09614 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
BUILDING PROJECT IDENTIFICATION PERMIT NUMBER
LOIN DRESS
ADAPPLICATION & PERMIT 09 14
AD
BUILDING -ELECTRICAL-PLUMBING -MECHANICAL
7
OWNER'S PLAN CHECK VALIDATION
NAME OTY. ELECTRIC PERMIT FEE
/ sr
PHONE F /.
NAMERACTDRs UTLETS-SWITCHES-RECEP 10.00/1.00
EaC.No. o - n i-• LIGHTING FIXTURES 10.00/1.00
CON A TOAs
ADDRESS APPLIANCES-RESIDENTIAL 4.00
PANELS 10.00 DATE OF APPLICATION
ARCRRECT ,,z3 of PANELS (OVER 200 AMP) 20.08 PLAN CHECK FEE P.C.NO.
OR
ENGINEER
EJC.No. SIGNS TRANS. 3.00
ADDRESS ENG. PERMIT CIRCUIT 5.00 PERMIT VALIDATION
ZIP EMP.METER OR POLE INS. 20.00 PAR)
ADDRESS AMOTORS SEE FEE SCH.
DRESS
APPLICANTS RE55
q . . SERVICE CHANGE 20.00 SEP p 4 1985
oo LICENSED CONTRACTORS DECLARATION TEMP.POLE 30.00 �s
a u� I hereby affirm that I am licensed under provisions of Chapter 9 CI ISM64111ISEDATE
y Z u ' (commencing with Section 7000)of Division 3 of the Business and re
4 BLDG. ELEC MECH
F D m Professions Code,and my license is in full force and effect. ,❑ ❑ ❑
Z O,�Z License ClasN Li,.Number
0 Z F o ❑316 - - `- Contractor
re ¢ 4 OWNER-BUILDER DECLARATION BUILDING PERMIT
S,
a U INFORMATION
w ; N I hereby affirm that I am exempt from the Contractor's License MISC.- REFER TO ORD
LL O 4 Law for the following reason.(Sea 7031.5,Business avd Pmlcssions VALUATION $/FT.
_ PERMIT ISSUANCE 10.00
� w F Code:Any city or county which requires a permit to construct,alter,
ar ¢ Q 2 Improve,demolish,Dr repair any Structure,prim to its Issuance,also ELEC.CONTR. LIQ NO. ELEC. )
ce
S, requires the applicant for such permit to file a signed statement that TOTAL PERMIT TO
n w m m he is licensed pursuant to the provisions of the Contractor's License
F >
Law(Chapter 9(commencing with Section 7000)ofDrvision 3 ofthe
E i o Business and Professions Code)or that he is exempt therefrom and FEET i
¢ r o the basis for the allugcJ exemQTY. PLUMBING PERMITption.Any violation o(Seclion 7031.5 *' STORIESI TYPE CONSTR.
ate _ by any applicant for a permit subjects the applicant toa civil penalty ALTER-DRAIN -WATER IEA.) 5.00
of not more than five hundred dollars(S500t):
❑ 1,as owner of the properly,or my employees with wages as BACK FLOW PROTECT. DEVICE 4.00 OCC.GROUP RES.UNITS
their sole compensation,will do the work,and the Onicture Is not
intended or offered for sale (Sec 7044, Business and ProfessionsDRAINS-FLOOR,ROOF,AREA,EA,CON D. 5.00
Code.'Tic 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 So.FT.FLOOR AREA TOTAL ACREAGE
himself or through his own employees.provided that such improve-
memsamnot intended or offered for sale.If,however,the building GAS-EA.SYSTEM-l1NC.40UTLETS 6.00
or improvement is sold within one year of completion,the owner- GAS EASYSTEM OVER 4 (EA) 200
builder will have the burden of proving that b - . - . .
iree did not build or - BUILDING USE
Prove for Purpose of safe.). RES IND CON PB Other
❑ I,as owner of the properly,am exclusively contracting with INDUSTRIAL WASTE INTER. 30.00 ❑ ❑ ❑ ❑
lice used 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 properly 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;License Law. SEWER-SANITARY-STORM EA.200ft/10.00 (TRACT NO. PARCEL NO.
❑ lam exempt under Sec. ,B.&1'.C.for Ibis WATER HEATER W/VENT 6.00
anon
Owner Dale WATER SYSTEM 5.80 ACC.DATE ACC.FILE NO.
WORK E RS'COMPENSAT ION DECLARATION WATER TREATING EQUIP. 5.00
1 hereby affirm that I have a certificate ofcnnsent Us sEl Fissure.
or a certificate of Workers'Compensation Insurance,or a certified ZONING ENG.SITE NO.
copy Ihercof(Sce.3500,Lab CT
Policy n Company '
Cer ihel -J copy is hereby famished. FIRE SPRINK ENERGY T-]4
Z Z fortified copy is IieA with tire oily inspection division.
O Applicant MISC.- REFER TO ORD, YE] N� v ❑ N[_]
jr w CERTD'ICAT E OF EXEaIPT ION FRONT WORKERS' PERMIT ISSUANCE 10.00 FLOOD ZONE A.L.U.C.
LU > COMPENSATION INSURANCE PLG.CONTR. - LIC.N0. PLG. '
�
Z 1'I'his section coed not be completed if the permit is for one TOTAL V E) N❑ Y E] NF
handrail dollars(S 100)or less)
U O I certify that in the performance of the work for which this per- OTY. MECHANICAL PERMIT FEE FEE SUMMARY
LL U mit is issued,1 shall not employ any person in any manner ,,as In
Q L) become subject to the Workers'Compensation Laws of California.
u Date ApplicantALTER OR ADD TO MECH. 5.00 BUILDING
} CO NOTICE TO APPLICANT: If,after making this Certificate of Ex-
♦- ? empfion,you should become subject to the Workers'Compensmioo 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 10=C.F.NL) 4.00
CONSTRUCTION LENDING AGENCY AIRHANDLING UNIT(OVER IQOOOO.F.M.) 6.00 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 parult is issued(Sec. MICROFILM
3097,GmCJ. HEATING UNIT(TO 100,000 B.T.U.) 8.00
Lender..,-
Lender's Address - / T HEATING UNIT(OVER 100,000 B.T.U.)9.50 ELECTRIC
I cattily that I have sbis apUEal An1l4 are that the above VENTILATION FAN (SINGLE) 4.00 ,rn
information is correct.I agree to comply with all city and county PLUMBING
ordinances and slate laws relating to building construction, and BOILER-COMP(3 H.P.or 100,000 B.T.U.) 6.00
hereby authorize representatives of this city to enter upon t1e
above-mentioned property for inspection purposes. BOILER-COMP(Over l00,000BTU)SEE FEE SCH. MECHANICAL
(We) agree to save, indemnify and keep harmless the City of MISC.- REFER TO ORD.
Cupertino against liabilities,judgments, costs and expenses which PERMIT ISSUANCE 10.00 CONST.TAX
may in any way accrue against said City in consequentt. of the .nl.
granting of flux permit. MECH.CONT. LIC.NO. MECH.
TOTAL TOTAL
Sngnat hr o App¢ani ontracto Oa'te
INSPECTOR COPY
si
APPLICANT TO FILL IN INFORMATION WITHIN RED LINES- USE BALL POINT PEN ONLY
0
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A10
BUILDING PROJECT IDENTIFICATION
APPLICATION &PERMIT
BUILDING - ELECTRICAL- PLUMBING - MECHANICAL
PERMIT NUMBER
09614BUILDINGADDRESS
OWNER'S
NAME
eZ_e_040_yV (L PHONE /_1fjA
QTY. ELECTRIC PERMIT FEE
PLAN CHECK VALIDATION
CONTRACTOR'S
NAME OUTLETS -SWITCHES- RECEP 10.00/1,00
LIGHTING FIXTURES 10.0011.00LIc.No per'
CONTRACTOR'S
ADDRESS
PPLIANCES- RESIDENTIAL 4.00
PANELS 10.00ONE #,5)79a - DATE OF APPLICATION
ARCHITECT +j Si
ORENGINEER
LIC. No.
PANELS LOVER 200 AMP) 20.00 PLAN CHECK FEE P.C. NO.
SIGNS TRANS. 3.00
ADDRESS ENG, SPECIALCIRCUIT 5.00 PERMITVp YiTh' 9Jfl.
gJ
EMP. METER OR POLE INS. 20.00ZIP
rSEP041985
City of Cupertino
APPLICANT'S
ADDRESS
7
MOTORS SEE FEE SCH.
SERVICE CHANGE 20.00
LICENSED CONTRACTORS DECLARATION TEMP. POLE 30,00
I hereby affirm that I am licensed under provisions of Chapter 9
commencing with Section 7000) -of Division 3 of the Business and
Professions Co e, a d m license is in full force and effect.
L' e se;Ja D- Lie. Number
D3t',-___ Contractor vgg=&J00_,
ISSUANCE DATE
BLDG. ELECT. PLG. M CfA
BUIL E
OWNER -BUILDER DECLARATION
I hereby affirm that I am exempt from the Contractor's License
Law for the following reason. (Sec. 7031.5, Business and 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 Contractors License
NINFOORMARMATIOON
MISC. - REFER TO ORD
VALUATION FT.
PERMIT ISSUANCE 10.00
ELEC. CONTR. LIC, NO. ELEC.
TOTAL PERMIT TO
QTY. PLUMBING PERMIT FEE
Law (Chapter 9 (commencing with Section 7000) ofDivision 3 of the
Business and Professions Code) or that he is exempt therefrom and
STORIEV TYPE ONSTR. 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 rive hundred dollars (5500).): ALTER -DRAIN &VENT -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.D0 OCC. GROUP RES. UNITS
intended or offered for sale (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 does such work
himself or through his own employees, provided that such improve
ments are not intended or offered forsate. If, however, the building
DRAINS -FLOOR, ROOF, AREA,COND. 5,00
FIXTURES - PER TRAP 5.00 SO. FT. FLOOR AREA TOTAL ACREAGE
GAS - EA. SYSTEM -1 INC.4 OUTLETS 6.00
or improvement is sold within one year of completion, the owner -
builder will have the burden of proving that he did not build orim- builder
prove for purpose of sale.).
q 1, as owner of the property, am exclusively contracting with
EA. SYSTEM -OVER 4 IEA.} 2,OD BUILDING USE
IND CON pe Other
ElEl 1:1 11INDUSTRIALWASTEINTER. 30.00
licensed contractors to construct the project (Sec. 7044, Business
and Professions Code: The Contractors License Law does not apply
to an owner of properly 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 contraeror(s) licensed pursuant to
the Contractors License Law. SEWER -SANITARY -STORM EA. 200ft/10.00 TRACT NO. PARCEL NO.
l am exempt under Sec. B.&P.C. for this WATER HEATER W/VENT 6.00
reason
Owner Date WATER SYSTEM 5.00 ACC. DATE ACC. FILE NO.
WORKERS'COMPENSATION DECLARATION WATER TREATING EQUIP. 5.00
1 hereby affirm that I have a certificate of consent to self -insure,
or a certificate of Workers' Compensation Insurance, or a certified ZONING ENG. SITE N0.
copth oE(5ec.3800, Lab.C.)
Poliyc o/r)fB L Company
PIKE SPAINK
Y N
ENERGY T44
Y N
Certified eOpy IS hereby furnished.
Certified copy is filed with the city inspection division.
Applicant MISC. - REFER TO ORD.
CERTIFICATE OF EXEMPTION 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
Y N Y N
QTY. MECHANICAL PERMIT FEE FEE SUMMARY
hundred dollars (S 100) or less:)
1 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.DD
NOTICE TO APPLICANT: if, after making this Certificate of Ex-
emption, you should become subject to the Workers' Compensation APPLIANCE 5.00 PLAN CHECK
provisions of the Labor Code, you must forthwith comply with
such provisions or this permit shall be deemed revoked.
FEEAIRHANDLINGUNIT (TO 10=CF. M.) 4.00
AIR HANDLING UNIT (OVER 10jD00C.F.M.) 6.00 SEISMIC FEECONSTRUCTIONLENDINGAGENCY
hereby affirm that there is a construction lending agency for
the performance of a work for which this permit is issued (Sec.
3097,Civ.C.).
Lender's Name
Lender's Address •
EXHAUST HOOD (WITH DUCT) 5.00 dG
MICROFILM
HEATING UNIT (TO 100,000 B.T,U.) 8.00
HEATING UNIT 100,000 B.T.U.19.5D ELECTRIC
q
1 certify that l have r a Is a`ppflca oltAl;a%%Te that the above VENTILATION FAN (SINGLE) 4.00 f,p p
information is correct. I agree to comply with all city and county
ordinances and state laws relating to building construction, and
PLUMBING
BOILER-ODMP(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- TAX
PERMIT ISSUANCE 10.00 /p,OO
grarQinW this permit. MECH. CONT. LIC. NO. MECH,
TOTAL J d TOTAL
Signatult4aLApplicantiContractor Date
OFFICE COPY