09633 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
BUILDING PROJECT lDENTIFICATION PERMIT NUMBER
BUILDING APPLICATION & PERMIT
ADDRESS
y 0' BUILDING - ELECTRICAL-PLUMBING-MECHANICAL y 3`r
OWNER'S - PLAN CHECK VALIDATION
"AME QTY. ELECTRIC PERMIT FEE
• CtJ�i) vrlorvE F .
CONTRACTORS OUTLETS-SWITCHES-RECEP 10.00/1.00
/.j d' uc.NO. ,E- LIGHTING FIXTURES 10.00/1.00
ADDRESS RS APPLIANCES 4.00
ADDRESS r
.� v NE A '4 7ya-5.1,e PANELS 10.00 DATE OF APPLICATION
ARCHDECT �. -9-�J PLAN CHECK FEE P.C.NO.
OR PANELS (OVER 200 AMP) 20.00
ENGINEER "
LIC.NO. SIGNS TRANS. 3.00
ARCH
.OR ENG. PERMIT VA 1
ADDRESS SPECIAL CIRCUIT 5.00 tf
ASZIP EMP. METER OR POLE INS. 20.00 SEP /p
ADDRESS S MOTORS SEE FEE SCH. �.4 1905
AOR E '
3 7 4 eR cf -�' SERVICE CHANGE 20.00 City Of Cupertino
'00 LICENSISD CONTRACTORS DECLARATION TEMP.POLE 30.00 pert)
a u. 1 hereby affirm that 1 am licensed under provisions o f Chapter 9 ISSUANCE DATE
H n
(commencing with Section 70001 of Division J of the Business and a BLDG. ELECT. PLG. MECH.
F m i Professions Co e,and my license is in full farce and effect. ❑ ❑ ❑
zO�, - License Class"a^'ao 'Con Number
O z Y o Daub-/O•d19f'A -2 Lie
Nu for
-3-P5
¢ a OWNER-B ILDER DECLARATION BUILDING PERMIT
a o d D INFORMATION
F
g LL m 1 hereby affirm that 1 am exempt from the Contractor's License MISC.- REFER TO ORD
ra sa Law for Ilia following reason.(Sec.7031.5,Bus inessand Professions PERMIT ISSUANCE 10.00 VALUATION $/FT.
rtCode:Any city or county which requires a permit to construct,utter, ELEC.OONTR, LIC.NO.¢ a o improve,demolish,or repair any structure,prior to its issuance,also ELEC.
6
w0 LL requires the applicant for R:CII permit to file 11 Signed state11 ent Ilial TOTAL PERMIT TO
Co he is licensed pursuant In tiro provisions of the Contrnclor i License
z r Law(Chapter 9(commencing with Section 7000)of Division 3 ofthe
a Business and Professions Code)or that he is exempt therefrom andQTY. PLUMBING PERMIT FEE
E i v
¢ $ the basis for the alleged exemption.Any violation of5eclion 7031.5 STORIES - TYPECONSTR.
to by any applicant for a permit subjects the applicant m oicivil penalty ALTER-DRAIN -WATER IEA.) 5.00
of not more than five hundred dollurs($500).)
Cl 1,as owner of the property,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 Structure is not
intended or offered for sale (Sec. 7044, Business and Professions DRAINS-FLOOR,ROOF,AREA,COND. 5.00
Code:"fire Contractor's License Law does not apply to an owner of
properly who builds Or improves thereon,and who does such work FIXTURES-PER TRAP 5.00 SD.FT.FLOOR AREA TOTAL ACREAGE
. .cuts re net hrough
ownemployees,for sake.
If.howevered that ,
the improve- GAS-EA.SYSTEM-11 NC.4 OUTLETS 6.00 ,
mems are not in[endeJ or offered for sole.IL however,the bui Wing
or improvement is sold within one year of completion, the owner- GAS-EA.SYSTEM-OVER 4 (EA.) 2,00
builder will have the burden of proving that he did not build or im- BUILDING USE
prove for purpose of sale.). INDUSTRIAL WASTE INTER3000 RE IND CON PB Other
. .
❑ 1,as owner of the property,am exclusively contracting with ❑ ❑ ❑ ❑
licensed contractors to construct the pfowr,(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 property who builds or improves thereon,and who LAWN SPRINKLERS-OVER 5 (EA.) 1.00
contracts for such projects with a contmetor(s)licensed pursuant to
the Contractor's License Law. SEWER-SANITARY-STORM EA.200ft/10.00 TRACT NO. PARCEL NO.
❑ lam 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.
WORK F;RS'COM PENSATION DECLARATION WATER TREATING EQUIP. 5.00
1 hereby affirm Thal 1 have a certificate ofconsent to sel&insure, ZONING Nx or a certificate of Workers'Compensation Insurance,or a certified ENG.SITE NO,
coPy thereof(Sec.3800,huh.C.l._
Policy Nn./�„9 ypLydomPn..y _
Q yy Cerlifled copy iz hereby funu5hed - FIRE SHRINK ENERGY T-H4
Z 2 ❑ Certified copy is fled with the city in pectlml division.
O Applicant MISC.- REFER TO ORD. Y ❑ N❑ Y [-] NEJ
~ rn PERMIT ISSUANCE 10.00
� - CIi RTIFICCOMOEEXITION IONPROMWORKfiRS' FLOOD ZONE A.LU.O
W COMPENSATION he coo INSU RA the PLG.CONTR. LIC.NO. PLG. ' Y N Y CD
D Z hundred
section need not he completed it the permit is lilr one TOTAL N
hundred dollars l8100)or less.)
U O 1 certify that in the performance of the work for which This per- QTY. MECHANICAL PERMIT FEE FEE SUMMARY
IL f- ' mil is issued,I shall not employ any person in any manner so as to
OL) become subject to the Workers'Compensation Laws of California.
d Date Applicant ALTER OR ADD TO MECH. 5.00 BUILDING
} to NOTICE TO APPLICANT: If,after making this Certificate of fix-
F'? emption,you should becumc subject to the Workers Compcnsatlmn 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=CF.M,) 4.00
CONSTRUCTION LENDING AGENCY AIR HANDLING UNIT(OVER 10MC.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 tet work lot which this permit is issued(Sec. MICROFILM
3097,Civ.C.). HEATING UNIT(TO 100,000 B.T.U.) 8.00 p p,
Lender's Name HEATING UNIT(OVER 100,000 B.T.U.)
Lem cr's Addres. ELECTRIC
fC�L"TIII2f�fia4renw�ihis application and slate That the above VENTILATION FAN (SINGLE) 4.00 ,l'.n,7
information is Correct- I agree to Comply with all city and county PLUMBING
ordinances and slate laws rcluting to building construction. and BOILER-COMP(3 H.P.or 100,000 B.T.U.) 6.00
hereby entimriee representatives lotiins inspection
this city es enter upon theaboveBOILER-COMP (Over 100,000 BTU)SEE FEE SCH. MECHANICAL
hereb m autiorizned property eforinsp of this
Purposes to,
(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 consequence of the /6.6 p
granting of this permit. MECH.CONT. LIC.NO. MECH.
���- f TOTAL TOTAL
Sqhl Appl nt/Contractor ISatc
INSPECTOR COPY
I