09619APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
BU LDI NG PROJECT I DENTI FICATI ON
APPLICATION &PERMIT
BUILDING - ELECTRICAL -PLUMBING -MECHANICAL
PERMIT NUMBER
oa��
IL
UD.DIN ESS
AD
OWNER'S
NAME
CITY. ELECTRIC PERMIT FEE
PLAN CHECK VALIDATION
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/ /d, PHONE 5 7 44 el
NAMERAcrORs
UTLETS-SWITCHES -RECEP 10.00/1.00
LIGHTING FIXTURES 10.00/1.00
r T LIC. No. c
CONTRACTOR '
ADDRESS
ADDRESS
PPLIANCES- RESIDENTIAL 4.00
l
_ PHON �, I p ., _
DATE OF APPLICATION
PANELS 1 O.00
p�
ORX/ ' ,L A J1
ENGINEER T 'J
LIC. NO.
PANELS (OVER 200 AMP) 20.00
PLAN CHECK FEE P.C. N0.
SIGNS TRANS. 3.00
ARCH. OR ENG
ARCHER
SPECIAL CIRCUIT 5.00
PERMIT �Llp'TION
,/
D
ZIP
AA
SEP L�
FFEMP. METER OR POLE INS. 20.00+
APPLICANTS
ADDRESS
MOTORS SEE FEE SCH.
s /7
1JV5
VJ
City of Cupertino
SERVICE CHANGE 20.00
LICENSED CONTRACTORS DECLARATION
TEMP. POLE 30.00
I hereby affirm that I am liecnsnd under provisions .(Chapter 9
(commencing with Section 7000) of Division 3 of the Business anti
Professions Code, and my license is in full force and effect
License Classe°Io-G.d;1 Lic. Number
Dituf- - / o - A 9 -.A L. -i _Contractor
ISSUANCE DATE
BLDG. ELECT I PLG. MEI
JJ
❑ ❑ ❑
t
S9 -.3'B 0WN1: R!iL41rA) TIONBUILDING
PERMIT'
R- EC LA RA
I hereby collo that I and exempt from the Contractor'snPrLicense
Code:Law ny citylowingreason.(h requiJse perminess t tocodProfessions
Code: Any city or county which rttWiresa permit to construct alter,
INFORMATION
MISC.- REFER TO ORD
PERMIT ISSUANCE 10.00
VALUATION
$/FT.
ELEC. CONTE. LIC. NO.
ELEC.
TOTAL
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 Contractors License
Law (Chapter 9 (commencing with Section 7000) of Division 3 of the
E IT TO '
D
Business and Professions Code) or that he is exempt therefrom and
QTY. PLUMBING PERMIT FEE
the basis for the alleged exemption. Any violation of Section 7031.5
STORIES
TYPE CONSTR.
by any applicant for a peroul subjects the applicant to a civil Pcnslly
ul Rol more than five hundred d0lars($500)J:
ALTER -DRAIN -WATER IEA.) 5.00
0 1, as owner of the property, or my employees wish wages as
their sole compensation, will do the work, and the st nrotere is not
BACK F LOW PROTECT. DEV ICE 4.00
OCC. CROUP
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
F IXTURES - PER TRAP 5.00
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
SOFT. FLOOR AREA
TOTAL ACREAGE
GAS - EA. SYSTEM - I INC.4 OUTLETS 6.00
or improvement is sold within one year of completion, the owner-
builder will have the burden of proving that he did not build or im-
prove for purpose of sale.).INDUSTRIAL
❑ I, as owner of the property, am exclusively contracting with
GAS - EA. SYSTEM -OVER 4 (EA.) 2.00
BUILDING USE
E IND CON PB Omer
❑ El ED 0
WASTE INTER. 3000
.
licensed contractors to construct the project (Sec 7044, Business
and Professions Code: T'he Contractor', License Low dues not apply
to :in owner of properly who builds or improves thereon, and who
LAWN SPRINKLERS- 1 INC 5 V.B. 6.00
ASseSSOHri PARCEL NO.
LAWN SPRINKLERS - OVER 5 (EA.( 1.00
contracts for such projects with a contmctods) licensed pursuant to
11¢ Contractors License Law.
SEWER -SANITARY -STORM EA. 200ft/10.00
TRACT NO.
PARCEL NO.
❑ Inco exempt under Sec.-. BAP.C. for this
oralmi
WATER HEATER W/VENT 6.00
Owner Date
WATER SYSTEM 5.00
ACC. DATE
ACC. FILE NO.
WORK ERS'COMPI �NSATION DECLARATION
WATER TREATING EQUIP. 5.00
I hereby affirm that I have a crai ficale ofconsent to self -insure.
or a Certificate of Workers' Compensation Insurance, or a certified
ZONING
ENG. SITE NO.
copy thereof (Sec. 380QLab Cfpany .
Policy No. f]y copy , nnpany ed. ��
Certified copy uherehy furnished. ad'
Certified copy is fled with the city inspection division.
Applicant
FIRE SPRINK
v[] N❑
ENERGY T24
vED NE]
MISC.- REFER TO ORD.
Ch RTIFICATF.OF EXEMPTION FROM WORKI. RS'
PERMIT ISSUANCE 10.00
FLOOD ZONE
A.L.U.C.
COMPF.NSAT70N INSURANCE
1' I' his. section need not be completed if the permit is for one
Y NEl
Y 0 IN
PLG. CONTE. LIC. NO.
PLG.
TOTAL
handfed dollars IS 100) or less.)
I certify that in the performance of the work for which this per-
mil is issued, I shall not employ any person in any manner so as to
(ITV MECHANICAL PERMIT FEE
FEE SUMMARY
BUILDING
beco is subject to the Workers' Compensation Laws of Calitisrnia.
Dam Applicant
ALTER OR ADD TO MECH. 5.00
NOTICE TO APPLICANY: If, after making this Certificate of Ex-
APPLIANCE 5.00
PLAN CHECK
FEE
iniplion, you should become subject to the Workers'Compensation
provisions of the Labor Code, you must forthwith comply with
such provisions or this permit shall be deemed revoked.
AIR HANDLING UNIT (TO 10MC.F.M.) 4.00
AIR HANDLING UNIT (OVER 10=C.EM.) 6.00
SEISMIC FEE
CON'STRUCfION L17NDING AGENCY
I hereby affirm that there is a construction lending agency for
lire performance of the work for which this permit is issued (Sec.
3097, Civ.C.).
Lender's Name
Lender's Address
EXHAUST HOOD (WITH DUCT) 5.00 p )j
MICROFILM
HEATING UNIT (TO 100,000 B.T.U.) 8.00 p Gd
HEATING UNIT (OVER 100,000 B.T.U.)9.50
ELECTRIC
VENTILATION FAN (SINGLE) 4.00 n„
�.r-G
I certify that I have read 1 r<app kation
information is correct. I agree to comply with all city anJ county
ordinances and state laws relating 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 property for inspection purposes. -
(We) agree to save, indemnify and keep harmless the City of
Cupertino against liabilities, judgments, costs and expenses which
may in any way accrue against said City in consequence of the
gramin of this permit.
MISC. - REFER TO ORD.
PERMIT ISSUANCE 10.00 / nn
CONST. TAX
MECH. CONT. LIQ NO.
MECH.
'
TOTAL
3 5 -0U
TOTAL
.
Igo "I re Applicant Con Dict., ate
INSPECTOR COPY
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APPLICANT TO FILL. IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
BUILDING PROJECT IDENTIFICATION
PERMIT
ELECTRICAL- PLUMBING - MECHANICAL
PERMITNUMB£R
p 9 619
BUILDINGAPPLICATION
ADDRESS '
lz2,
BUILDING
OWNER'S
NAME
lLJPHONES-71 1'T.
QTY. ELECTRIC PERMIT FEE
PLAN CHECK VALIDATION
NONTRACTbR•s -
NAME OUTLETS -SWITCHES-RECEP 10.00/1.00
LIGHTING FIXTURES 10.09/1.00Ic. No.
CONTRACTOR'SAPP
ADDRESS
LIAN_CES-RESIDENTIAL 4.00
PANELS 10.00 DATE OF APPLICATION
ARCHITECT .t '
ORENGINEER
LIC. No.
PANELS IOVER 200 AMP) 20.00
PLAN CHECK FEE P•C. NO.
SIGNS TRANS. 3.00
ARCH. OR ENG.
SPECIALADDRESS CIRCUIT 5.00
PER TION
TEMP. METER OR POLE INS. 20,00ZIP
n ,( pSEPtil41985
CRY of Cupertino
APPLICANT'S
ADDRESS
MOTORS SEE FEE SCH.
SERVICE CHANGE 20.00
LICENSED CONTRACTORS DECLARATION TEMP, POLE 30.00
I hereby affirm that I am licensed 'under provisions of Chapter 9
commencing with Section 7000) of Division 3 of the Business and
Professions Coe and my license is in full force and effect.
Lic. Number 3
t S'• -Contractor
ISSUANCE DATE
BLDG-
0
ELECT.
E
PLG. M
OWNER -BUILDER DECLARATION
I hereby affirm that I am exempt from the Contractor's License
Law for the following reason. (See. 7031.5, Businessand 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 (or such permit to file_ a signed statement that
he is licensed pursuant to the provisions of the Contractor's License
BUILDING PERMIT'
INFORMATION
MISC. - REFER TO ORD
VALUATION
PERMIT ISSUANCE 10.00
ELEC. CONTR. LIC. NO. EIEC.
TOTALE 1T TO
QTY. PLUMBING PERMIT FEE
Law (Chapter 9 (commencing with Section 7000) of Division 3 of the
Business and Professions Code) or that he is exempt therefrom, and
STORIES TYPE CONSTR. the basis for the alleged exemption. Any violation of Section 7031.5
by any applicant for a permit subjects the applicant toa civil penalty
of not more than five hundred dollars ($500).): ALTER DRAIN &VENT -WATER IEA.] 5:00
I, as owner of the property, or my employees with wages as
their sole compensation, will do the work, and the structure is not
BACK FLOW PROTECT. DEVICE 4.00 oCC. GROUP RES; UNITS
DRAINS -FLOOR, ROOF, AREA, COND, 5.00intendedorofferedforsale (Sec. 7044, Business and Professions
Code: The Contractor's License Law does not apply to an owner of
properly who builds or improves (hereon, 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
FIXTURES - PER TRAP 5.00 SO. FT. FLOOR AREA TOTAL ACREAGE
GAS - EA. SYSTEM - 1 INC.4 OUTLETS 6.00
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-
prove for purpose of sale.).
1, as owner of the property, am exclusively contracting with
GAS - EA. SYSTEM -OVER 4 {EA.) 2,00 BUILDING USE
IND CON PB Other
INDUSTRIAL WASTE INTER. 30,00
LAWN SPRINKLERS - 1 INC 5 V.B. 6.00licensedcontractorstoconstructtheproject (Sec. 7044, Business
and Professions Code: The Contractor's License Law docs not apply
Io an owner of property who builds or improves thereon. and who
ASSESSORS PARCELNO.
LAWN SPRINKLERS - OVER 5 (EA.) 1.00
contracts for such projects with a contractor(s) licensed. pursuant to
the Contractor's License Law. SEWER SAN ITARY-STORM EA. 200ft/10,00 TRACT NO. PARCEL NO.
El I am exempt under Sec. B.&P.C. for [tis
reason
WATER HEATER W/VENT 6.00
Owner Date WATER SYSTEM 5.00 ACC.DATE ACC. FILE N0,
WATER TREATING EQUIP, 5.00WORKERS'COMPENSATION DECLARATION
1 hereby affirm that i have a certificate of consenL to self -insure,
or a certificate of Workcrs' Compensation Ins u ce, or a cern lied ZONING ENG. SITE NO.
copy thereof (Sec. 3800, Lab.C.).
Polic o.P Ompany
FIRE SPAINK
Y E] N
ENERGY T-24
Y N[]
t ertified copy is hereby furnished.
Certified copy is Filed with the city inspection division.
Applicant MISC. - REFER TO ORD.
CERTIFICATE OF EXEMPTION FROM WORKERS' PERMIT ISSUANCE 10-001 FLOOD ZONE A.LUX.
PLG. CONTR. LIC. NO. PLG,
TOTAL
COMPENSATION INSURANCE
This section need not be completed if the permit is for one Y N Y N
QTY. MECHANICAL PERMIT FEE FEE SUMMARY
hundred dollars (S 100) or less.)
I certify that in the performance of the work for which this per-
mit is issued, I shall not employ any person in any manner so as to
become subject to the Workers' Compensation Laws of California.
Date Applicant BUILDINGALTERORADDTOMECH. 5.00
NOTICE TO APPLICANT: If, after making this Certificate of Ex-
APPLIANCE 5.00 PLAN CHECKemption, you should become subject to the Workers' Compensation
provisions of the Labor Code, you must forthwith comply with
such provisions or this permit shall be deemed revoked.
FEEAIRHANDLINGUNIT (TO 10,13M C.F.M.) 4.00
AIR HANDLING UNIT (OVER 10=C.F.M,) 6.00 SEISMIC FEECONSTRUCTIONLENDINGAGENCY
I hereby affirm that there is a construction lending agency for EXHAUST HOOD (WITH DUCT) 5.00 p0
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 cf-zV
UNIT (OVER 100,000 B.T.U.)9.5D ELECTRIC
Lender's Name.
HEATINGLender's Address
certify that I have read This application and state that the above VENTILATION FAN (SINGLE) 4.00 ap
information is correct. I agree to comply with all city and county
ordinances, and state laws relating to building construction, and
PLUMBING
BOILER -COMP (3 H.P. Or 100,000 B.T.U.) 6.00
BOILER -COMP lover 100,000 BTU) SEE FEE SCH. MECHANICALherebyauthorizerepresentativesofthiscitytoenteruponthe
above-mentioned property for inspection purposes.
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 way accrue against said City in consequence of the,
CONST. TAXPERMITISSUANCE10.00 /0.00
gr nti of this permit. MECH. CONT. LIC- NO, MECH.
9 ,
TOTAL
3 6--ve TOTAL
Sign Applicant(Contractor Date
OFFICE COPY