8505 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
BU LDI NG PROJECT 1 DENTI FICATI ON PERMIT NUMBER
BpILpINc APPLICATION & PERMIT
ADDRESS ^ /\
S Te}1i11 � BUILDING -ELECTRICAL-PLUMBING-MECHANICAL
OWNOR'S
NAME * PLAN CHECK VALIDATION
• BAS OF CUPERTINO P12DIEI 207 OTV. ELECTRIC PE RMIT FEE
NOAME AcroRs UTLETS-SWITCHES-
RECEP 10.00/1.00
U..NO.323864 LIGHTING FIXTURES 10.00/1.00
�t CONTRALTOfl'S �t
aooREss 20823 Stevens . Crl1 B1 Vd FFLIANCES-RESIDENTIAL 4.00
' PHONE PANELS 10.00 DATE OF APPLICATION
t
l OR PANELS (OVER 200 AMP) 20,00PLAN CHECK FEE P.C.NO.
ENGINEER PAID
t► L .No. SIGNS TRANS. 3.00
ADDRESS 18008 SKYPARK CR. #-200 SPECIALCIRCUIT 5.00 UUMVV L�§
CA ZIP 0971 1 O
L1§
R
EMP.METER OR POLE INS. 20.00 u�,r 4 U CD !
ADDRESS. 20823 Stevens Crk Blvd MOTORS SEE FEE SCH. Clfy Of Cupertino
qrmnu SERVICE CHANGE 20.00
woo LICENSED CONTRACTORS DECLARATION TEMP.POLE 30.00
¢ u u I hereby uflirm that 1 am licensed under provisions of Ch.,tcr'I y
w A e, (commeremy with Section 7000)of Division 3 of tilt Business and ISSUANCE DATE
r G Z Professions Coda,and my license is in full Cnrce and effect.
BLD ELECT.: PLG, MECH.
Z o w- License Class /]C 111 Lia Number-_'�..23 � .
9 w L w Date T/7+_Co/%9H'Bh�r_-Contractor_�a.S=� '
¢_ a w a OWNER-BUILDER DECLARATION
BUILDING PERMIT L
D MISC.- REFER TO ORD INFORMATION
'w g N 1 hereby'affirm that I am exempt from the Contractor's License
uOj Law for the following rcason.(Sec.7031.5.1;usintssand Professions VALUATION $/FT.
- PERMIT ISSUANCE 10.00
S �>f Code:Any city or county which requires a permit to construct.alter,
/
¢ ¢ o O improve,demolish.Or repair any structure,prior to its issuance,also ELEC.CONTR. LIC.N0. ELEC.
LL requires the applicant for such permit to it,a signal statem,nt that TOTAL
he is licensed pursuant to the provisions of the C.ntna:loi s License PERMIT TO
HZQ Law(Chapter 9(commmoculg with Section 7000)of Division 3.1111,
E O Business and Professions Code)or that he is exempt therefrom and QTY. PLUMBING PERMIT FEE '
¢ ithe basis for the allAny
F m alleged exemption,subjects
tsthea applicant
action malty a STORIES TY C TR.
a ; _ by any applicant fora permit dollars(he0).): unl macivil penalty ALTER-DRAIN -WATER (EA.) 5.00 /
III of not more than five hundred dollars(SS00)J:
1:- ❑ I,as owner of the property,or my employees with wages as OCC. UP S.UNITS I I I their sole compensation,will do the work,and the structure is not BACK FLOW PROTECT.DEVICE 4.00
intended or offered for sale (Sec. 7044, Business and Professions DRAINS-FLOOR,ROOF,AREA,CONO. 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 SO.FT.Ft.t* EA TOTAL ACREAGE
himself or through his own employees,provided that such insprove-
t eats are not intended or offered for sale.if,however,the building GAS-EA.SYSTEM-l1NC.40UTLETS 6.00
.I or impmvemenl is sold within oneyear of completion,lilt owner-
builder will have the burden of proving that hGAS-EA.SYSTEM-OVER 4 (EA.) 2.00 e did not build or no- BUILDING USE
prove:for purpose.I'salcJ' INDUSTRIAL WASTE INTER. 30.00 REs IND CON PB Curie,
❑" 1,as owner of the property,am exclusively contracting with ❑ ❑ ❑ ❑
1 . licensed cmitladors to construct the project(Sec. 7044,Business LAWN SPRINKLERS-1 INC 5 V.B. 6.00 ASSESSORS PARCEL NO.
1 and Professions Code:The Contractor's License Law does not apply
pallor owner of property who builds or improves thereon,and who LAWN SPRINKLERS-OVER 5(EA.) 1.00
/ contracts for such projects with a contractoos)licensed pursuant to SEWER-SANITARY-STORM EA.200ft/10.00
lire Contractors License Law. TRACT NO. PARCEL NO.
rca❑ I am exempt under Sec. ,B.SP.C.for this WATER HEATER W/VENT 6.00
son
Owner ')am WATER SYSTEM 5.00 ACd.ffATEV IACD FILE NO.
WORK ERS'COMPENSATION DECLARATION WATER TREATING EQUIP. 5.00
�l ,
I hereby alfininof Ilial I have a certificate I consent to a certified
I or a certificate.f Workers'Compensation Insurance,or a certified ZONING ENG.SITE NO.
rop¢yythereof(Sec.3800,Lab.C..
IF Cerr led, p i<sC We.d ur is led FIRE SPRINK ENERGY T 24
! z 2 Cer[ifi,•H `qpy IF Iv' I cti I I son.
O i Applicant nu _{J.r��� 1 MISC.- REFER TO ORD. v ❑ N❑ v ❑ NQ
".CC CB RTI F I CA11:01'1:X1:M PT ION PROM WOR K FRS' PERMIT ISSUANCE 10.00 FLOODZONE A.L.U.C.
W > COMITNSATION INSURANCE PLG,CONTR. LIC.NO. PLG.
d O (Phis section need not be completed if tire Permit is for one TOTAL Y❑ N❑ Y❑ N❑
Z 11 unit red doll ars(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 I- mit is issued,I Shall not employ any person in any manner so as to
i� U become subject to the Worker:Compensation Laws of California.
;i Date-Applicant ALTER OR ADD TO MECH. 5.00 BUILDING Q0
} N NOl'ICE TO APPLICANT: If,after making this Certificate at Lx-
(= ?, emption,you should become subject to the Workers'Compensation APPLIANCE
/- 1 provisions of the Labor Code, you most forthwith comply with 5.00 PLAN CHECK
U such provisions or this permit shall be dccnred revoked. AIR HANDLING UNIT(TO 10OMCF.M.) 4.00 FEE
CONST'RUCT'ION LENDING AGENCY AIR HANDLING UNIT(OVER 10=C.EM.) 6.00 SEISMIC FEE
.r I hereby affirm Oml 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. MICROFILM
` 3097,Cie C.). HEATING UNIT(TO 100,000 B.T.U.) 8.00
Lender's Name
Lender's Address HEATING UNIT(OVER 100,000 B.T.U.)9.50 ELECTRIC
' I certify that l have read this application and slate that Ore above VENTILATION FAN (SINGLE) 4.00
• information is correct. I agree to comply with all cily and county PLUMBING
ordinances and state laws relating to building construction, and BOILER-COMP(3 H.P.or 100,000 B.T.U.) 6.00
hereby authorize representatives for
of this city to enter upon the BOILER-COMP (Over 100,000 BTU)SEE FEE SCM. MECHANICAL
/ ahovamentioned property for vesp of this
purposes. -
(We) agree to save, indemnify and keep harmless the City of MISC.- REFER TO ORD.
{, Cupertino against liabilities,judgments, costs and expenses which CONST.TAX r�
,t may in any way accrue against Said City in consequence of the PERMIT ISSUANCE 10.00
granting Of this permit MECH.CONT. LIC.NO. MECH.
r TOTAL TOTAL G d
i nature o p Nor Data I Q �r
INSPECTOR COPY '
I