHECK FEE P.C.NO.
OR �.✓rs��/YllfGr y0 7. SIGNS 6.00
ENGINEER
LIC.NO. SIGNS TRANS. 3.00
ADDRESS ENo. SPECIAL CIRCUIT 5,00 PERMIT VALIDA ION
ZIP EMP.METER OR POLE INS. 15.00
ADDRESS r/
AMOTORS SEE FEE SCH. (�
ADDRESS
SERVICE CHANGE 10.00
w.0 o LICENSED CONTRACTORS DECLARATION
rt u 1 hereby affirm that I am licensed under provisions of Chapter 9 ISS E DATE
w a i (commencing with Section 7000)of Division 3 of the Business and
r w i Professions Code,and my license is in full force and,effect SLOG. EL PLG. MECH.
Z 0 m License Class um
Lie.Nber
W
Uate Contractor
Qy�J
¢_ ¢w a OWNER-HUILUER DECLARATION •BUT DING PERMIT
°
A.U MISC.— REFER TO ORD I FORMATION
X ; I hereby affirm that I am exempt From the Contractor License
r u w a Law for the following reason.(Sec.7031.5,Businessand Professions PERMIT ISSUANCE 6 VALUATION §/FT.
Fw> E Code,Any city lir county which requires a permit to construct,alter,
¢
'<° Improve,demolish,or repair any slruclum,prior to its issuance,also ELEC.CONTR, LIC.NO. ELEC.
R a u requires the applicant for such permit to file a signed statement that TOTAL u
A w m w he is licensed pursuant to the provisions of file Conlracloi s License PERMIT TO
a Low(Chapter 9(commencing with Section 7000)of Division 3 of the
s q 0 Business and Professions Code)or that he is exempt therefrom and OTY. PLUMBING PERMIT FEE
¢i-S Ilse basis for the alleged exemption.Any violation of Section 7031.5
n ;_ by any applicant for a permit subjects the applicant to a civil penally STORIE If
TVP CONSTR.
of not more than five hundred dollars ISSOOL): ALTER-DRAIN&VENT-WATER (EA.) 4.00
❑ 1,as owner of the properly,or my employees with wages as BACK FLOW PROTECT.DEVICE their sole compensation,will do the work,and the structure is not 2.00 OCC.GROUP RES.UNITS
intended or Offered for sale (See. 7044, Business and Professions DRAINS-FLOOR,ROOF,AR EA,COND. 4.00
Code:The Contractor's License Law does not apply to an owner of
q property who builds or improves thereon,and who does such work FIXTURES-PER TRAP 4.00a0.FT.FLOOD AREA TOTAL ACREAGE
s himself or through his own employees,provided that such improve-
mentsorenolintendedor offered for sale.If,however,the building GAS-EA.SYSTEM-11NC.40UTLETS 4.00
"''•j or improvement is sold within one year of completion,the owner
builder will have the burden of proving that he did not build or im- GAS-EA.SYSTEM-OVER 4(EA.) 1.00 BUILDINCuME
prove for purpose of sale.). RES IND O PB DIME
INDUSTRIAL WASTE INTER. ❑ ❑
❑ Las owner OI the properly,he exclusively contracting with 20.00El
and Pro contractors to The
the project(Sec.7044,Business LAWN SPRINKLERS-1 INC 5 V.B.
and Professions Code:The Commclor's Lianse law does not apply 5.00 ASSESSOPARCEL NO.
to an owner of property who builds or improves thereon,and who LAWN SPRINKLERS-OVER 5(EA.) 1.00
rs
contracts for such projects with a contracloris)licensed puaont to
the Contractor's License Law. SEWER-SANITARY-STORM EA.200ft/8.00 TRACT NO. PARCEL NO.
l am exempt under Sec. ,B.6.P.C.for this
reason
WATER HEATER W/VENT 4.00
Owner Date WATER SYSTEM 4.00 ACC.DATE ACC.FILE NO.
WORKF.RS'COMPENSATION DECLARATION WATER TREATING EQUIP. 4.00
h ^ 1 hereby affirm that I have a certificate are....I to self-insum,
/}CJ or a certificate of Workers'Compensation Insurance,or u certified ZONING ENG.SITE NO.
copy thereof(Sec.3800,Lub.C.).
O Policy No. Company
ed OpY 1, sed. FIRESPRINK ENERGY T
Z ZO �❑ i ifi a is de vilh c cit on division. 20
F _ MISC.- REFER TO ORD. Y C] IN Y E] N�
� y CERTIFICATE OF EXEMPTION FROM WORKERS' PERMIT ISSUANCE 6.00
W > COMPENSATION INSURANCE PLG.CONTR, LIC.NO. PLG FLOOD ZONE L.U.C.A.
fL o (This section need not he completed if the permit is fur one TOTAL Y❑ N� Y[—] NEIU O hundred dollars($100)or lose.)
1 certify that in the performance of the work for which this per- OT,r MECHANICAL PERMIT F6E FEE SUMMARY
LL k.. mit is issued,i shall not employ any person in any manner sur as to
O W become subject to the Workers'Compensation Laws of California.
o-} Date APPLICANT:
I ALTER OR ADD TO MECH. 4,00 BUILDING 0. NOTICE TO APPLICANT: L after making ihis.Cerlificale of Ex-
F. Z eruption.you should become subject to the workers'Compensation APPLIANCE
provisions of the Labor Code, you most forthwith comply with 4.00 PLAN CHECK
U such provisions or this permit shall be deemed revoked. AIR HANDLING UNIT(TO 10pI10CF.M.) 3.00 FEE
CONSTRUCTION LENDING AGENCY AIR HANDLING UNIT(OVER 10=C.F.M.) 5.00 SEISMIC FEE
I hereby affirm that then is a construction lending agency for EXHAUST HOOD(WITH DUCT) 2,00
the performance of the work for which this permit is issued(Sec.
3097,Civ.C.L HEATING UNIT(TO 100,000 B.T.U.) 4.00 MICROFILM
Lender's Name
Lender's Address HEATING UNIT(OVER 100,000 B.T.U.)7.50 ELECTRIC
1 I certify that I have read this application and state that the above VENTILATION FAN (SINGLE) 3,00
.rural ion is correct. I agree to comply with all city and county
mancas and stale laws relating to building construction. and BOILER-COIVP(3 H.P.or 100,000 B.TU.) 4.00 PLUMBING
hereby authorize represenlalives of This city to enter upon the
., above-mentioned property for inspection purposes. BOILER-COMP(Over tOp,000 HTULSEE FEE SCR. MECHANICAL
-(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 3 00 CONST.TAX
may in any way lice a 'ud said City in consequence of the
ming of per A MECN.CONT. LIC.NO. MECH.
TOTAL TOTAL
Srgnatureol'A
it nt/ ontiactor ate
OFFICE COPY