10829 I
APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
BUILDING PROJECT IDENTIFICATION PERMIT NUMBER
BUILDING APPLICATION & PERMIT 10 8 2 9
ADDRESS
g 1. BUILDING -ELECTRICAL-PLUMBING-MECHANICAL
OWNER'S
PLAN CHECK VALIDATION
NAME a.SI�^ QTY. ELECTRIC PERMIT FEE
eg PHONE
: J NTRACTOR$,�. 1 OUTLETS-SWITCHES-RECEP 10.00/1.00
NAME G1 WJLI
oW
LIC.rvo. LIGHTING FIXTURES 10.00/1.00
AoDrvDTRACTo�i Kl � x-I\DfoJSiT, lq1 APPLIANCES-RESIDENTIAL 4.00
PHONE PANELS 10.00 DATE OF APPLICATION
ARCHITECT
PANELS (OVER 200 AMP) 20,00 PLAN CHECKFEE P.C.NO.
OR
ENGINEER
LIC.NO. SIGNS TRANS. 3.00
ARCW OR ENG. 6.00 PERMIT VALIDATION
ADDRESS SPECIAL CIRCUIT
ZIP EMP.METER OR POLE INS. 20.00
APPLICANT'S \11 Olt Yl`I�r-Op S.t- MOTORS SEE FEE SCH.
ADDRESS -x ` t"1 1� W/-uy ,-•"
SERVICE CHANGE 20.00
O ¢i $ s
'02 LICENSED CONTRACTORS DECLARATION
a v 1 hereby art,.that I am licensed under provisions of Chapter 9 ISSUANCE DA/E
w a N (commencing with Section 7000)of Division 3 of the Business and BLDC. ELECT. PLG. MECH.
v,w z 1'rofessions Cod•,an y license is in full for'• c cI. ❑ ❑ ❑
Z2 O w - Licimnklass Lic.Number L
Q Ix H ce Oure ^t Contractor
F " umb=*+G BUILDING PERMIT
= ¢w u OWNER-BUILDER DECLARATION d INFORMATION
w LL t- I hereby affirm that I am exempt front the Contractor's License MISC.- REFER TO ORD
VALUATION $/FT.
LLOa Law for the following reason.(Sec.7031.5,Businessind Professions PERMIT ISSUANCE 10.00
� - 0 Code:Any city or county which requimsa permit loconstrct,alter,
ac Q¢ 0 improve,demolish,or repair any structure,prior to its issuance,also ELEC.CONTR. LIC.NO. ELEC.
-O u requires the applicant for such permit to file a signed statement that TOTAL PERMIT TO
n w m he Is licensed pursuant to the provisions of the Contractor's License
H z Q
Law(Chapter 9(commencing with Section 7000)of Division3of the
f i D Business and Professions Code)or that he is exempt therefrom and QTY. PLUMBING PERMIT FEE
¢ r e the basis for the alleged exemption.Any violation of Section 7031.5 STORIES TYPE CONSTR.
a ;m by any applicant for a pt,nnll subjects the applicant to a civil penalty ALTER-DRAIN&VENT-WATER (EA.) 5.00
of not more than five hundred dollars(5500).):
O 1,as owner of the property,or my employees with wages as BACK FLOW PROTECT. DEVICE 4.00 DCC.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 docs not apply to an owner of
property who builds or improves thereon,and who does such work FIXTURES-PER TRAP 5.00 50.FT.FLOOR AREA TOTAL ACREAGE
himself or through his own employees,provided drat such improve- GAS EA.SYSTEM-I INC.4 OUTLETS 6.00
meats are not intended or offered for sale.IL however,the building
t or improvement is sold within one year of completion, the owner- GAS-EA.SYSTEM-OVER 4(EA.) 2.00 BUILDING USE
builder will have the burden of proving that he did not build or im- RES IND CON PB Omer
prove for purpose of sale.). INDUSTRIAL WASTE INTER. 30.00 ❑ ❑ ❑ ❑ 11❑ I,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 ASSESSORS PARCEL NO.
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
EWER-SANITARY-STORM EA.200ft/10.00 TRACT NO. PARCEL NO.
Bit,Contractor's License Law.
❑ I am exempt under Sec. ,B.&P.C.for this WATER HEATER WIVE11T 6.00
on
Owner Date WATER SYSTEM 5.00 ACC.DATE ACC.FILE NO.
WORK F-RS'COMPENSATION DECLARATION WATER TREATIPPIEP%P. 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 •L'
copy the rcgf S c. 800,Lab.C.� a T
Policy N Company
Q ❑ Certified ' ISIIereby mihed. //iJ FIRE SPRINK ENERGY T-24
Z Z 0"Cerffie y Is liy I the city
inyp�ton t Is MISC.- REFE POORD.
Applicant Ll=�7J'f6�.GC1 Y❑ N❑ Y ❑ N❑
I--' - PERMIT ISSUANCE 10.00 , FLOOD ZONE A.L.U.C.
CC > CERTIFICATE 01'EXEMPTION 17ROM WORKERS'
LU _ COMPENSATION INSURANCE PLG.C`ONTR.Clp Gr LIC.NO. PLG. I/
CL CK[OA sO TOTAL lD Y❑ N❑ Y ❑ N❑
(This action need not be complete) if the permit is for one
=) Z hundred dollars($100)or less.)
U O I certify that in the pcihr.xHce of IIIc Work tis which this per- QTY. MECHANICAL PERMIT FEE FEE SUMMARY
mit is issued,I shall not employ any person in any manner so as to
Ow become subject to the Workers Compensation Laws of California. BUILDING
Date Applicant I ALTER OR ADD TO MECH. 5.00
} irs NOTICE TO APPLICANT: IL after making this Certificate of Fx-
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 deenhed revoked. AIR HANDLING UNIT(TO 10,000CF.M.) 4.00
CONSTRUCTION LENDING AGENCY AIR HANDLING UNIT(OVER 10AMC.F.M.) 6.00 SEISMIC FEE
I hereby affirm that there is a construction lending agency for EXHAUST HOOD(WITH DUCT) 5.00
the perforn..ace of to work for which this permit is issued(Sec. HEATING UNIT(TO 100,000 B.T.U.) 8.00 MICROFILM
3097,CH.C.).
I.cnder's Name HEATING UNIT(OVER 100,000B.T.U.)9.50 ELECTRIC
Lender's Address
• 1 certify(bat 1 have read this application and state that the above VENTILATION FAN (SINGLE) 4.00 PLUMBING
-
information is correct. I agree to comply with all city and county
BOILER-COMP(3 H.P.
ordinances and state lows relating to building construction, and of 100,000 B.T.U.) 6.00
hereby authorim representatives of this city to enter upon the BOILER-COMP love,100,000 BTU)SEE FEE SCH. MECHANICAL
above-mentioned property for inspection purposes.
(We) agree to save, indemnify and keep harmless the City of MISC.- REFER TO ORD.
Cupertino n liabilities,jq gmen(s,costs and expenses which CONST.TAX
may in y y accru of st said City in consequence of the PERMIT ISSUANCE 10.00
gmnt o S permit MECH.CONT. LIC.NO. MECH.
�?�(� TOTAL TOTAL
Signature of) ant/C.mmsto,
fApplicant/Commstor ate
OFFICE COPY
I
APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
BUILDING PROJECT IDENTIFICATION PERMIT NUMBER
BUILDING APPLICATION & PERMIT 10 8 2 9
ADDRESS
g 1. BUILDING -ELECTRICAL-PLUMBING-MECHANICAL
OWNER'S
PLAN CHECK VALIDATION
NAME a.SI�^ QTY. ELECTRIC PERMIT FEE
eg PHONE
: J NTRACTOR$,�. 1 OUTLETS-SWITCHES-RECEP 10.00/1.00
NAME G1 WJLI
oW
LIC.rvo. LIGHTING FIXTURES 10.00/1.00
AoDrvDTRACTo�i Kl � x-I\DfoJSiT, lq1 APPLIANCES-RESIDENTIAL 4.00
PHONE PANELS 10.00 DATE OF APPLICATION
ARCHITECT
PANELS (OVER 200 AMP) 20,00 PLAN CHECKFEE P.C.NO.
OR
ENGINEER
LIC.NO. SIGNS TRANS. 3.00
ARCW OR ENG. 6.00 PERMIT VALIDATION
ADDRESS SPECIAL CIRCUIT
ZIP EMP.METER OR POLE INS. 20.00
APPLICANT'S \11 Olt Yl`I�r-Op S.t- MOTORS SEE FEE SCH.
ADDRESS -x ` t"1 1� W/-uy ,-•"
SERVICE CHANGE 20.00
O ¢i $ s
'02 LICENSED CONTRACTORS DECLARATION
a v 1 hereby art,.that I am licensed under provisions of Chapter 9 ISSUANCE DA/E
w a N (commencing with Section 7000)of Division 3 of the Business and BLDC. ELECT. PLG. MECH.
v,w z 1'rofessions Cod•,an y license is in full for'• c cI. ❑ ❑ ❑
Z2 O w - Licimnklass Lic.Number L
Q Ix H ce Oure ^t Contractor
F " umb=*+G BUILDING PERMIT
= ¢w u OWNER-BUILDER DECLARATION d INFORMATION
w LL t- I hereby affirm that I am exempt front the Contractor's License MISC.- REFER TO ORD
VALUATION $/FT.
LLOa Law for the following reason.(Sec.7031.5,Businessind Professions PERMIT ISSUANCE 10.00
� - 0 Code:Any city or county which requimsa permit loconstrct,alter,
ac Q¢ 0 improve,demolish,or repair any structure,prior to its issuance,also ELEC.CONTR. LIC.NO. ELEC.
-O u requires the applicant for such permit to file a signed statement that TOTAL PERMIT TO
n w m he Is licensed pursuant to the provisions of the Contractor's License
H z Q
Law(Chapter 9(commencing with Section 7000)of Division3of the
f i D Business and Professions Code)or that he is exempt therefrom and QTY. PLUMBING PERMIT FEE
¢ r e the basis for the alleged exemption.Any violation of Section 7031.5 STORIES TYPE CONSTR.
a ;m by any applicant for a pt,nnll subjects the applicant to a civil penalty ALTER-DRAIN&VENT-WATER (EA.) 5.00
of not more than five hundred dollars(5500).):
O 1,as owner of the property,or my employees with wages as BACK FLOW PROTECT. DEVICE 4.00 DCC.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 docs not apply to an owner of
property who builds or improves thereon,and who does such work FIXTURES-PER TRAP 5.00 50.FT.FLOOR AREA TOTAL ACREAGE
himself or through his own employees,provided drat such improve- GAS EA.SYSTEM-I INC.4 OUTLETS 6.00
meats are not intended or offered for sale.IL however,the building
t or improvement is sold within one year of completion, the owner- GAS-EA.SYSTEM-OVER 4(EA.) 2.00 BUILDING USE
builder will have the burden of proving that he did not build or im- RES IND CON PB Omer
prove for purpose of sale.). INDUSTRIAL WASTE INTER. 30.00 ❑ ❑ ❑ ❑ 11❑ I,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 ASSESSORS PARCEL NO.
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
EWER-SANITARY-STORM EA.200ft/10.00 TRACT NO. PARCEL NO.
Bit,Contractor's License Law.
❑ I am exempt under Sec. ,B.&P.C.for this WATER HEATER WIVE11T 6.00
on
Owner Date WATER SYSTEM 5.00 ACC.DATE ACC.FILE NO.
WORK F-RS'COMPENSATION DECLARATION WATER TREATIPPIEP%P. 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 •L'
copy the rcgf S c. 800,Lab.C.� a T
Policy N Company
Q ❑ Certified ' ISIIereby mihed. //iJ FIRE SPRINK ENERGY T-24
Z Z 0"Cerffie y Is liy I the city
inyp�ton t Is MISC.- REFE POORD.
Applicant Ll=�7J'f6�.GC1 Y❑ N❑ Y ❑ N❑
I--' - PERMIT ISSUANCE 10.00 , FLOOD ZONE A.L.U.C.
CC > CERTIFICATE 01'EXEMPTION 17ROM WORKERS'
LU _ COMPENSATION INSURANCE PLG.C`ONTR.Clp Gr LIC.NO. PLG. I/
CL CK[OA sO TOTAL lD Y❑ N❑ Y ❑ N❑
(This action need not be complete) if the permit is for one
=) Z hundred dollars($100)or less.)
U O I certify that in the pcihr.xHce of IIIc Work tis which this per- QTY. MECHANICAL PERMIT FEE FEE SUMMARY
mit is issued,I shall not employ any person in any manner so as to
Ow become subject to the Workers Compensation Laws of California. BUILDING
Date Applicant I ALTER OR ADD TO MECH. 5.00
} irs NOTICE TO APPLICANT: IL after making this Certificate of Fx-
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 deenhed revoked. AIR HANDLING UNIT(TO 10,000CF.M.) 4.00
CONSTRUCTION LENDING AGENCY AIR HANDLING UNIT(OVER 10AMC.F.M.) 6.00 SEISMIC FEE
I hereby affirm that there is a construction lending agency for EXHAUST HOOD(WITH DUCT) 5.00
the perforn..ace of to work for which this permit is issued(Sec. HEATING UNIT(TO 100,000 B.T.U.) 8.00 MICROFILM
3097,CH.C.).
I.cnder's Name HEATING UNIT(OVER 100,000B.T.U.)9.50 ELECTRIC
Lender's Address
• 1 certify(bat 1 have read this application and state that the above VENTILATION FAN (SINGLE) 4.00 PLUMBING
-
information is correct. I agree to comply with all city and county
BOILER-COMP(3 H.P.
ordinances and state lows relating to building construction, and of 100,000 B.T.U.) 6.00
hereby authorim representatives of this city to enter upon the BOILER-COMP love,100,000 BTU)SEE FEE SCH. MECHANICAL
above-mentioned property for inspection purposes.
(We) agree to save, indemnify and keep harmless the City of MISC.- REFER TO ORD.
Cupertino n liabilities,jq gmen(s,costs and expenses which CONST.TAX
may in y y accru of st said City in consequence of the PERMIT ISSUANCE 10.00
gmnt o S permit MECH.CONT. LIC.NO. MECH.
�?�(� TOTAL TOTAL
Signature of) ant/C.mmsto,
fApplicant/Commstor ate
OFFICE COPY