09620 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
BUILDING PROJECT lDENTIFICATION PERMIT NUMBER
ewunNc APPLICATION & PERMIT
ADDRESS
BUILDING-ELECTRICAL-PLUMBING -MECHANICAL 09620
OwrvER'r - PLAN CHECK VALIDATION
rvgmE CITY, ELECTRIC PERMIT FEE
�. � n J .. - eA PHDNE
rvrRnc.ol R's
NAME UTLETS-SWITCHES-RECEP 10.00/1.00
LIC.NO. ,c a n LIGHTING FIXTURES 10.00/1.00
ADDDRESSRESS DOFs PPLIANCES-RESIDENTIAL 4.00
A
F.HONE s _ PANELS - 10.00 DATE OF APPLICATION
ARCHITECT �,)� -( a/ PANELS (OVER 200 AMP) 20.00 PLAN CHECK FEE P.C.NO. .
OR T 6
ENGINEER
I-C.No. SIGNS TRANS. 3.00
ARCH,OR ENG. PERMIT VALIDATION
ADDRESS SPECIALCIRCUIT 5.0I
ZIP TEMP.METER OR POLE INS. 20.00 PAID
APPLICANT'S MOTORS SEE FEE SCH.
ADDRESS M G ✓ n ' SERVICE CHANGE 20.00 SEP p 4 1985
wo o LICENSED CON'I'RACTORS DECLARATION '!/ TEMP.POLE 30.00 {t y' f (�'' .tip
¢ u 1 hereby affirm that 1 am licensed under provisions of Chapter 9 CI ISs�ANL` gau.n
Haw (commencing with Section 7000)of Division 3 of the Business and - BLDG. ELECT. PLG. C .
F m z Professions Code and my license is in full force and effect.
Z o m License Classn n_c a, Lin.NumberEl
O � FO D3Ye ,�/O-g9.VA+laa-.d/Connmctor�� ❑ ❑ 1
a y '�'� 9-B s BUILDING PERMIT
¢ ¢ w a OWNI7 R UILDER DECLARATION
INFORMATION
o A MISC.- REFER TO ORD
w 3 u I hereby affirm that I so exempt from the Contractors License VALUATION
H u o a Law for the following reason.(Sec.7031.5,Busincssand Professions PERMIT ISSUANCE 10.00
t. 2 impCods Any c olish cor my whiny Structure p riot 1 ocoretra c alter,
rt S Q Q improve,demolish,or repair any slum LLrte,prior t.its issuance,also ELEC.CONTR. LIC.N0. ELEC.
ca
O ac LL retinues the applicant for such permit to file a signed statement that TOTAL PE MIT TO
n w m he is licensed pursuant to the provisions of the Contractor's License
HZQLaw(Chapter 9 fcommeneing with Section 7000)of Division 3 ofthe
Business and Professions Code)or that lie is exempt therefrom and DTV. PLUMBING PERMIT I FEE i
¢ ro thebasis for the alleged exemption.Any viola)ion of Sect ion 7031.5 's P: STOACS TYP9 CONSTR.
P. ;m by any applicant for a permit subjects tire mplicant toa civil penalty ALTER-DRAIN& VENT-WATER (EA.) 5.00
of not more than five hundred dollars(8500).)'.
❑ I,as owner of the property,or my tmpberye"will, wages as BACK FLOW PROTECT. DEVICE/ 4.00 OCC.GROUP RES.UNITS
their sole compensation,will do the work,and the seture,k not s
intended or offered for sale (Sue. 7044, Business and Professions DRAINS-FLOOR,ROOF,AREA,COND. 5.00
Code:The Contract.,',License Law dues not apply To an owner of
property who builds UIimproves thereon,and who docs Such Work FIXTURES-PER TRAP 5.00 SO.FT.FLOOR AREA TOTAL ACREAGE
himself or through his own cuilloyces,provided that such improve GAS-EA.SVSTEM-1 8.00
menu are not intended or oifi red for sale.If however,tie building
or improvement is sold within one year of completion,the own c, . -OVER 4 (EA.) 2.00- GAS-EASYSTEM
builder will have the harden of proving that he did not build or inn- BUILDING USE
prove for purpose of sale.). INDUSTRIAL WASTE INTER. 30.00 E IND CON PB Omer
❑ I,as owner of the property,am exclusively contacting will ❑ ❑ ❑ ❑
licensed contractors to construct the project(Sec. 7044,Business LAWN SPRINKLERS- 1 INC 5 V.B. 6.00ASSESSORS PARCEL N0.
and Professions Cod,:The Contractor's License U.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 eonnmetor(s)licensed pursuant to
the Contractor's License Law. SEWER-SANITARY-STORM EA.200ft/10.00 TRACT No. PARCEL No.
❑ Iamexemptunder Sec. .B.&P.C.fco O,i, WATER HEATER W/VENT 6.00
reason
Owner Dune WATER SYSTEM 5.00 ACC.DATE ACC.FILE NO.
WORKI'RS'COMPI!NSYI'Ice DECLARA'rl ON WATER TREATING EQUIP: 5.00
I hereby affirm Our I have a certificate of conseN to sclfciasarc,
or a certificate of Workers'Compensation Insurance,or a certified ZONING ENG.SITE NO.
copy No.,f(See44Co p.ny ab 1.___ /
Policy No.�;pyCo hereby-`fished. [(.g,
0 Certified copy isherebyfiled(with the FIRE SPRINK ENERGY TZ4
Z Z ❑ Certified copy is filed with the city inspection division. MISC.- REFER TO ORD.
0 Applicant v❑ N❑ v ❑ N❑
CC va PERMIT ISSUANCE 10.00 FLOOOZONE A.L.U.C.
LU CERTIFICATEOFEXEMPTION FROM WORKERS'
W COMPENSATION INSURANCE PLG.CONTR. LIC.NO. PLG. V❑ N❑ Y [:] N[]d (This section need not be completed if the permit is for one TOTAL
Z hundred dollars($100)or lets.)
U 0 1 certify that in the performance of the work for Which this per- OTY. MECHANICAL PERMIT FEE FEE SUMMARY
IL F mil is issued,1 shall not employ any person in any manner so as to
Ow become subject to the Workers'Compensation Laws of California. BUILDING
o. Date Appl,c°nt ALTER OR ADD TO MECH. 5.00
} va NOTICE TO APPLICANT: If,after making this Certificate of Its-
' F Z emption,you should become Subject no the Workers'Compensation APPLIANCE 5.00 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=CF.M) 4.00
CONSTRUCTION LENDING AGENCY AIR HANDLING UNIT(OVER 10=C.EM.) 6.00 SEISMIC FEE
I hereby affirm that there is a Construction lending agency for EXHAUST HOOD(WITH DUCT) 5.00
the performance of the work for which this permit is issued(Sec. HEATING UNIT(TO 100,000 B.T.U.) 8.00 n MICROFILM
u.
Lender's Name HEATING UNIT 100,000 B.T.U.)9.50
Ltnde,'s ndaes �et•p.E ELECTRIC
I certify that I hove,end-this ali�lieatfo�id slate that life above, VENTILATION FAN (SINGLE) 4.00 .nA
inkno union is correct. I agree to comply with all City and coaNy PLUMBING
• ordinances and mat, laws relating m building construction, and BOILER-COME(3 H.P.or 100,000 B.T.U.) 6.00
hereby authorize representatives of this city to enter upon the BOILER-COMP(Over 100,000 BTU)SEE FEE SCH. MECHANICAL
above-mm,tioncd property for im'pcchun purposes.
r (We) agree to save, indemnify and keep harmless 0m City of MISC.- REFER TO ORD.
Cupertino against liabilities,judgments, costs and expenses which PERMIT ISSUANCE 1000 CONST.TAX
may in any way accrue against said City in conwrucnec of th .
e
gin it of thio permit. MECH.CONT. LIC.NO. MECH.
TOTAL01,60 TOTAL
gnu ure of Applicant/Contactor are
J +
INSPECTOR COPY
O
Z Z
I.., y
LU >
O.. O
D Z
Uo
LL 1--
0
ELOEL
N
A
APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
BU'I*LDI NG PROJECT I DENTI FICATION
APPLICATION & PERMIT
BUILDING - ELECTRICAL -PLUMBING -MECHANICAL
PERMIT NUMBER
09620BUILDING
ADRI'
dE59
ODD
9-
OwNEITSNAME
CG ¢ Al Cja PrroNE 9'I-J 8
QTY. ELECTRIC PERMIT FEE
PLAN CHECK VALIDATION
CONTRACTOR'S
NAME UTLETS -SWITCHES - R ECEP 10,0011.00
LIGHTING FIXTURES 10,0011.00LIC. ND /-4,0
CONTRACTOR'S
ORE58ADDRESS
APPLIANCES - RESIDENTIAL 4.00
PANELS 10.00pT5TONE , Jp DATE OF APPLICATION
ARCHITECT .
ORENGINEER
LIC. NO.
PANELS (OVER 200 AMP) 20.00
PLAN CHECK FEE P.C.NO.
SIGNSTRANS. 3,00
ADDRESS ENG' SPECIAL CIRCUIT 5.00 PERMIT VALIDATION
TEMP. METER OR POLE INS. 20.00ZIP PAID
SEP 4 1985
APPLICANT'S
ADDRESS,,
MOTORS SEE FEE SCH.
CE
LLLIICNSEDCONTRACTORS DECLARATION TEMPI
POLEANGE
30.00
1 hereby affirm that I am licensed under provisions Of Chapter
commencing with Section 7000) of Division 3 of the Business and
Professions Coe and my license Ishii full fore and effect.
Le'* nseslass a' te. Number
DSfEr " °
J '
contractor
BLDG. EL CT.
13UILDING PERMIT
INFORMATION
9-.3-1e'4
OWNER -BUILDER DECLARATION
1 hereby affirm that f am exempt from the Contractor's License
Law for the following reason. (Sec. 7031.5, Business and Professions
Code: Any city or county which requires a permit to construct, alter,
improve, demolish, or repair any structure, prior to its issuance. also
requires the applicant for such permit to file a signed statement that
he is licensed pursuant to the provisions of the Contractor's License
MISC. - REFER TO ORD
SIFT.
PERMIT ISSUANCE 10.
001VALUATION
CLEC, CONTR. LIC. NO. ELEC.
TOTALp MITTO
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 Uh
STORIES TYPE CONSTR. 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 (5500).): ALTEfl DRAIN $VENT WATER (EA,) 5.00
1, 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
Property who builds or improves thereon, and who does such work
himself or through his own employees, provided that such improve
mems are not intended Or Offered forsale. If, however, the building
FIXTURES - PER TRAP 5.00 SO. FT. FLOOR AREA TOTALACREAGE
GAS EA. SYSTEM -1 INC. A 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 forpurposeofsale.).
as owner of the property, am exclusively contracting with
E INC) CON Pa other
INDUSTRIAL WASTE INTER. 30.00
licensed contractors to construct the project (Sec. 7044, BusinessLAWN
and Professions Code: The Contractors License Law does not apply
to an owner of property who builds Or improves thereon. and who
SPRINKLERS • 1 INC 5 V.B. 6.T00ASSESSORSPARCELNO.
LAWN SPR IN KLERS - OVER 5 (EA.) 1.00
contracts for such projects with a contractor(s) licensed pursuant to
the Contractor's License Law. SEWER -SANITARY STORM EA. 200ft110.00 TRACT NO. PARCEL NO.
I am exempt under Sec. BAP.C. for this WATER HEATER WIVENT 6.00
reason
Owner Date WATER SYSTEM 5.00 ACC. DATE ACC. FILE NO,
WATER TREATING EQUIP, 5.00WORKERS'COh1PENSATION DECLARATION
1 hereby affirm that I have a certificate of consent to self -insure,
or a certificate Of Workers' Compensation Insurapce, or a cert*f' d
copy there (ec. 3800, Lab.C.} /
ZONING ENG. SITE NO.
P. O.ompany L/
FIRE SPRINK
Yo N[3
ENERGYT-Z4
Y ] N
Cer[iGCd Copy iS hereby fUrnish[d.
Certified copy is filed with the city inspection division.
Applicant MISC. - REFER TO OR
CERTIFICATE OF EXEMPTION FROM WORKERS' PERMIT ISSUANCE 10-001 FLOOD ZONE A.L.U.C.
ALG. 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 t11e performance Of the work for which this per.
mit is Issued, 1 shall not employ any person in any manner so as to
BUILDING
become subject to the Workcre Compensation Laws of California.
Date Applicant
NOTICE TO APPLICANT: if, after making this Certificate of Ex-
ALTER OR ADD TO MECH. 5.00
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=C.F.M.) 4.00
AIR HANDLING UNIT (OVER 10p00C.F.M.1 6.00 SEISMIC FEECONSTRUCTIONLENDINGAGENCY
I hereby affirm that there is a construction lending agency for EXHAUST HOOD (WITH DUCT) 5.00 .5; pQ
the performance of a work for which this permit is issued (See.
3097, Civ.C.).
MICROFILM
HEATING UNIT (TO 100,000 8.T.U.) 8.00
HEATING UNIT (OVER 100,000 B.T.U.19.50 ELECTRIC
Lender's Name
Lender's Addre -
1 certify that 1 have rea this applgtla d slate that the above VENTILATION FAN. (SINGLE) 4.00
e51 -
DO
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 (Over 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
l;rarltinof this permit.
CONST. TAXPERMITISSUANCE10.00 14P.00
MECH, CONT. LIC. NO. MECH,
R e t TOTAL3/•p0 TOTAL
Fignbwe afApplicant/Contractor, Date
OFFICE COPY