09535 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
BU LD1 NG PROJECT I DENT]FICATION PERMIT NUMBER
BuTDING
ADDRESS APPLICATION & PERMIT 09535
ADDRESS
ce 4c, . 16
BUILDING - ELECTRICAL-PLUMBING-MECHANICAL
wNE PLAN CHECK VALIDATION
NAME QTY. ELECTRIC PERMIT FEE
.f PRONE b 7�_7V)f
NAME ACT s OUTLETS-SWITCHES-RECEP 10.00/1.00
Q- -LC
.No. LIGHTING FIXTURES 10.00/1.00
AR
ADDRESSSS
DN PPLIANCES-RESIDENTIAL 4.00
PHONE PANELS 10.00 DATE OF APPLICATION
PRC E PANELS (OVER 200 AMPI 20.00 PLAN CHECK FEE P.C.NO.
ENGINEER
LIC.No. SIGNS TRANS. 3.00
ADDRESS ENG' SPECIAL CIRCUIT 5.00 PERMIT`j9F, Tp°r
ZIP EMP.METER OR POLE INS. 20.00 AUG
1
ADDRESS MOTORS SEE FEE SCH. AUG 2 3 1965
AoonCA J8
SERVICE CHANGE 20.00
o o LICENSED CON TRACTORSDECLARA'I DON TEMP.POLE 30.00 . City Of Cupertino
a o w I hereby affirm that I am licensed under provisions of Chapter 9 ISSUANCE DATE
,o a N (commencing with Section 7000)of Division 3 of the Business and BLDG. ELECT. PLG. MECH.
r w z Professions Code,an(Lm_y license is in full force and effect.
o i m W License Class Lic.Number_@L�(,�1
Dute Contractor
a r E BUILDING PERMIT
¢ ¢ a OWNER-BUILDER DECLARATION
o d v INFORMATION
w 3 LL H 1 hereby affirm that 1 um exempt from the Contractor's License MISC.- REFER TO ORD
LLoj Law for the following reason.lSec.7071.5,Businessund Profession, • PERMIT ISSUANCE 10.00 VALUATION SIFT.
Code:Any city or county which requiresa permit Lnconsom,r ht.,
Q ¢ <a improve,demolish,or repair any structure,prior to its issuance,also ELEC.CONT R. LIC.NO. ELEC.
ir m LL requires the applicant for such permit to filo o signed statement that TOTAL PERMITTO
d w he is licensed pursuant to the provisions of the Contractor's License
FiQ
Law(Chapter 9(commencing with Sectimi 7000)of Division 3 ofthe
4 o Business and Professions Cod,)or that lie is exempt therefrom and QTY. PLUMBING PERMIT FEE
¢ r o the basis for the alleged exemption.Any violation ol'Section 7031.5 STORIES TYPE CONSTR.
u ; m by any applicant for a permit subjects ate applicant to a civil penalty ALTER-DRAIN -WATER (EA.) 5.00
of not more than five hundred dollars(5500).1:
❑ L 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 far Sale (Sec. 7044, Business and P,ol'essions DRAINS-FLOOR,ROOF,AREA,COND. 5.00
code*The Contractor's Liconsc Law docs not ally to an owner of
property who builds or Improves thereon.and who dries such work Q FIXTURES-PER TRAP 5.00 () 50.FT.FLOOR AREA TOTAL ACREAGE
himself or through his own employees,provided Ilwt such improv,
meets are not intended or offered for sale.It,however,the building GAS-EA.SYSTEM-1 INC.40UTLETS 6.00 00
or improvement is sold,within ooa year of conbplclion, the owner. GAS-EA.SYSTEM-OVER 4(EA.) 2.00 BUILDING USE
builder will have lire burden of proving than he did not build or int-
proveforpurposeofsale')' INDUSTRIAL WASTE INTER. 30.00 RES IND CON PB Omer
❑ 1,as owner of the property,am exclusively contracting with ❑ ❑ ❑ ❑ ❑
licensed 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 docs 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 coninclocs)licensed Pursuant to ll//,,
the Contract.,',License Law. SEWER-SANITARY-STORMEA.200ft/10.00 W TRACT NO. PARCEL NO.
❑ l am exempt under Sec.-,B.&P.C,tib,this WATER HEATER W/VENT 6.00
reason
Owner Date WATER SYSTEM 5.00 ^d0 ACC.DATE ACC.FILE NO.
W'ORKERS'CO.NPENSATION DECLARATION WATER TREATING EQUIP. 5.00
I hereby utfirm that 1 have a certificate of consent to self-insure. ZONING ENG.SITE NO.
or a certificate of Workers'Compensation Insurance,or a certified
copy thereof(Sec 3800,Lab C.).
Policy No. Company
Q ❑ Certified copy is hereby furnished. FIRE SPRINK ENERGY T$4
Z 2 9. Cenifed�opy is filed with the city inspection division. ❑ ❑ ❑ ❑
O A ican.1 n('g eta/g RISC.- REFER TO ORD. Y N v N
~ w .�_ PERMIT ISSUANCE 10.00 W
LU CIiRTIFlGO.NiPENEXEMPIWION INS FROM WORKERS' FLOOD ZONE a.L.U.C.
W > CO\IPIiNSATION INSURANCE PLG.CONTR. � LIC.NO. PLG. f�•11
CL O (This section need not be completed if the permit is for one TOTAL VV Y❑ N❑ Y ❑ N❑
Z hundreJ dollars(5100)or less.)
U O I certify that in the performance of the work for which this per- QTY. MECHANICAL PERMIT FEE FEE SUMMARY
LL H mit is issued,I Shall not employ any person in any manner so as to
U become subject to the Workers'Compensation Laws of California.
ad Date Applicant BUILDING
Q.
} to NOTICE TO APPLICANT: If,after raking this Certificate of Ex- ALTER OR ADD TO MECH. 5.00
r 2 emption,you should become subject to the Workers'Compensation APPLIANCE 5.00 PLAN CHECK
provisions of the Labor Code, you must loxthwith comply with FEE
CJ such provisions or this permit shall be deemed revoked. AIR HANDLING UNIT(TO 10=C.F.M.) 4.00
CONS'fRUC1'ION LENDING AGENCY AIR HANDLING UNIT(OVER 10=C.F.M.) 6.00 SEISMIC FEE
I hereby uIfirn that there is a construction lending agency lox EXHAUST HOOD (WITH DUCT) 5.00
the performance of the work for which this purnit is issued(Sec. - MICROFILM
3097,CN.C.). HEATING UNIT(TO 100,000 B.T.U.) 8.00
Lender's Name HEATING UNIT(OVER 100,000 B.T.U.)Lenders Address ELECTRIC
I cenil'y that I have read this application and State that the above VENTILATION FAN (SINGLE) 4.00 p�E)
• information is correct. I agree to comply with all city and county PLUMBING V Ly
oninances and state laws relating to building construction, and BOILER-COMP(3 H.P.or 100,000 B.T.U.) 6.00
hereby authorve representatives of this city to enter upon the BOILER-COMP lover 100,000 BTU)SEE FEE se H. MECHANICAL
above-mentioned property Ibr inspection purposes
(Wu) agree to save, indemnify and kucp lizrnticss the City of MISC.- REFER TO ORD.
Cupertino against liabilities,judgments, costs and uxpenses which PERMIT ISSUANCE 10.00 CONST.TAX
may in any ay accrue ugaimst said City in consequence of the
".RI t t permit. MECH.CONT. LIC.NO. MECH.
�Oed `6 b lIn TOTAL TOTAL
Sig / �anl/Contractor Date `
INSPECTOR COPY
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APPLICANT TO FILL IN INFORMATION WITHIN RED LINES -USE BALL POINT PEN ONLY
BUILDING PROJECT I DENTI FICATION
SU[ D&G APPLICATION & PERMIT
AO RE S
BUILDING - ELECTRICAL -PLUMBING -MECHANICAL
PERMITNUMBER
p 9535
OWNER'S
r
NOW PHONE Jyj-f QTY. ELECTRIC PERMIT FEE
PLAN CHECK VALIDATION
CONTFIACrOR'S
NAME OUTLETS -SWITCHES -RECEP 10.0011.00
LIGHTING FIXTURES 10.0011.00I(
J'!}
Ic,NO.
CONTRACTOR'S
AOUjjE55 PPLIANCES- RESIDENTIAL 4.00
PANELS 10.00
rJ
r, PHON _26 DATE OF APPLICATION
ARCHITECT-
ORPANELS
ENGINEER
Llc. No.
OVER 200 AMP) 20.00 PLAN CHEL AIDyljl
P,C.NO.
SIGNS TRANS. 3.00
ADDRESS ENG' SPECIAL CIRCUIT 5.00 It
j0t1i
EMP. METER OR POLE INS. 20.00ZIP
City Of CIlp8 IR0AN75ADDRESSMOTORSSEEFEESCH.
SERVICE CHANGE 20.00
LICENSED CONTRACTORS DECLARATION TEMP. POLE 30,00
1 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, an license is in full force a
License ss Lie. Number
ISSUANCE DATE
SLOG. ELECT. PLG. MECH,,
Dale Contractor
BUILDING PERMIT
INFORMATIONOWNER -BUILDER -DECLARATION
T hereby affirm that [ 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 Contractor's License
MISC. - REFER TO ORD
PERMIT ISSUANCE 10.00
VALUATION SIFT.
ELEC. CONTR. LIC. N0. ELEC,
TOTAL PERMIT TO
QTY. PLUMBING PERMIT FEE
Law (Chapter 9 (commencing with Section 7000) of Division 3 ofthe
Business and Professions Code) or that he is exempt therefrom and IL
STORIES T PE CONSTR. the basis for the alleged exemption. Any violation of Section 7031.5
by any applicant for a permit subjects the applicant toa civil penalty
of not more than five hundred dollars ($500).): 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 F LOW PROTECT, DEVICE 4,00 OCC. GROUP RES. UNITS
DRAINS -FLOOR, ROOF, AREA, COND. 5.00intendedorofferedforsale (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 for sale. If, however, the building
F,IXTUR ES - PER TRAP 5•QO SO FT. FLOOR AREA TOTAL'ACREAGE
GAS - EA. SYSTEM -1 1NC.4 OUTLETS 6.00 GVU
or improvement is sold within one year of completion, the owner
builder will have the burden of proving that he did not build or im-
prove for purpose o f safe.).
Li 1, as owner of the property, am exclusively contracting with
GAS - EASYSTEM OVER 4 (EA.) 2.00 BUILDING use
RES IND CON PB ocher
I N D UST R I A L WASTE INTER. 30.00
licensed contractors. to construct the project '(Sec.7044,Business
and Professions Code: The Contractor's Lice nsc Law does not apply
to an owner of property who huilds or improves [hereon, and who
LAWN SPRINKLERS -1 INC5 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 Contractors License Law. SEWER -SANITARY -STORM EA. 2t1 1000 . SEWER S[V[TARYT00fAQ TRACT NO. PARCEL NO.
L am exempt under Sec. B.&P.C. for this
reason
WATER HEATER WJVENT 6.00
Owner Date WATER SYSTEM 5.00 ACC. DATE ACC. FILE NO.
WATER TREATING EQUIP. 5.00WORKERS'COMPENSATION DECLARATION
1 hereby affirm that I have a certificate of consent to self -insure,
or a certificate of Workers' Compensation Insurance, ora certified ZONING ENG. SITE NO.
copy thereof (Sec. 3800, Lah.C.).
Policy No- Company
FIRE SPRINK
Y N
ENERGY T•Za
Y E)N
Certified copy Is hereby furnished.
Certifte p s filed wiy r the city inspection division.
AFp cantT iL(•p\ MISC. - REFER TO ORD.
CERTIFICATE OF EXEMPTION FROM WORKERS' PERMIT ISSUANCE 10.00 FLOODZONE A.I_u.C,
PLG, CONTR. LIC. NO. PLG.
TOTAL
COMPENSATION INSURANCE
This scctidn need not be completed if the permit is for one
Y N Y N
hundred dollars (S 100) or less.)
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 QTY. MECHANICAL PERMIT FEE I FEE SUMMARY
BUILDING
become subject to the Workers' Compensation Laws of Califomia.
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 should become subject to the Workers' Compensation
provisions of the Labor Code, you must forthwith comply with
such provisions or this permit shall be deemed revoked.
FEEAIRHANDLINGUNIT (TO 10J=C.F.M.) 4.00
AIR HANDLING UNIT (OVER 10=C.F.M.) 6.00 SEISMIC FEECONSTRUCTIONLENDINGAGENCY
1 hereby afTirm that there is a construction lending agency for
the performance of the work_ for which this permit is issued (Sec.
3097, Civ.C.),
EXHAUST HOOD (WITH DUCT) 5,00
MICROFILM
HEATING UNIT (TO 100,000 B.T.U.) 8.00
HEATING UNIT (OVER 100,000 B.T.U.) 9.50 ELECTRIC
Lender's Name
Lender's Address
I certify that I have read this application and state that the above
information is correct. 1 agree to comply with all city and county
ordinances and slate laws relating to building construction, and
VENTILATION FAN (SINGLE) 4.00
PLUMBING f tV
BOILER- COMP (3 H.P.Or 100,000 B.T.U.) 6.00
BOI LER-COMP (Over 100,000 BTUI 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
m anyayue against said City in consequence oC thegrMECH.
CONST. TAXPERMITISSUANCE10.00
CONT. LIC, N0, MECH.
TOTAL
S(Contrac[or Date
TOTAL
OFFICE COPY