7262 APPLICANT TO FILL IN,I RMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
BUILDING PROJECT IDENTI TION PERMIT NUMBER
ADILDING APPLICATION & MIT
DDRES
(Y-J DING=ELECTRICAL—PLUMBING—MECHANICAL
O NEP'$ 7262
'NPM PLAN CHECK VALIDATION
/It f(,,) �fr TY ELECTRIC PERMIT FEE -
oNE Df
CONTRACTORS -
N M OUTLETS-SWITCHES-RECEP 5.00/1.00
LIC.rvo. —/ LIGHTING FIXTURES 5.00/1.00
copgRAcroR's - .. APPLIANCES-RESIDENTIAL 4.00
PHON PANELS5.00 DATE OF APPLICATION'
ARCRIT CTt ff.y{�r 01 PLAN CHECK FEE P.C.NO.
OR ,g1riY�,F� /�/�( SIGNS� � 6.00 � ,
ENGIrvEER I
uc.NO SIGNS TRANS. 3.00
AENG. PERMIT VALIDATION
ADDRESS
oREss SPECIAL CIRCUIT 5.00 p _
` zIr ITEMP.METER OR POLE INS. 15.00 6190�,'
APPLICANT'$ -
ADDRESS MOTORS SEE FEE SCH.
SERVICE CHANGE 10.00 - I{y /`❑'U O{ne
'0o LICENSED CONTRACTORS DECLARATION �
a z W I hereby,off irm that I am licensed under provisions of Chapter 9 1, ISSUANCE DATE
,Ha< H (mmm 'encg witlI.Sectimn 7000)of Division 3 of the Business and BLDG. ELECT. PLG. MECH.
H w z ProfeLicense ode d my license is in full for f J - ❑ ❑, /
2 o m 0- License Lin Number,_ fs ,- l
-il
H w ale Contractor CI ofCupertino Q y
¢ ¢ w a -BUILDER DECLARATION BUILD,ING'PERMIT.'.4a;;x�
MISC,— ,'REFER TO ORD INFORMATION."
I that 1 am exempt from the Contractor's License VALUATION $/FT.'
F +. o a L or 1 re o1 wing reason.(Sea 7031.5,Business and Professions PERMIT ISSUANCE 6.00
Code:Any cit or county which requires a permit to construct. ]let,
ce X 4 D improve,demolish,or repair any structure,prior to its issuance,also ELEC.CONTR. 'L IC.'NO.
ELEC. /
mLL requires the applicant for such permit to file a signed Statement that TOTAL PERMIT TO
n w he is licensed pursuant to the provisions of the Conlractor:s License
F,z 't0
Law(Chapter 9(commencing with Section 7000)of Division 3 ofthe /-V r /CPQ
j 4 O Business'and Professions Code)or that Ire is exempt therefrom and QTY. PLUMBING PERMIT FEE ON/J•6r'�
X r $ the basis for the alleged exemption.Any violation of Section 703 L5 STORI .TYPE CONSTR
d by any applicant for a permit subjects the applicant to a civil penalty ALTER-DRAIN -WATER (EA.).q,00 A
of not more than five hundred dollars($500).):
❑ I,as owner, r the property,or my employees with wages as - BACK FLOW PROTECT.DEVICE 2,00 OCC.GROUP"
their snit compensation,will the work,and the structure is not RES.UNITS
intended or offered for sale(Sec.,7044, Business and Professions DRAINS-FLOOR,ROOF,AREA,CONE). 4.00
Code:The Contractor's License Law does not apply to an owner of
property who builds or improves[hereon,and who does such work FIXTURES PER TRAP 4.00 I' S0,FT.FLOORAREA TOTALACREAGE
himself or through his own employees,provided that such improve-
mentsamnotintendedorofferedforsale.If,however,the building GAS-EA.SYSTEM-1 1 NC.4 OUTLETS 4.00.
or improvement is sold within one year of completion,the owner,
budder will have the burden of proving that he did not build or im- GAS-EA.SYSTEM-OVER 4(EA.) 1.00 BUILDING USE
prove for purpose of sale.). INDUSTRIAL WASTE INTER:. RES IND CON' ;PB .mar
❑ Las owner of the property, 20.00 ❑ ❑ ❑' ❑
p p y,am exclusively contracting with.
licensed emotmcmrs to construct the projeel'(Sce. 7044,Business LAWN'SPRINKLERS.-1 INC 5 V.B. 5.00. 'ASSESSOR
and Professions Code:The Contractor's License Law does not apply S PARCEL NO. "
to an owner of propefty.who'builds or improves thereon,and who LAWN SPRINKLERS-OVER 5(EA.) ' im '
contracts for such projects with a contractorts)licensed pursuant to
the Contractor's License Law. SEWER-SANITARY-STORM EA.200ft/8.00 TRACT NO. PARCEL NO.
❑ lam exempt under Sea ,B.&P.0 for this reason WATER HEATER W/VENT, 4.00
Owner Date WATER SYSTEM 4.00
ACC.DATE ACC.FILE NO.
WORK ERS'COMPENSATION DECLARATION , WATER TREATING EQUIP: 4.00 - )
I hereby affirm that I have a certificate of consent to self-insure,
or a certificate of Wmrs'9/6mpensalion Insurance,or a certified - ZONING ENG.SITE NO.
copy the40t
,LSD CJ.
Policy ea C '
Q. ❑ Cenonshed' FIRE SPRINK ENERGY T-24
z ❑ C •d with the city inspection division.
F,— Applican - MISC.: REFER TO ORD. Y ❑ N❑ Y � NQ
CC y CF EXEMPTION FROM WORKERS' PERMIT ISSUANCE 6.00 FLOOD ZONE A.Lu.C.
LU >' ENSATION INSURANCE PLG.CONTR: LIC.NO. PLG.
d O (This he completed if lire permit is for one TOTAL v 'N V N
0 Z hundredorlessJ
U O 1 certify that inthe performance of the work for which this per- CITY. MECHANICAL PERMITFEE FEE SUMMARY
LL F- mil is issued,I shall not employ any person in any manner so as to
O W become subject to the Workers'Compensation Laws of California.
Ill. Date - Applicant ALTER OR ADD TO MECH. 4.00 BUILDING 3�sS'+�
} In NOTICE *10 APPLICANT: If,after making this Certificate of Ex-
? emption,you should become subject to the Workers'Compensation APPLIANCE 4.00 PLAN CHECK
provisions of the Labor Code, you must forthwith comply with
U Such provisions or this perm[shall be deemed revoked. AIR HANDLING UNIT(TO 10,ODDC.F.M.) 3.00 FEE
CONSTRUCTION LENDING AGENCY AIR HANDLING UNIT(OVER 10=C.RM.) 5.00 SEISMIC FEE
I hereby affirm that there is a construction lending agency for EXHAUST HOOD (WITH DUCT) - 2.00
the performance of the work for which this permit is issued(Sec. MICROFILM
3097,Civ.C.). HEATING UNIT(TO 100,000 B.T.U.) 4.00
Lender's Name
Lender's Address HEATING UNIT(OVER 100,000 B.T.U.P.50 'ELECTRIC
I certify that l have read lIds application and state that the above VENTILATION FAN (SINGLE) 3.00
information is correct. I agree to comply with all city and county PLUMBING
ordinances and state laws relating to building construction, and BOILER-COMP(3 H.P.or 100,000 B.T.U.) 4:00
hereby authorize repro tatforinspection
s of this city,to enter upon the BOILER-COMP (Over 100,000 BTU)SEE FEE SCM. MECHANICAL
hereby
mcut. •d to y for inspe f this
purposes.
(We) emnify and keep harmless the City of MISC.- REFER TO ORD.
Cuper' ' dements, costs and expenses which CONST.TAX
ma against said City in cons entree of the 'PERMIT ISSUANCE 300
'a�/ MECH.CONT. LIC.NO. TOTAL
licant/Contractor Date TOTAL S�
• OFFICE COPY' -
APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
BUILDING PROJECT IDENTIFICATION PERMIT NUMBER BUILDING APPLICATION & PERMIT
'
ADOfl ES
-- C I DING - ELECTRICAL-PLUMBING-MECHANICAL 262
Gas...P PLAN CHECK VALIDATION
NAM• PHONE\�'II/1,llIJ)(, yy -zb TY. ELECTRIC PERMIT FEE
NorMrRAcron UTLETS-SWITCHES-RECEP 5.00/1.00
uc.No. / LIGHTING FIXTURES 5.00/1.00 "
cONrRACTDRs
A PPLIANCES-RESIDENTIAL 4.00
1 O
�ONE , PHON S _ PANELS 5.00 DATE OF APPLICATION
ARCHIT CTSIGNS 6.00 PLAN 5 CHECK OR P.0 N0.
R Igr'rN /1/ `F01�NGINEER f
1 uc.No. . SIGNS TRANS. 3.00
nooaEss ENG' SPECIAL CIRCUIT 5,0D PERMIT VALIDATION
ZIP rFEMP.METER OR POLE INS. 15.00 I
AMOTORS SEE FEE SCH.
AODRESS DRE55
SERVICE CHANGE 10.00 �` _ G
�0 0 LICI!NSIiD CONTRACTORS DECLARATION l "/��/O
a u w I hereby affirm that I am licensed under provisions of Chnplcr 9 ISSUANCE DATE 1
H G (,mnunan,irle with Section 7000)of Division 3 of lh Buxi ss and BLDG. ELECT. PLG. MECH.
H m z Proferiou ;ride-' d my license is in full for
z o w- ADate
Lie Number
o H w / Contractor
a yi•�.., ! BUILDING PERMIT
m w
-BUILDER DECLn RAnoR INFORMATION
w5.o a y 1 lhW I :un exec t from the Contractor's License MISC.- REFER TO ORD F VALUATION $/FT.
o ¢ wing ruuson.'(Su.703 L5,Business anA l'rnfesslons pERMyT ISSUANCE 6.00 v
Ecoo Code!Anycll or county which requimsa permit to construct,alter, ? dv-u
re <o improve,demolish,or repair any structure,prior to its issuance,also ELEC.CONTR. LIC.NO. ELEC. V
u requires the lipplicant for such permit to file a signed statement that T `i
` wOTAL PERMIT TO
m he is licensed Iursuant to the provisions of the Contractor's License
r z i
Law(Chirpier 9fpomm0)
encing with Section 700of isi
Divon 3of the
Z, o Business and Pro Rssions Code)or teat he is exempt themfront and QTY. PLUMBING PERMIT FEE u2/1G1.- .lT•w
m r o the basis for the allegicl'exemption:Any violation of Section 7031.5 STORIeT TYPE CONSTR.
i,:u2 by any applicant for a permit subjects the applicant toa civil penalty gLTER-DRAIN -WATER (EA.) 4.00
of not more than five hundred dollars($500).):
❑ 1,as owner of the property,or my employees with wages as BACK FLOW PROTECT.DEVICE 2.00 OCC.GROUP RES.UNITE
their sole compensation.will do the work,and the structure is not
intended or offered for sale (Sec. 7044, Business and Professions DRAINS-FLOOR,ROOF,AREA,COND. 4.00
Code:'file 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 4.00 SO,FT.FLOOR AREA TOTAL ACREAGE
• himselfor through his own employees,provided that such improve-
us .
menare not intended or offered for sale.If,however.the building GAS-EA.SYSTEM-1 4.00
or improvement is sold within one year of completion, the owner- GAS-EASYSTEM-OVER (EA.) 1.00 BUILDING USE
builder will have the burden of proving that he did not build or im . RES IND CON PB Omer
prove for purpose ofmle.). INDUSTRIAL WASTE INTER
❑ 1,as owner of tiro property,am exclusively contrucling with . 20.00 ❑ ❑ ❑ ❑ ❑
licensed contractors to construct the project(Sec. 7044,Business LAWN SPRINKLERS- 1 INC 5 V.B. 5.00 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
contracts for such projects with a contmetorls)licensed pursuant to
the Contractor's License Law. SEWER-SANITARY-STORM EA.200ft/8.00 TRACT NO. PARCEL NO.
❑ 1 an exempt under Sec B.&P.C.for this WATER HEATER W/VENT 4:00
mason
Owner Date WATER SYSTEM 4.00 ACC.DATE ACC.FILE NO.
WORK ERS'COM PENSATION DECLARATION IWATER TREATING EQUIP. 4-00
1 hereby affirm flat I have a certificate of consent to self-insure, - ZONING
cerliflca[e of Wor rs' mpensalion Insurance;or a certified ENG.SITE NO."
-f copy thcreof(Scu.3 ,L' C .
Policy No. II a
O ❑ Cenified ' ruin ca. FIRESPRINK ENERGY T 24
Z Z ❑ Curlifie d with the city inspection division. MISC.- REFER TO ORD.
O? Applicant Y ❑ N❑ Y ❑ N❑
CC W CI, OE 1 NEMP1'ION FROM WORKERS' PERMIT ISSUANCE 6.00 FLOOOZONE A.L.U.C.
LU > PENSATION INSURANCE PLG.CONTR. LIC.NO. PLG.
CL Z (This Wolin cud nut be completed if the pe nn if is lin one TOTAL Y❑ NE] Y ❑ No
hundred dollar 8100)or less.)
U O• 1 certify that in the performance of the work for which this per- DTV. MECHANICAL PERMIT FEE FEE SUMMARY
LL F - mit is issued, I shall not employ any person in any manner so as to
become subject to the Workers'Compensation Laws of California.
O LU BUILDING
O_ Date Appli,tial ALTER OR ADD TO MECH. O 4.00
}.m NOTICE 10 APPLICANT: IL after making this Certificate of Ex-
Z empfion,you should become sweet to to Workers'Compensation APPLIANCE 4.00 PLAN CHECK
provisions of the Labor Code, you must forthwith comply with FEE
CJ such provisions or this permit shall be deemed revoked. AIR HANDLING UNIT(TO 10=C.F.M.) 3-00
CONSTRUCTION LENDING AGENCY AIR HANDLING UNIT(OVER 10MIC.F.M.) 5.00 SEISMIC FEE S�
I hereby affirm Hct Ilene is a construction lending agency for EXHAUST HOOD(WITH DUCT) 2.00
the Pcrlinmance.of the.work for which this permit is issued(Sec. MICROFILM
3097,Civ.C.). HEATING UNIT(TO 100,000 B.T.U.) 4.00
Lenders Name - 'H EATI NG UN IT(OV ER 100,000 B.T.U.)7.50
Lender's Address ELECTRIC
I curtly that I have read this application and nate that the above VENTILATION FAN (SINGLE) 9,00
• information is correct. I agree to comply with all city and county PLUMBING
ordinances and state laws relating to building construction, and BOILER-OOMP(3 H.P.or 100,000 B.T.U.) 4.00
hemby aufhmize repro,((moves of this city to enter upon the BOI LER-COMP(Over 100,000 BTU)SEE FEE SCH. MECHANICAL
above-menti d prop y I'or inspection purposes.
(We) a unify and keep harmless the City of MISC.- REFER TO ORD.
Cuper' gmenls, costs and expenses which CONST.TAX
ma against said City in consequence of the PERMIT ISSUANCE 3.00
�-^ MECH.CONT. LIG NO. MECH.
TOTAL TOTAL S
licant/Contractor Date
INSPECTOR COPY 1
APPLICANT TO FILL IN,I RMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
BUILDING PROJECT IDENTI TION PERMIT NUMBER
ADILDING APPLICATION & MIT
DDRES
(Y-J DING=ELECTRICAL—PLUMBING—MECHANICAL
O NEP'$ 7262
'NPM PLAN CHECK VALIDATION
/It f(,,) �fr TY ELECTRIC PERMIT FEE -
oNE Df
CONTRACTORS -
N M OUTLETS-SWITCHES-RECEP 5.00/1.00
LIC.rvo. —/ LIGHTING FIXTURES 5.00/1.00
copgRAcroR's - .. APPLIANCES-RESIDENTIAL 4.00
PHON PANELS5.00 DATE OF APPLICATION'
ARCRIT CTt ff.y{�r 01 PLAN CHECK FEE P.C.NO.
OR ,g1riY�,F� /�/�( SIGNS� � 6.00 � ,
ENGIrvEER I
uc.NO SIGNS TRANS. 3.00
AENG. PERMIT VALIDATION
ADDRESS
oREss SPECIAL CIRCUIT 5.00 p _
` zIr ITEMP.METER OR POLE INS. 15.00 6190�,'
APPLICANT'$ -
ADDRESS MOTORS SEE FEE SCH.
SERVICE CHANGE 10.00 - I{y /`❑'U O{ne
'0o LICENSED CONTRACTORS DECLARATION �
a z W I hereby,off irm that I am licensed under provisions of Chapter 9 1, ISSUANCE DATE
,Ha< H (mmm 'encg witlI.Sectimn 7000)of Division 3 of the Business and BLDG. ELECT. PLG. MECH.
H w z ProfeLicense ode d my license is in full for f J - ❑ ❑, /
2 o m 0- License Lin Number,_ fs ,- l
-il
H w ale Contractor CI ofCupertino Q y
¢ ¢ w a -BUILDER DECLARATION BUILD,ING'PERMIT.'.4a;;x�
MISC,— ,'REFER TO ORD INFORMATION."
I that 1 am exempt from the Contractor's License VALUATION $/FT.'
F +. o a L or 1 re o1 wing reason.(Sea 7031.5,Business and Professions PERMIT ISSUANCE 6.00
Code:Any cit or county which requires a permit to construct. ]let,
ce X 4 D improve,demolish,or repair any structure,prior to its issuance,also ELEC.CONTR. 'L IC.'NO.
ELEC. /
mLL requires the applicant for such permit to file a signed Statement that TOTAL PERMIT TO
n w he is licensed pursuant to the provisions of the Conlractor:s License
F,z 't0
Law(Chapter 9(commencing with Section 7000)of Division 3 ofthe /-V r /CPQ
j 4 O Business'and Professions Code)or that Ire is exempt therefrom and QTY. PLUMBING PERMIT FEE ON/J•6r'�
X r $ the basis for the alleged exemption.Any violation of Section 703 L5 STORI .TYPE CONSTR
d by any applicant for a permit subjects the applicant to a civil penalty ALTER-DRAIN -WATER (EA.).q,00 A
of not more than five hundred dollars($500).):
❑ I,as owner, r the property,or my employees with wages as - BACK FLOW PROTECT.DEVICE 2,00 OCC.GROUP"
their snit compensation,will the work,and the structure is not RES.UNITS
intended or offered for sale(Sec.,7044, Business and Professions DRAINS-FLOOR,ROOF,AREA,CONE). 4.00
Code:The Contractor's License Law does not apply to an owner of
property who builds or improves[hereon,and who does such work FIXTURES PER TRAP 4.00 I' S0,FT.FLOORAREA TOTALACREAGE
himself or through his own employees,provided that such improve-
mentsamnotintendedorofferedforsale.If,however,the building GAS-EA.SYSTEM-1 1 NC.4 OUTLETS 4.00.
or improvement is sold within one year of completion,the owner,
budder will have the burden of proving that he did not build or im- GAS-EA.SYSTEM-OVER 4(EA.) 1.00 BUILDING USE
prove for purpose of sale.). INDUSTRIAL WASTE INTER:. RES IND CON' ;PB .mar
❑ Las owner of the property, 20.00 ❑ ❑ ❑' ❑
p p y,am exclusively contracting with.
licensed emotmcmrs to construct the projeel'(Sce. 7044,Business LAWN'SPRINKLERS.-1 INC 5 V.B. 5.00. 'ASSESSOR
and Professions Code:The Contractor's License Law does not apply S PARCEL NO. "
to an owner of propefty.who'builds or improves thereon,and who LAWN SPRINKLERS-OVER 5(EA.) ' im '
contracts for such projects with a contractorts)licensed pursuant to
the Contractor's License Law. SEWER-SANITARY-STORM EA.200ft/8.00 TRACT NO. PARCEL NO.
❑ lam exempt under Sea ,B.&P.0 for this reason WATER HEATER W/VENT, 4.00
Owner Date WATER SYSTEM 4.00
ACC.DATE ACC.FILE NO.
WORK ERS'COMPENSATION DECLARATION , WATER TREATING EQUIP: 4.00 - )
I hereby affirm that I have a certificate of consent to self-insure,
or a certificate of Wmrs'9/6mpensalion Insurance,or a certified - ZONING ENG.SITE NO.
copy the40t
,LSD CJ.
Policy ea C '
Q. ❑ Cenonshed' FIRE SPRINK ENERGY T-24
z ❑ C •d with the city inspection division.
F,— Applican - MISC.: REFER TO ORD. Y ❑ N❑ Y � NQ
CC y CF EXEMPTION FROM WORKERS' PERMIT ISSUANCE 6.00 FLOOD ZONE A.Lu.C.
LU >' ENSATION INSURANCE PLG.CONTR: LIC.NO. PLG.
d O (This he completed if lire permit is for one TOTAL v 'N V N
0 Z hundredorlessJ
U O 1 certify that inthe performance of the work for which this per- CITY. MECHANICAL PERMITFEE FEE SUMMARY
LL F- mil is issued,I shall not employ any person in any manner so as to
O W become subject to the Workers'Compensation Laws of California.
Ill. Date - Applicant ALTER OR ADD TO MECH. 4.00 BUILDING 3�sS'+�
} In NOTICE *10 APPLICANT: If,after making this Certificate of Ex-
? emption,you should become subject to the Workers'Compensation APPLIANCE 4.00 PLAN CHECK
provisions of the Labor Code, you must forthwith comply with
U Such provisions or this perm[shall be deemed revoked. AIR HANDLING UNIT(TO 10,ODDC.F.M.) 3.00 FEE
CONSTRUCTION LENDING AGENCY AIR HANDLING UNIT(OVER 10=C.RM.) 5.00 SEISMIC FEE
I hereby affirm that there is a construction lending agency for EXHAUST HOOD (WITH DUCT) - 2.00
the performance of the work for which this permit is issued(Sec. MICROFILM
3097,Civ.C.). HEATING UNIT(TO 100,000 B.T.U.) 4.00
Lender's Name
Lender's Address HEATING UNIT(OVER 100,000 B.T.U.P.50 'ELECTRIC
I certify that l have read lIds application and state that the above VENTILATION FAN (SINGLE) 3.00
information is correct. I agree to comply with all city and county PLUMBING
ordinances and state laws relating to building construction, and BOILER-COMP(3 H.P.or 100,000 B.T.U.) 4:00
hereby authorize repro tatforinspection
s of this city,to enter upon the BOILER-COMP (Over 100,000 BTU)SEE FEE SCM. MECHANICAL
hereby
mcut. •d to y for inspe f this
purposes.
(We) emnify and keep harmless the City of MISC.- REFER TO ORD.
Cuper' ' dements, costs and expenses which CONST.TAX
ma against said City in cons entree of the 'PERMIT ISSUANCE 300
'a�/ MECH.CONT. LIC.NO. TOTAL
licant/Contractor Date TOTAL S�
• OFFICE COPY' -