11997 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
BUILDING PROJECT IDENTIFICATION PERMIT NUMBER
BUILDING APPLICATION & PERMIT 11997
ADDRESS 10OW pharlap Drive BUILDING—ELECTRICAL—PLUMBING—MECHANICAL
OWNER'S PLAN CHECK VALIDATION
"AME [� [�f1 DTV. ELECTRIC PERMIT FEE
Aire. J. W. Brake PRDNE255-1578
CONTRACTORS UTLETS-SWITCHES-RECEP 10.00/1.00
NAM!lE •
tla8 Hearin UC.N- 465266 LIGHTING FIXTURES 10.00/1.00
CONTRACTORSADDREss - APPLIANCES-RESIDENTIAL 4.00'
195 Commercial St.PHONE739-0516 PANELS 10.00 DATE OF APPLICATION
ARCHITECT PANELS (OVER 200 AMP) 20.00 PLAN CHECK FEE P.C.NO,
OR SunnyvaleV -Y
ENGINEER
LIC.No. SIGNS TRANS. 3.00
ARCH.OR ENG. SPECIAL CIRCUIT 5,00 PERMIT VALIDATION
ADDRESS
nP EMP.METER OR POLE INS. 20.00
APPucnrvrs IMOTORS SEE FEE SCH.
ADDRESS
SERVICE CHANGE 20,00 /0 yam
woo LICENSED CONTRACTORS DECLARATION O 1'
a u w 1 hereby affirm that 1 am licensed under provisions Of Chapter 9 ISSUANCE DATE
G a e (commencing with Section 7000)of Division 3 of the Business and BLDG. ELECT. PLG. MECH.
H m i Professions Code,.1 ys��+e Ise ism full forc48 ffe El ❑ 1-=1
2.0 rn — License FyIs Lie.Number YD LJ
O m I- 0 Dale W Contractor
— —
¢ Y¢a OWNER-BUILDER DECLARATION BUILDING PERMIT
E: o a MISC.— REFER TO ORD INFORMATION
X ; 0 I hereby affirm that I am exempt from the Contractor's License
w o¢ Law for the following reason.(Sec.7031.5,Business and Professions PERMIT ISSUANCE 10.00 VALUATION S/FT.
Code:Any city or county which requiresa permit to construct,alter,
Q ¢Q improve,demolish,or repair any structure,prior to its issuance,also ELEC.CONTE. LIC,NO. ELEC.
A. 6 c ¢ requires the applicant for such permit to file a signed statement that TOTAL PERMIT TO
X re Ise is licensed pursuant to the provisions of the Contractor's License
H z r Law(Chapter 9(commencing with Sect ion 7000)of Division 3 oflhe Af
< Business and Professions Code)or that he is exempt therefrom and DTV. PLUMBING PERMIT FEE
the basis for the alleged exemption.Any violation of Section 7031.5
STORIES TYPE CONSTR.
by any applicant for a permit SuhjtctS tire applicant ton civil penalty ALTER-DRAIN&VENT-WATER (EA.) 5.00
of not more than five hundred dollars(S500)J:
❑ 1,as owner of the property,or my employees with wages as BACK FLOW PROTECT.DEVICE 4.00
their sole compensation,will do the work,and the structure is not OCC.GROUP RES.UNITS
intended or Offered for sale(Sec. 7044, Business and Professions DRAINS-FLOOR,ROOF,AR EA,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 SO.FT.FLOOR AREA TOTAL ACREAGE
himself or through his own employees,provided that such improve- GAS-EA.SYSTEM-iINC.40UTLETS 6.00
ments are not intended or offered for sale.If,however,the budding
or imder will
is Sold within ane year of completion,the owner- GAS-EASYSTEM•OVER 4 IEA) 200 BUILDING USE
buier will have the burden of proving that h . . .
e did not build or an- RES IND CON PB Omer
prove for purpose of sale.). INDUSTRIAL WASTE INTER. 30.00
❑ 1,as owner of the properly,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:'file Contractor's License Law does not apply
to an owner of properly who builds or improves thereon,and who LAWN SPRINKLERS-OVER 5(EA.) 1.00
contracts forsuch projemewith acontraetods)licensed pursuant to SEWER-SANITARY-STORM EA.20011/10.00
the Contractor's License Law. TRACT NO. PARCEL NO.
❑ lam excmptundcr Seca ,B.&P.C.I'orthls WATER HEATER W/VENT 6.00
reason
Owner Date WATER SYSTEM 5.00 PCC.DATE ACC.FILE NO.
WORK ERS'COMPENSATION DECLARATION WATER TREATING EQUIP. 5.00
I 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 thIR1-_L=`lAu7pan.c.).
policy Nn+ ZV1u�Pany -died Pac
O Certified copy is herpekb.�y1 furnyish��edyS FIRE SPRINK ENERGY T44
Z Z Certifieskti&gs RBawjt1I1113 city inspaction division. ❑ ❑ ❑ ❑
O Applicant AB 41116 MISC.- REFER TO ORD. Y N Y N
W CI:R'fIFICATE OF.EXEMPTION PROM WORKERS' PERMIT ISSUANCE 10,00
FLOOD ZONE A.L.U.C.
LU COMPENSATION INSURANCE PLG,CONTR. LIC.NO. PLG.
1 O (This section need not be completed if tire permit is for One TOTAL Y❑ IN Y❑ N❑
::) Z hundred dollars IS 100)or less.)
U O I Certify chat in the performance of the work for which this per, OTY. MECHANICAL PERMIt• FEE FEE SUMMARY
LL f mit is issued,1 shall not employ any person In any manner so as to
O W become subject to the Workers'Compensation Laws of California.
Date Applicam ALTER OR ADD TO MECH. h t 5.00 BUILDING
>- US NOTICE TO APPLICANT: If,after making this Certificate of lix-
? emPtion,you should became subject to the Workers'Compensalion APPLIANCE 5.00 PLAN CHECK
provisions of the Labor Code, you must forthwith comply withFEE
U such provisions Or this permit shall be deemed revoked AIR HANDLING UNIT(TO 10A00C.F.M,) „ 4100
CONSTRUCTION LENDING AGENCY AIR HANDLING UNIT IOVER'10 .F.M.16.00 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. AIUNIT(TO 100, 0 B.T.U.) 8.00 MICROFILM
3097,Civ.CJ. HETNG 00
0
Lender's Name HEATING UN IT(OV ER 100,000 B.T.U.)9.50 ELECTRIC
Lender's Address
I certify that I have read this application and state that the above VENTILATION FAN (SINGLE) 4.00
information is correct. I agree t0 comply with all city and county PLUMBING
1 ordinances and state laws relating to building construction, and BOILER•COMP 13 H.P.or 100,000 B.T.U.) 6.00 ``
hereby authorize representatives of this city to enter upon the
above-mentioned property for inspection purposesBOILER-COMP(Over 100,000 BTU)SEE FEE SCH. MECHANICAL W
. �
(We) agree to save, indemnify and keep harmless the City of MISC.- REF R T RD.
Cupertino against liabilities,judgments, costs and expenses which 'A OD CONST.TAX
may in an 'y accrue against said City in consequence of the PERMIT ISSUANCE D.00 '!l
gmnlin psis permit MECH.CONT. C.N0. M H.
ne fAoli � D7i80D TOTAL
Sigdature of Applicant ontracmr Dute (.��P"v' 16_
0FFICE COPY /