12752 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
BU LDI NG PROJECT IDENTIFICATION PERMIT NUMBER
BDILDING. APPLICATION & PERMIT 12752
ADDRESS
.� BUILDING - ELECTRICAL-PLUMBING-MECHANICAL
NAME^S _ PLAN CHECK VALIDATION
QTY. ELECTRIC PERMIT FEE i1
CONTRACTOR'S UTLETS-SWITCHES-RECEP 10.00/1.00
NAME `
C6� h1/- uc.No,�'J LIGHTING FIXTURES 10.00/1.00
CONTRACTOR'S {�
aooREss PPLIANCES-RESIDENTIAL 4.00 1
.1C�,k�� ,y(,(� RONE - - PANELS '10.00 .p ATE OF APPLICATION
ARCHITECT PANELS (OVER 200 AMP) 20.00 PL NCHECK FEE P.C.NO.
OR
ENGINEER
Lac.NO. SIGNS TRANS. 3.00 i D
ARCH.OR ENG.
ADDRESS CIRCUIT 5.00 ERMIT VALIDATION
ADDRESS
ZIP. EMP-METER OR POLE INS. 20.00 JA9 2 31981
APPLICANTS MOTORS SEE FEE SCH,
ADDRESS �{l wt p..
SERVICE CHANGE 20.00 V' Wpert1n
wo o LICENSED CONTRACTORS DECLARATION ,
¢ U U I hereby affirm that I am licensed under provisions of Chapter 9 ISSUANCE DATE
v, n (Commencing with Section 7000)of Division 3 of,lhe Business and BLOQ ELECT. PLG. ME
r m i Professims Code n license is in full force and (fpcL„ ❑' ❑ ❑
z o to- License Cla s Lic.Number % > /d'
g 0 Date Contractor Or I
a Y s BUILDING PERMIT
¢ ¢ w OWNER-BUILDER DECLARATION INFORMATION
oa MISC.- REFER TO ORD
X u y I hereby affirm that I am exempt from the Contractor's License VALUATION $/FT.
F LL o a Law for the following reason.(Sea 7031.5,Business and Professions PERMIT ISSUANCE 10.00
mCode:Any city or county which requiresa permit to construct,alter,
rt rt > 2 improve',demolish,or repair any structure,prior to its issuance,also ELEC.CONTR. LIC.NO. ELEC.
- 0 ¢ requires the applicant for such permit to file a signed statement(hat TOTAL IT TO
wm he is licensed pursuant to the provisions of the Contractor's License
F z i Law(Chapter 9(commencingwith Section 7000)of Division of[he
f i o Business and Professions Code)or that he is exempt therefrom and QTY. PLUMBING PERMIT FEE
¢F m 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 ALTER-DRAIN&VENT-WATER (EA.) 5.00
of not more than five hundred dollars(S500).L
❑ 1,as owner of the property,or my employees with wages as BACK FLOW PROTECT. DEVICE 4.00 oce.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. 5.00
Code:The Contractor's License Law does not apply to an owner of
property who builds or improves thereon,and who does such work F IXTUR ES-PER TRAP 5.00 sa FT.FLooR aREa TOTAL ACREAGE
himself or through his own employees,provided that such improve.
ments are not intended or offered for sale.If,however,the building GAS-EA.SVSTEM-I INC.40UTLETS 6.00
or improvement is sold within one year of completion,the owner- GAS'-EA.SYSTEM-OVER 4 IEA.) 2.00 BUILDING USE
builder will have the burden of proving that he did not build or im- S IND C PB Omar
prove for purpose of sale.). INDUSTRIAL WASTE INTER. 30.00 CJ T) ❑
❑ 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. 6.00 gssESSO R ELNO.
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.2001ft/10.00 TRACTN PARCEL NO.
0 lam exempt under Sec.-,FL&P.C,for this WATER HEATER W/VENT 6.00
reason
Owner Date WATER SYSTEM - 5.00 ACC.OATE ACG FILE NO,
-WORKERS'COMPENSATION DECLARATION WATER TREATING EQUIP. 5.00
1 hereby affirm that I have a certificate of consent to self-insure, ZONING ENG.SITE NO.
or a certificate of Workers'Compensation Insurance,or a certified
copy thereof Sec. 80pp,
Q lePolicy No Xmpimy a1bL[59Rf/�[�
, ❑ Certified CopyIshereby(urpished. FIRE SPRINK ENERGY T.24
Z Z �Certifidopy i{ filed with the city inspection division. MISC.- REFER TO ORD. y N y N
O� ApphcansltY=l^ HYi4RNL� ❑' ❑ ❑ ❑
� N CERTIFICATE OF EXEMPTION FROM WORKERS' PERMIT ISSUANCE 10.00 FLOOOZONE A.L.U.C.
LL > COMPENSATION INSURANCE, PLG.CONTR. LIC.NO. PLO y❑ N❑ Y ❑ N❑
d 0 (This section need not be Completed if the permit is for one TOTAL
Z hundred dollars IS 100)or less.)
U O 1 certify that in the performance of the work for which this per. QTYMECHANICAL PERMIT FEE FEE SUMMARY
LL P mit is issued,1 shall not employ any person in any manner so as to
OL) become subject tothe Workers'Compensation Laws of California. BUILDING
Date Applicant ALTER OR ADD TO MECH. 5.00
} ED NOTICE.TO APPLICANT: If,after making this Certificate of Es-
F ? emption,you should become subject to 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 10MC.F.M.) 4.00
CONSTRUCTION LENDING AGENCY AIR HANDLING UNIT(OVER 10MC.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 the work for which this permit is issued(Sea MICROFILM
3097.Civ.C.). HEATING UNIT(TO 100,000 B.T.U.) 8.00
Lender's Name HEATING UNIT(OVER 100,000 B.T.U.)9.50 ELECTRIC -
Lender's Address
1 rmaii'o that I have read this application and state that theaboveounty VENTILATION FAN (SINGLE) 4.00
information n correct 1 agree to comply with all city and county BOILER-nP13 H.P.or 100,000 B.T.U.) 6.00 G ` ' PLUMBING
ordinances and stale laws relating to building construction, and
hereby authorize representatives ec this city es enter upon the BOILER-COMP (Over 100 0 BTU)SEE FEE SCH. MECHANICAL
above-mentioned property for inspection purposes.
(We) agree to save, indemnify and keep hairiness the City of MISC.- EFER TO ORD.
Cupertino against liabilities,judgments, costs and expenses which �`2 a CONST.TAX
may in any way accrue against said City in consequence of the PERMIf ISSUANCE 10.00
ayting of this permit. \ MECH.CONT. LIC.NO. H.
TOTA / �o TOTAL
Signature of Applicant/Contractor Dale '�.�, �. �>..f L{1 (f7
OFFICE COPY
APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
BU LDI NG PROJECT IDENTIFICATION PERMIT NUMBER
BDILDING. APPLICATION & PERMIT 12752
ADDRESS
.� BUILDING - ELECTRICAL-PLUMBING-MECHANICAL
NAME^S _ PLAN CHECK VALIDATION
QTY. ELECTRIC PERMIT FEE i1
CONTRACTOR'S UTLETS-SWITCHES-RECEP 10.00/1.00
NAME `
C6� h1/- uc.No,�'J LIGHTING FIXTURES 10.00/1.00
CONTRACTOR'S {�
aooREss PPLIANCES-RESIDENTIAL 4.00 1
.1C�,k�� ,y(,(� RONE - - PANELS '10.00 .p ATE OF APPLICATION
ARCHITECT PANELS (OVER 200 AMP) 20.00 PL NCHECK FEE P.C.NO.
OR
ENGINEER
Lac.NO. SIGNS TRANS. 3.00 i D
ARCH.OR ENG.
ADDRESS CIRCUIT 5.00 ERMIT VALIDATION
ADDRESS
ZIP. EMP-METER OR POLE INS. 20.00 JA9 2 31981
APPLICANTS MOTORS SEE FEE SCH,
ADDRESS �{l wt p..
SERVICE CHANGE 20.00 V' Wpert1n
wo o LICENSED CONTRACTORS DECLARATION ,
¢ U U I hereby affirm that I am licensed under provisions of Chapter 9 ISSUANCE DATE
v, n (Commencing with Section 7000)of Division 3 of,lhe Business and BLOQ ELECT. PLG. ME
r m i Professims Code n license is in full force and (fpcL„ ❑' ❑ ❑
z o to- License Cla s Lic.Number % > /d'
g 0 Date Contractor Or I
a Y s BUILDING PERMIT
¢ ¢ w OWNER-BUILDER DECLARATION INFORMATION
oa MISC.- REFER TO ORD
X u y I hereby affirm that I am exempt from the Contractor's License VALUATION $/FT.
F LL o a Law for the following reason.(Sea 7031.5,Business and Professions PERMIT ISSUANCE 10.00
mCode:Any city or county which requiresa permit to construct,alter,
rt rt > 2 improve',demolish,or repair any structure,prior to its issuance,also ELEC.CONTR. LIC.NO. ELEC.
- 0 ¢ requires the applicant for such permit to file a signed statement(hat TOTAL IT TO
wm he is licensed pursuant to the provisions of the Contractor's License
F z i Law(Chapter 9(commencingwith Section 7000)of Division of[he
f i o Business and Professions Code)or that he is exempt therefrom and QTY. PLUMBING PERMIT FEE
¢F m 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 ALTER-DRAIN&VENT-WATER (EA.) 5.00
of not more than five hundred dollars(S500).L
❑ 1,as owner of the property,or my employees with wages as BACK FLOW PROTECT. DEVICE 4.00 oce.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. 5.00
Code:The Contractor's License Law does not apply to an owner of
property who builds or improves thereon,and who does such work F IXTUR ES-PER TRAP 5.00 sa FT.FLooR aREa TOTAL ACREAGE
himself or through his own employees,provided that such improve.
ments are not intended or offered for sale.If,however,the building GAS-EA.SVSTEM-I INC.40UTLETS 6.00
or improvement is sold within one year of completion,the owner- GAS'-EA.SYSTEM-OVER 4 IEA.) 2.00 BUILDING USE
builder will have the burden of proving that he did not build or im- S IND C PB Omar
prove for purpose of sale.). INDUSTRIAL WASTE INTER. 30.00 CJ T) ❑
❑ 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. 6.00 gssESSO R ELNO.
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.2001ft/10.00 TRACTN PARCEL NO.
0 lam exempt under Sec.-,FL&P.C,for this WATER HEATER W/VENT 6.00
reason
Owner Date WATER SYSTEM - 5.00 ACC.OATE ACG FILE NO,
-WORKERS'COMPENSATION DECLARATION WATER TREATING EQUIP. 5.00
1 hereby affirm that I have a certificate of consent to self-insure, ZONING ENG.SITE NO.
or a certificate of Workers'Compensation Insurance,or a certified
copy thereof Sec. 80pp,
Q lePolicy No Xmpimy a1bL[59Rf/�[�
, ❑ Certified CopyIshereby(urpished. FIRE SPRINK ENERGY T.24
Z Z �Certifidopy i{ filed with the city inspection division. MISC.- REFER TO ORD. y N y N
O� ApphcansltY=l^ HYi4RNL� ❑' ❑ ❑ ❑
� N CERTIFICATE OF EXEMPTION FROM WORKERS' PERMIT ISSUANCE 10.00 FLOOOZONE A.L.U.C.
LL > COMPENSATION INSURANCE, PLG.CONTR. LIC.NO. PLO y❑ N❑ Y ❑ N❑
d 0 (This section need not be Completed if the permit is for one TOTAL
Z hundred dollars IS 100)or less.)
U O 1 certify that in the performance of the work for which this per. QTYMECHANICAL PERMIT FEE FEE SUMMARY
LL P mit is issued,1 shall not employ any person in any manner so as to
OL) become subject tothe Workers'Compensation Laws of California. BUILDING
Date Applicant ALTER OR ADD TO MECH. 5.00
} ED NOTICE.TO APPLICANT: If,after making this Certificate of Es-
F ? emption,you should become subject to 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 10MC.F.M.) 4.00
CONSTRUCTION LENDING AGENCY AIR HANDLING UNIT(OVER 10MC.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 the work for which this permit is issued(Sea MICROFILM
3097.Civ.C.). HEATING UNIT(TO 100,000 B.T.U.) 8.00
Lender's Name HEATING UNIT(OVER 100,000 B.T.U.)9.50 ELECTRIC -
Lender's Address
1 rmaii'o that I have read this application and state that theaboveounty VENTILATION FAN (SINGLE) 4.00
information n correct 1 agree to comply with all city and county BOILER-nP13 H.P.or 100,000 B.T.U.) 6.00 G ` ' PLUMBING
ordinances and stale laws relating to building construction, and
hereby authorize representatives ec this city es enter upon the BOILER-COMP (Over 100 0 BTU)SEE FEE SCH. MECHANICAL
above-mentioned property for inspection purposes.
(We) agree to save, indemnify and keep hairiness the City of MISC.- EFER TO ORD.
Cupertino against liabilities,judgments, costs and expenses which �`2 a CONST.TAX
may in any way accrue against said City in consequence of the PERMIf ISSUANCE 10.00
ayting of this permit. \ MECH.CONT. LIC.NO. H.
TOTA / �o TOTAL
Signature of Applicant/Contractor Dale '�.�, �. �>..f L{1 (f7
OFFICE COPY