9372 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
BU LDI NG PROJECT I DENTI FICATI ON PERMIT NUMBER
ADDRESS APPLICATION & PERMIT 9372
ADDRESS
BUILDING - ELECTRICAL-PLUMBING-MECHANICAL
Owry R' PLAN CHECK VALIDATION
NAME QTY. ELECTRIC PERMIT FEE
PHONE
rvame cons UTLETS-SWITCHES-RECEP 10.00/1.00
All
Llc.rvo. LIGHTING FIXTURES 10.00/1.0'CON0
ADD c oR PPLIANCES-RESIDENTIAL 4.00 O
ADDRESS el /fq�
PHONE PANELS 10.00 DATE OF APPLICATION
'ARSWOR ec PANELS (OVER 200 AMP) 20.00 PLAN CHECK FEE D.C.N0.
ENGINEER
uo NO. SIGNS TRANS. 3.00
ADDRESS ENO. SPECIALCIRCUIT 5.00 PERMIT VAIIQIM,�
ZIP EMP.METER OR POLE INS. 20.00 ��-��1�,�/
APPLICANT RMOTORS SEE FEE SCH. SEP U 51985
ADDRESS
SERVICE 6 HANGE 20.00
woo LICCNSHD CONTRACTORS DECLARAT TEMP.POLE 30.00 City of Cupertino
a U. 1 hereby affirm that 1 am licensed under provisions of Cha,h r 9 ISSUANCE DATE
H G w (commencing with Section]000)of Division 3 of the Business and BLDG. ELE T. PLG. MECH.
H m z Professions Codc,and,,,,my license is in lull force and effect. ❑ ❑ ❑
Z, O w - License Class Lia.Number
9 m
[)are Cmdmcmr-7CNl
< m P BUIL ING PERMIT
¢ ¢o al U OWNER-BUILDER DECLARATION IN RMATION
E
3 a. H 1 hereby affirm that I am exempt from the Contractor's License MISC.- REFER TO ORD
a- a-
Law for the following reason.ISec.7031.5.Business and Professions PERMIT ISSUANCE 1000 G VALUATION $/FT.
Code'.Any city orcounty which requires a permit to construct,alter,
pQ ¢ pimprove, Or repair any Strut'tum,prior to its Issuance.also ELEC.CONTR. LIGNO. ELEC.
i w m¢ requires the applicant for such permit to file a signed statement that / TOTAL ERMIT TO
he is licensed pursuant m the provisions of the Contractor's License
z a Law.(Chapter 9(cpmmencingwith Section 7000).(Division 3 of the
I x U Business and Professions Code)or thatonhe is exempt therefrom and QTY. PLUMBING PERMIT FEE
¢r o the basis for the alleged exemption.Any violation of Section 7031.5 STORI 5 YPE CONSTR.
e. byanyapplicamfor a permit subjects the applicant to a civil penalty r -y
of not more than five hundred dollars($500).) ALTER-DRAIN& VENT-WATER (EA.) 5.00
:
❑ I,as owner of the property,or my employees with wages as BACK FLOW PROTECT. DEVICE 4.00 OCC.GROUP RES.UNITS
their sole compensation,will do the work,and the structure N not
intended or offered for sale (Sec. 7044, Business and Professions DRAINS-FLOOR,ROOF,AREA,COND. 5.00
Code:The Contractor's License Law does not apply to an owner of
property who builds or improves thereon,:md who does such work FIXTURES-PER TRAP 5.00 50.FT.FLOOR AREA TOTAL ACREAGE
• himself or through his own employees,provided that such reprtrve-
merits are not intended or offered for sale If,however,the building GAS-EA.SYSTEM-1 INC.4 OUTLETS 6.00
ser improvement is sold within one year of completion, the owner- GAS EASYSTEM-OVER 4 IEA) 200
builder will have the burden of proving that h - . . .
e did not build or im- BUILDING USE
prove for purpose of sole.). INDUSTRIAL WASTE INTER. 30.00 RE IND CON PB Omer
❑ 1,as owner of the property,am exclusively contracting with
licensed contractors to construct the project(Sec.7044,Business LAWN SPRINKLERS- 1 INC 5 V.B. ' 6.00ASSESSORSPARCEL NO.
and Professions Codc:The Comractor's License Law does not apply
to an owner of property who builds or improves thereon,and who LAWN SPRINKLERS-OVER 5 (EA.) 1.(T
contracts for such projects with a conlructoos)licensed pursuant to
the Contractor's License Law. SEWER-SAN ITAR V-STORM EA.200ft/10.00 ACT NO. PARCEL NO,
❑ lam exempt under Sec. ,B.dP.C.for this WATER HEATER W/VENT 6.00
reason
Owner //�� Date WATER SYSTEM 5.00 ACC.DATE ACC.FILE NO.
34&I!6�/h NSATION DECLARATION' WATER TREATING EQUIP. 5.00
1 hereby affirm that 1 have a certificate ofconsent to self-insure. ZONING
or a certificate of Workers'Compensation Insurance,or a certified ENG.SITE NO.
copy(hereof lScc.3800,Lab.C.).
Policy No. Company
Q ❑ Certified copy'is hereby'famished. FIRE SPRINK ENERGY T.I4
Z 2 Certlne opy is fla with the city inspection division.
FO A, hca,u 4;;. F� / y '�„g MISC.- REFER TO ORD. y � NEJ Y [J NE]
S2 d�TI9 PERMIT ISSUANCE 10.00
LL - 017 INSUROA1 WORKERS' FLOODZONE A.L.0 c.
W 7 COMPF.NSAI'IOh'INSURANCIi PLG.CONTR. LIC.NO. PLG. YE] N� Y � N�
Z m
(This suction need not be completed it the permit is for one TOTAL
hundred dollars IS 100)or less.)
U 0 1 certify that in the performance of the work for which this per- QTY. MECHANICAL PERMIT FEE FEE SUMMARY
LL U mil is issued,1 shall not employ any person in any manner so as to
become subject to the Workers'Compensation Laws of California.
DO Unto Applicant BUILDING
} to NOI'ICI:TO APPLICANT'. If,after making this Certificate of Ex- ALTER OR ADD TO MECH. 5.00
? emption,you should become subject to the Workers'Compensation APPLIANCE 5.00 PLAN CHECK
provisions of the Labor Code, you must forthwith comply wile FEE
U such provisions or this permit shall be deemed revoked. AIR HANDLING UNIT(TO 10S W C.F.M.) 4.00
CONSI'RUCIIoN LENDING AGENCY AIR HANDLING UNIT(OVER 10=C.F.M.) 6.00 SEISMIC FEE
1 hereby affirm that there is a construction lending agency for EXHAUST HOOD (WITH DUCT) 5.00
the performance of lire work for which this permit is issued(See MICROFILM
3097,Civ.C.L H EATING UN IT TO 100,000 B.T.U.) 8.00
Lender's Name H EATI N G U N IT(OV ER 100,000 B.T.U.)9.50
Lender's Address ELECTRIC
1 certify that I have read this application and slate that the above VENTILATION FAN (SINGLE) 4.00
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.) 6.00
hereby authorize representatives of dais city to enter upon the
above-mentioned property for inspection purposes. BOILER-COMP(Ove.100,0008TU)5EE FEE SCH. MECHANICAL
(We) agree to save, indemnify and keep harmless the City of MISC.- REFER TO ORD.
Cupertino .,.just age?;ies,judgments, costa'n
expenses which PERMIT ISSUANCE 10.00 CONST.TAX
may in any way a we against said City in con ucnce of lire
grant n o his it. ECH.CONT. UC.NO. MECH.
r TOTAL
TOTAL
Sim t o J?t on dor -
INSPECTOR COPY
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APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE B'POINT PEN ONLY
BUILDING PROJECT IDENTIFICATION
APPLICATION & PERMIT
BUILDING - ELECTRICAL -PLUMBING -MECHANICAL
PERMIT NUMBER
n t /
9J 372
BUILDING
OWNER'S-/
NAME !t
PHONE5-'% u I
QTY. ELECTRIC PERMIT F££
PLAN CHECK VALIDATION
DATE OF APPLICATION
CONTRACTOR'S
NA
J
11 LIC.NOfJ 4FI> f
UTLETS -SWITCHES - REC£P 10,001.1,00
LIGHTING FIXTURES 10.0011.00
CADDRESSON RACTOR'S hH
l
L3 -4,A 1pfJ PHONE ajl-3P}
APPLIANCES - RESIDENTIAL 4.00
PANELS 10.00 d
ORENGINEER
LOC. No.
PANELS PANELS (OVER 200 AMP) 20.00
PLAN CHECK FEE P.C. NO.
SIGNS TRANS. 3.00
AARCH.
ORDDRESS ENG.
ZIP
SPECIAL CIRCUIT 5,00 PERMITVALIDATION
P+JD
a7S
Cit of mertino5ANCEATE
EMP. METER OR POLE INS. 20.00
APPLICANT'SMOTORS
ADDRESS
y p
SES FEE SCH.
SERVICE CHANGE 20.00
LICENSED CONTRACTORS DECLARAtt6N
1 hereby affirm that I am licensed under provisions of Chapter 9
commencing with Section 7000) of Division 3 of the Business and
Professions Cade• d y license is in full fort fre
License Class f
ce
Lic, Number
Date
1Z 01_;?_
Contractor
OWNER -BUILDER DECLARATION
1 hereby affirm that I am exempt from the Contractor's License
Law for the following reason. (Sec. 7031.5, Business and Professions
Code: Any city or cou my which requires a permit to construct, alter,
improve, demolish, or repair any structure, prior to its issuance, also
requires the applicant for such permit to 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 Professions Cade)' or that he is exempt therefrom and
the basis for the alleged exemption. Any violation of Section 7031.5
by any applicant for a permit subjects the applicant to a civil penalty
of not more than five hundred dollars ($500),);
1, as owner of the property, or my employees with wages as
their sole compensation, will do the work, and the structure is not
intended or offered for sale (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 does such work
himself or through his own employees. provided that such improve-
ments are not intended or offered for sale, If, however, the building
or improvement is sold within one year of completion, the owner-
builder will have the burden of proving that he did not build or iin-
prove for purpose of sale.).
El 1, as owner of the 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
contracts forsuch projects with a contractor(s) licensed pursuant to
the Contractors License Law.
0 1 am exempt under Sec. ,S.&P.C.for this
reason
TEMP. POLE 30.00
BLDG, ELE T. PLG. MECH.
BUIL PERMIT
N RMATION
MISC. - REFER TO ORD
VALUATION lFT.
PERMIT ISSUANCE 10.00 Q"
ELE . CONTR. L[G. NO.
1 y
GUf
ELEC.
TOTAL ER I7 7
KQTY. PLUMBING PERMIT FEE
STORIES TYPE CONSTR.
ALTER-RAIN&VENT-WATER{EA.) 5.00
BACK FLOW PROTECT. DEVICE 4.00 OCC. GROUP RES. UNITS
DRAINS -FLOOR, ROOF, AREA, COND. 5.00
FIXTURES -PER TRAP 5.00 SO. FT. FLOOR AREA TOTALACREAGE
GAS- EA. SYSTEM -1 INC.4 OUTLETS 6.00
GAS - EA. SYSTEM - OVER 4 (EA.) 2.00 BUILDING USE
R IND CON PB Other
INDUSTRIAL WASTE INTER, 30.00
LAWN SPR INKLERS-1 INC5 V.B. 6.00 ASSESSOR5PAHCELNO.
LAWN SPRINKLERS - OVER 5 (EA.) 1.00
SEWER -SANITARY -STORM EA. 2001tl10.00 ACT NO. PARCEL NO.
WATER HEATER WJVENT 6.00
Owner + %
j(
Date
5JM%6/PL4t6'1%C9 NSATION DECLARATION
1 hereby affirm that ! have a certificate of consent to self -insure,
ora certificate of workers' Compensation Insurance, or a certified
copy thereof (Sec. 3600, Lab.C.)•
Policy No. Company
0 Certified copy is hereby furnished.
pf Cerilfi P l with therc nspection division,
Applicant y , 1
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
This sec[ion need not be completed If the permit is for one
hundred dollars (S 100) or less.)
I certify that in the performance or ihe.work for which this per-
mit is issued, 1 shall not employ any person in any manner so as to
become subject to the Workers Compensation Laws of Catifotni:i.
BUILDINGDateApplicant
WATER SYSTEM r 5.00 ACC. DATE ACC. FILE NO.
WATER TREATING EQUIP 5.00
ZONING ENG. SITE NO,
FIRE SPRINK
Y N
ENERGY T-24
Y N MISC. REFER TO ORD.
PERMIT ISSUANCE 10.00 FLOOD ZONE
Y N
A.L.U.C.
Y t, 11
PLG. CONTR, LIC. NO. PLG,
TOTAL
QTY. MECHANICAL PERMIT FEE FEE SUMMARY
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' Compensalion
provisions of the Labor Code, you must forthwith comply with
such provisloris or this permit shall be deemed revoked.
CONSTRUCTION LENDING AGENCY
hereby affirm drat there is a construction lending agency for
the performance of the work for which this permit is issued (Sec.
3097, Civ.C.).
Lender's Name
APPLIANCE 5.00 PLAN CHECK
FEEAIRHANDLINGUNIT (TO 10A00QF, NQ 4.00
AIR HANDLING UNIT (OVER 10p00C•F.M.) 6.00 SEISMIC FEE
EXHAUST HOOD (WITH DUCT) 5.00
MICROFILM
HEATING UNIT (TO 100,000 B.T.U.) 8•00
H EATING UNIT (OV ER 100,000 B.T.U.) 9.50 ELECTRICLender's Address
I certify that have read this application and state that the above
information is correct. I agree to comply with all city and county
ordinances and state laws relating to building construction, and
hereby authorize representatives of this city to enter upon the
above-mentioned property for inspection purposes.
We) agree to save, ' demnify and keep harmless the City of
Cupertino against Iia 'ties, judgments, costs and expenses which
may in any way erste againdpid City in consequence of the
grant' it. (%ECH.
VENTILATION FAN (SINGLE) 4,00
PLUMBING
BOILER-COMP(3 H.P,or 100,000 B.T.U,) 6.00
BOILER -COMP (Over 100,0017 BTU) SEE FEE SCH. MECHANICAL
MISC. - REFER TO ORD,
CONST. TAXPERMITISSUANCE10.00
CONT. LIC. NO. MECH,
TOTAL
TOTAL
Signa o Applicant/Contractor to
OFFICE COPY