The URL can be used to link to this page

10247APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY •!�3/%/A��y� BUILDING PROJECT IDENTIFICATION APPLICATION & PERMIT BUILDING -ELECTRICAL -PLUMBING -MECHANICAL PERMITNUMBER 10247 BIl LOING AOORE55 Cupertino Civic Center 10 Torre Avenue OWNER'S NAME City ofCupertino PHONE QTY. ELECTRIC PERMIT FEE PLAN CHECK VALIDATION NAMERACTORs UTLETS-SWITCHES -RECEP 10.00/1.00 LIGHTING FIXTURES 10.00/1.00 LIC. NO. CONTRA p� ADDRESS P.O. 11VX 5629 415 PPLIANCES- RESIDENTIAL 4.00 Redwood ClCA94063P-O.E 64-8081 DATE OF APPLICATION PANELS 10.00 ARCHITECT Ho an -East-IhnsLvier FOfl ll GINEEP , Olt ASSOC. uc. No. PANELS (OVER 200 AMP) 20.00 PLAN CHECK FEE P.C. NO. SIGNS TRANS. 3.00 ARCH. E°ss ENG' - SPECIAL CIRCUIT 5.00 PERMIT VALIDATION ) I (vY\ EMP. METER OR POLE INS. 20.00 -ZIP AS ADDREDDRESSS MOTORS SEE FEE SCH. P.O. BOX 5629.Redwood City,CA94063 ISERVICE CHANGE 20.00 � v LICENSED CONTRACTORS DECLARATION TEMP. POLE 30.00 1 hereby affirm that I am licensed under provisions of Chapter 9 (commencing with Section 7000) of Division 3 of the Business and Pro essions Cody 1yyyy��yy ffGy'pdi is in full force Y,e(f�y License Class 1a L1LL1.1.ic. Number /14Si� ISSUANCE DATE BF.DG. ELECT. PLG. EC ❑ ❑ ❑ Dale_exT (F./ �_Conlructor.- O e4_ `^'•C OWNER -BUILDER DECLARATION I hereby collo that 1 ora exempt from the Contractor's License Plnf¢ssions Law for the followingreason. eSec.7 ices a perm Code: Any city or county which requirespermit 10 construct, alter, mit to BUILDING PERMIT INFORMATION MISC.- REFER TO ORD PERMIT ISSUANCE 10.00 VALUATION $ T. ELEC. CONTR. LIC. N0. ELEC. TOTAL improve, demolish• or repair any permit tostructure, prior to its issuance, also the dp u applicant for tiro permit ID file a Cont statement that requires islicensed he is licensed pursuant to the provisions of the Contractor's License PE T Section Division 3ofthe (Chapter 9(CusionsC Busi is7000) Business and Professions Code) or that he is exempt therefrom and Code) exempt DTV. PLUMBING PERMIT FEE 5T0 IES TYPE CONSTR. of Section malty by basis for the alleged exemption. Any applicant subjectsthe $500).licam loacivil penally by any applicant for hundred of not more than five hundred Dollars (E500).): ALTER-DRAIN-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. 5.00 intended or offered for Sale (Sec. 7044, Business and Professions Code: The Contractor's License Low 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 oroffered for sale. If. however. the building FIXTURES - PER TRAP 5.00 GAS - EA. SYSTEM -1 INC.4 OUTLETS 6,00 a0. FT. FLOOR AREA TOTAL ACREAGE or improvement is sold within one year of completion, the owner - builder will have the burden of proving that he did not build or ma. prove for purpose of sale.). ❑ 1, as owner of the properly, am exclusively contracting with GAS - EA. SYSTEM - OVER 4 (EA.) 2.00 BUILDING USE RES IND PB Omer 111:1N ❑ ❑ INDUSTRIAL WASTE INTER. 30.00 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 LAWN SPRINKLERS - 1 INC 5 V.B. 6.00 LAWN SPRINKLERS - OVER 5 (EA.) 1.00 ASSESSOR PARCELNO. contracts for such projects with a conlractoN s) licensed pursuant to the Contractor'sxpt License Lata. SEWER -SAN STAR V -STORM EA. 200ft/10.00 TRACT NO. -PARCEL NO. ❑ laaexempt nmp[under Sec,., B &P.C. I'or this reason WATER HEATER W/VENT 6.00 Owner Date WATER SYSTEM 5.00 ACC. DATE ACC. FILE NO. WORKERS'COMPENSA'IION DECLARATION WATER TREATING EQUIP. 5.00 1 hereby affirm that 1 have a certificate of consent to self -insure. or a certificate or a certificate of 3800,Workers' Count, ..)'n e�o�' c rli;ied (of 38 �tsQ"T/ ZONING ENG. SITE NO. Policy No. Company �a'} tl tTI, �- _ FIRE SPRINK YE] N ❑ ENERGY T-24 V ❑ N❑ ❑ Certified Copy is herby ur Certifie o Is ��`ve�� 111 city inspection division. canl�� - MISC. REFER TO ORD. CERT I FICATE OF EA S;ITION FROM WORKERS' PERMIT ISSUANCE 10.00 FLOOD ZONE A. L. U. C. PLG. CONTR. LIC. NO. PLG. TOTAL COMPENSATION INSURANCE. (This section need not be completed if the permit is for one V ❑ N❑ I y ❑ N❑ hundred.dollars (E 100) or less.) I certify that in the performance of tire 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 CulI orma. Date Applicant NOTICE TO APPLICANT:, If, after making this Certificate of Ex- D M CHANICA PER I / FEE ALT OR ADD TO MECH. 5.00 FEE SUMMARY BUILDING APPLIANCE 5.00 PLAN CHECK emption, 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 FEE AIR HANDLING UNIT (OVER 10MC.F.M.) 6.00 SEISMIC FEE CONSTRUCTION LENDING AGENCY 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 (Sec. 3097, Civ.CJ. MICROFILM HEATING UNIT (TO 100,000 B.T.U.) 8.00 Lender's Name T1G1I12 Lender's Address HEATING UNIT 100,000 B.T.U.)9.50 ELECTRIC I 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 ordinances and state laws relating to building construction, and PLUMBING BOILER-COMP(3H.P.or100,000B.T.U.) 6.00 BOI LER•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. 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 true against Said Cily in Con qua cc of the granting f his it, CONST. TAX PERMIT ISSUANC 10.00 MECH. CONT. LIC. NO.MECH. TDT"` TOTAL Sign ure of App ca rector ate OFFICE COPY