09609 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
SIIBUI LDI NG PROJECT I DENTI FICATI ON - PERMIT NUMBER
BUILDING APPLICATION & PERMIT 09609
ADDRESS
BUILDING - ELECTRICAL-PLUMBING-MECHANICAL
OWNER'S PLAN CHECK VALIDATION
NAME QTY. ELECTRIC PERMIT FEE
vroNE _ D
NOMERAcroRs UTLETS-SWITCHES-RECEP 10.00/1.00
-ti„ LIC No. LIGHTING FIXTURES 10.00/1.00
ADDRESS TORS PPLIANCES-RESIDENTIAL 4.00
p /wOrvE�g/ _ PANELS 10.00 DATE OF APPLICATION
FSflCmTECT�{J� C;. 9'A 36 PANELS (OVER 200 AMPI 20.00 PLAN CHECK FEE P.C.NO,
ENGINEER
LIC.No. SIGNS TRANS. 3.00
ARCH On ERG.
ADDRESS ' SPECIAL CIRCUIT 5,00 PERMI VOP
ZIP EMP.METER OR POLE INS. 20.00 �+ ILL.•//
APPLICANTS MOTORS SEE FEE SCH. SEP O t.4 1f1pC
_e��� SERVICE CHANGE 20.00 t JCC77JJ
0 i
Foo LICENSED CONTRACTORS DECLARATION TEMP.POLE 30.00 /ty Of CuPert�
aI hereby afffnm that I fen licensed under provisions of Chapter 9 n�
0
Z i ISSUANCE DATE
¢
Professions
with Section 700e i Of Division 3 of effect, ss and - BLDG. ELECT. PLG. MECH.
H N i Professions Code,and my license is in full force and effect ❑ ❑ ❑
oi m a License Class Lia Number
m r j Uatc Contruc[Dr
¢ a w a OWNER-BUILDER DECLARATION BUILDING PERMIT
w ;, � I hereby at'firin that 1 um exempt from the Contractor's License MISC.- REFER TO ORD INFORMATION
u0 ¢ Law for the following reason(Sec.7031.5,Ifusinessand Professions VALUATION $/FT.
- PERMIT ISSUANCE 10.00
Code:Any city or county which requires a permit to construct.alter,
ELEC.CONTR. LIC.NO.
ar rt ¢ p improve,demolish,or repair any structure,prior to its issuanc0.also ELEG.
O u nouires the applicant for such permit to file a signed statement that TOTAL
n w m he is licensed pursuant to the provisions of life Contractor c License PERMIT TO
H z i
Law(Chapter 9(commencing with Section 7000)of Division 3 ofthe
4 o Business and Professions Code)or that he is exempt therefrom and CITY. PLUMBING PERMIT FEE
CEI the basis for file alleged excmptlonatio
.Any violn of Section 703 1.5 TYPE CONSTR.
n3 by any applicant for a permit subjects the applicant to a civil penalty
of not more than five hundred dollars(S500L): ALTER-DRAIN& VENT-WATER (EA.) 5.00
O L as owner of the property,or my employees with wages as BACK FLOW PROTECT. DEVICE 4,00 DCG GROUP RES.UNITS
sole compensation,will do the work,end lite 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 FIXTURES-PER TRAP 5.00 J SO.FT.FLOOR AREA TOTALACREAGE
himself or through his own employees-provided that such ire".ve-
mea(s are not intended or offered fur sale.If.however,life budding GAS-EA.SYSTEM-1 INC.4 OUTLETS 6.00 '
or improvement is sold within one year of completion,the owner- GAS EASYSTEM OVER 4(EA ) 2.00
builder will have the burden of proving that he did not b - . - .
uild or int- BUILDING USE
prove for purpose o(sale.). INDUSTRIAL WASTE INTER. 30.00 RES IND CON Pa Other
O I,as owner of the property,am exclusively contracting with ❑ El El a ❑
licensed contractors to construct the project(Sec. 7(144,Business LAWN SPRINKLERS-I 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
OOntmels for such projects with n contmetons)licensed pursuant to
the Contractor's License Law, SEWER-SANITARY-STORM EA.200ft/10.00 TRACT NO. PARCEL NO.
O lam exempt Under S,,.-,B&KC,for this
on WATER HEATER W/VENT 6.00
Owner Date WATER SYSTEM - 5.00 ACC.DATE ACC,FILE NO,
W'ORKERS'COMPENSATION DECLARATION WATER TREATING EQUIP. 5.00
I hereby uffinn that 1 have a certificate of consent to self-insure,
or a certificate of Workers'Compensation Insurance,or a certified ZONING ENG.SITE NO.
copy thereof(Sec.3800,Lxb.C.l n
Poll No.nq.Ar, Company ..•� l! ., -
O D C'crtif icd copy is hereby furnished. If
z Z B Certified copy is filed with the city inspection division. T FIRE SPRINK ENERGY T 24
HO Applicant MISC.- REFER TO ORD. Y❑ NE] Y [] NE]
OC NCERTIFICATE 01'EXEMPFION FROM WORKERS' PERMIT ISSUANCE 10.00 FLOOD ZONE A.L.U.C.
W > COE IPENSATION INSURANCE PLG.CONTR, LIC.NO. PLG.
CL o ('Phis section need not be completed if the permit is for one TOTAL Y❑ N� V N�
0Z Iormted do 11 ars($100)or lcSQ
U O 1 certify than in the pcHmurance of the work for which this Per- GTY. MECHANICAL PERMIT FEE FEE SUMMARY
IL b- mit is issued,I shall not employ any person in any manner so as to
become subject to the Workers'Compensation Laws of California.
ED
Uaa• Applicant ALTER OR ADD TO MECH. 5.00 BUILDING
�-
to NOTICE TO APPLICANT: If,after making this Ccrtificale of 1!x-
F ? enhption,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 oshmre
r this permit all be deemed revoked. AIR HANDLING UNIT(TO 10=C.F.M.) 4.00
CONSTR UCIION L17NDING AGENCY AIR HANDLING UNIT(OVER 10=C.EM.) 6.00 SEISMIC FEE
1 hereby affirm that there is a construction lending agency for EXHAUST HOOD(WITH DUCT) 5.00 f,
the performance of the work for which this permit is issued(Sec. MICROFILM
3097,Civ,C.). HEATING UNIT(TO100,000 B.T.U.) 8.00
Lender's Name
Lender's Address HEATING UNIT(OVER 100,000 B.T.U.)9.50 ELECTRIC
I certily that I hav add'1Lisp(rfca ion�nd state that the above VENTILATION FAN (SINGLE) 4.00 y
• ordinances n correct. I agree to comply with all city and county BOILER-COMP(3 H.P.or 100,000 B.T.U.) 6.00 PLUMBING
ordinances and slate laws relating to building construction,c, and
hereby authorize representatives of this city to enter upon theabove- BOILER-COMP(Over 100,000 BTU)SEE FEE SCH. MECHANICAL
hereby autioncd property represor entatives
ofth i purposes.
(We) agree to save, indemnify and keep harmless the City of MISC.- REFER TO ORD,
Cupertino againstliabilities,judgments, costs and expenses which PERMIT ISSUANCE 10.00 CONST.TAX
may in any way accrue against said City in conmqucnee of the 7 p,pp
granting of this Permit. MECH.CONT. LIC.NO. MECH,
D TOTAL TOTAL
hgn re Of Applicant amine ar Date
INSPECTOR COPY
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APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT'PEN ONLY
RUI LDI NG PROJECT IDENTIFICATION APPLICATION & PERMIT
BUILDING -ELECTRICAL- PLUMBING -MECHANICAL
PERMIT,NUMBER
9 fi Q 9BUILDINGADDRESS,0
OWNER'S
NAME
PHONE i.4 JW_J_54J?
W
QTY, ELECTRIC PERMIT FEE
PLAN CHECK VALIDATION
CONTRACTOR'S
NAME OUTLETS- SWITCHES - RECEP 10,0011,00 '
LIGHTING FIXTURES 10,00/1.00AepLIC-NO.4,T I D
DATE OF APPLICATION
CONTRACTOR'S
ADDRESS
J 7 -:V -_R
PPLIANCES- RESIDENTIAL 4.00
PANELS 10.00
RCHI7EC
OROENGINEER
LIC.NO.
PANELS (OVER 200 AMP) 20.00 PLAN CHECK FEE P.C. NO,
SIGNS TRANS. 3,00
ARCH. OR ENG,
ADORESS SPECIAL CIRCUIT 5.00 PERMIT VALIDATION
PAPA/ EMP. METER OR POLE INS. 20.00ZIP
0AAP
v k 19pC
Ci ,
77J
City
ISSUANCE G
AVPLICANT'S
q:7- a p
MOTORSADDRESS. SEE FEE S_CH.
SERVICE CHANGE 20,00
LICENSED CONTRACTORS DECLARATION
I hereby affirm that I am licensed under provisions of Chapter 9
commencing with Section 7000). of Division 3 of the Business and
Professions Code, and my license is in full farce and effect.
License Class Lie. Number
TEMP. POLE 30.00
BLDG. ELECT. PLG MECH, I
Date Contractor
BUILDING PERMIT
INFORMATIONOWNER -BUILDER DECLARATION
I hereby affirm that I am exempt from the Contractor's License
Law, for the following reason. (Sec. 703 L5, Businessand 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
Law (Chapter 9 (commencing with Section 7000),of Division 3 of the
Business and Professions Code) or that he is exempt therefrom and
MISC. - REFER TO ORD
PERMIT ISSUANCE 10,00
VALUATION 1'FT.
ELEC. CONTR, LIC. NO: ELEC.
TOTAL PERMIT TO
r
1) IQTY, PLUMBING PERMIT FEE_
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 (8500).): ALTER DRAIN &VENT -WATER (EA,1 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 (See. 7044, Business and Professions
Code: The Contractor's License Law does norapply to an owner of
property who builds or improves thereon, and who does such work
himself or through his own employees, pr6ided.that such improve-
ments are not intended or offered'forsale. 1f, however, the building
F IXT(1R ES - PER TRAP 5.00 SO. FT. FLOOR AREA TOTAL ACREAGE
GAS- EA, SYSTEM - I INC.4 OUTLETS 6.00
or improvement is sold within one.year of completion, the owner-
builder will have the burden of proving that b e did not build or im-
prove for purpose of sale.),
1, as owner of the property, am exclusively contracting with
GAS - EASYSTEM -OVER 4 {EA) 2A0 BUILDING USE
REs IND , CON PB Other
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 ASSESSORS PARCEL NO.
LAWN SPRINKLERS -OVER 5 (EA.) 1,00
contracts for such projects with a contractor(s) licensed pursuant to
the Contractor's License Law. SEWER -SAN ITARY-STORM EA. 200ft11 0.00 TRACT NO. PARCEL NO.
1 am exempt under Sec. B.&P,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'COMPENSATIONDECLARATION
1 hereby affirm that I have a certificate of consent to self -insure,
or a certificate of Workers' Compensation I9surance, ora certified
copythereoF(Sec.3800,Lab.C.)"yyt 5/
ZONING ENG, SITE NO.
Policy'No.P.4?ompany
V Certified copy is hereby furnished,
Cerdfied' Copy is filed with the city inspection division.
Applicant
FIRE SPRINK
y L]N E]Y
ENERGY T-24
N MISC. - REFER TO ORD,
CERTIFICATE OF EXEMPTION FROM WORKERS' PERMIT ISSUANCE 10.00 FLOOD ZONE A.L.U.C.
PLG. CONTR. LIC. NO. DLG,
ITOTAL
COMPENSATION INSURANCE
This section need not be completed if the permit is for one
Y N Y E:] N[_]
QTY.' MECHANICAL PERMIT FEE FEE SUMMARY
hundred dollars ($ 100) or less.)
I certify that in the performance of the work for which this per-
mit is issued, I shall not employ any person in any manner, so as to
BUILDING
become subject to the Workers' Compensation Laws of California.
Date Applicant ALTER OR ADD TO MECH. 5.00
NOTICE TO APPLICANT. If, after making this Certificate.of Ex-
APPLIANCE 5.00 PLAN CHECKemption, you shouldbecome subject to the Workers' Compensation
provisions of,the Labor Code, you must forthwith comply with
such provisions or this permit shall be deemed revoked,
FEE
AIR HANDLING UNIT {TO 10)000QF,M.) 4.00
AIR HANDLING UNIT (OVER 10MOC.F,M.) 6.00 SEISMIC FEECONSTRUCTIONLENDINGAGENCY
1 hereby affirm that there is a construction lending agency for EXHAUST HOOD (WITH DUCT) 5.00 -.d!?
the performance of the work for which this permit is issued (Sec.
3097,Civ.C:).
MICROFILM
HEATING UNIT (TO 100,0008.T.U.) 8.00
HEATING UNIT (OVER 100'000B,T.U.)9.50 ELECTRIC
Lender's Name
Lender's Address
I certify that,l have rea this app is ion d state that the above VENTILATION FAN (SINGLE) 4.00 8,00
information is correct. I agree to comply with all city and county
ordinances and state laws relating to building construction, and
PLUMBING
BOILER COMP (3 H.P. Or 100,000 B.T,U.1 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
CONST, TAXPERMITISSUANCE10.00 X0.00
granting of this permit. MECH. CONT. LIC. N0, MECH"
63,
m
p 3 7
TOTAL
3 /.00 TOTAL
Signa of A plicant(Conttactor Date
OFFICE COPY