4933 (3) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
i
BUILDING PROJECT IDENTIFICATION PERMIT NUMBER
BUILDING APPLICATION & PERMIT 4933
AooRrxsne Results Way Cupertino BUILDING - ELECTRICAL-PLUMBING-MECHANICAL
OWNER'S PLAN CHECK VALIDATION
n.! NAME
Measurex Corp. 255-150 TY. ELECTRIC PERMIT FEE
PHONE
CONTRACTORS
AMC OUTLETS-SWITCHES-RECEP 5.00/1.00
Stop Fir4, Inc•LID No. 433114 LIGHTING FIXTURES 5.00/1.00
CONTRACTOR APPLIANCES-RESIDENTIAL 4.00
A...00 E. Brokaw293-34
o2E PANELS 5.00 DATEAPPLICATION
CHECK
ARCHITECT SIGNS 6.00 PLAN CHECK FEE P.C.N0,
OR
ENGINEER
LIC,NO, SIGNS TRANS. 3.00
moo Ess ENG. SPECIAL CIRCUIT 5.00 PERMIT VALIDATION•
ZIP EMP.METER OR POLE INS. 15.00 / r,
APPLICANT$
ADDRESS MOTORS SEE FEE SCH. J
SERVICE CHANGE 10.00
w
02 LICENSED CONTRACTORS DECLARATION
a o U I hereby affirm that 1 am licensed under provisions of Chapter 9 ISSUANCE DATE
y a a
(commencing with Section 7000)of Division 3 of the Business anA BLDG. ELECT. PLG. MECH:
F y z I'mfe � QDl ��nse IL-1 dull foi-43d3' fr 14, (7
z o o Lice �';sem.LR v', u'AlII�� El 1:111 0
Q $ Dulc Cs trucinY a nC I. -
xE BUILDING PERMIT
rc Q w ¢ OWNER-BUILDER DECLARATION INFORMATION
Z oa ° MISC.- REFER TO ORD
w 3 y I hereby'affirm that I am exempt from the Contractor's License VALUATION SOFT.
F ;� o 4 Law for the following reason.(Sec.703 I.S.Business and Professions PERMIT ISSUANCE 6.00
f �� f Code:Any cityorcounty which reyuircxa permit to Constmc,alter. ELEC.CONTE. LIC.NO.
a D improve,demolish,or repair any'structure,prior to its issuance,also ELEC.
BE
Q requires the applicant for such perrait to fila'a signed staterrun1 Ilon TOTAL PERM TO
K
Cr IL he is licensed pursmuL to the provisions of the Contractors License �"' TO
Law(Chapter 9 leonl mmrcingwith Section 7000)of Division Sof the
a Nosiness and I'ru&,,ions Code)or that he is e,xmnpt thercl'nnn and QTY. PLUMBING PERMIT FEE
F o the basis for the alleged exemption.Nry vio'alion of Section 7031.5 STORIES TYPE CONSTR.
s ; by any applicant for a permit subjects the applicant to a civil penally ALTER-DRAIN -WATER IEA.) 4.00
of not more than five hundred dollars(S5001):
❑ 1,as owner of the property.or my employees with wages as BACK FLOW PROTECT.DEVICE - 2.00 OCC.GROUP RES.UNITS
their sole compensation,will do the work,and the aructure is not
intended or offered for sale (Sec. 7044. Business and Professions DRAINS-FLOOR,ROOF,AR EA,COND. 4.00
Code:The Contractor's License Law does not apply to an owner of
Property who builds a t....rive,Ili,cou,and who docs such work F IXTUR ES-PER TRAP 4.00 SG.FT.FLOOR AREA TOTAL ACREAGE
. alerts are lot re his or offered Ito, le.It, that sick 1, )cc'
GAS-EA.SYSTEM-1 4.00
niente are not rended oroffered
on for sola It,however,the building or improvement is sold within one year of completion,the owner- GAS EASYSTEM-OVER 4 (EA ) 1.00 BUILDING USE
budder will have the burden of proving that he did not buil)or im - . .
RES IND CON PB Other
prove for purpose of sale.). INDUSTRIAL WASTE INTER. 20.00 ❑ ❑ ❑ ❑ ❑
❑ owner of tire ms
e property, exclusively contracting with
licensedd contractors do construct the
prsiject ISec. 7044,of imply LAWN SPRINKLERS- 1 INC 5 V.B. 5.00 ASSESSORS PARCEL No.
to n Professions Codeproperty
The Contractor's s Licene Law docs not apply -.
to I owner of properly who builds t r improve,ensedthereon,and who LAWN SPRINKLERS-OVER 5 IEA-) 1.00 f
Contracts for such projects with a amlmcVnL5)licenced pursuant In
the Convunur's License Law. . SEWER-SANITARY-STORM EA.200ft/6.00 TRACT NO. PARCEL No.
❑ Into exempt under See .B.RRC.tin this WATER HEATER W/VENT 4.00
reason
Dude Owner WATER SYSTEM 4.00 ACC.DATE ACC.FILE NO.
WORK ERS'CONPRNSA'I ION DECLARATION WATER TREATING EQUIP. 4.00
1 hereby affirm that I hove a ca Nificatc of asnscm to 1111-v sure, ZONINGor a certificate of Workers'Co niensition Insumnee,ora eerified ENG.SITE NO.
copy thereof(See.3800.Lab.C.),
U Pity N..-C(n.pany
1t. C'ertlfled copy if 11 ere by ftlrillxr,d. FIRE SPRINK ENERGY T-24
Z Z ❑ Certiti yyyw kiiVc,6tl, ill I zpcction division. MISC.- REFER TO ORD.
O Applicant 1L Y❑ N❑ Y ❑ N❑
Cc: N CERT'D'ICA IF OF EXE.MPI ION FROM WORKERS' PERMIT ISSUANCE 6.00 FLOOD ZONE A.L.UC..
LU > CO.Ni PIMWION INSURANCE PLG.CONTR. LIC.NO. PLG.
CL CI 1'1'hi,s section Cecil not be completed if the permit is for one TOTAL Y❑ N❑ Y❑ N❑
2 hundred dollars IS 100)or ILSs.)
U O I certify owt in the pert omroncc oI'Ore work to,which thi.v per- CITY. MECHANICAL PERMIT FEE FEE SUMMARY
lL 1- mit is issued, I shall not employ any person in any Inunner xo as to
Ow become subject to the Workers'Conlpen,itioh Laws of Calil'oriia.
LU Dale Apphcunt ALTER OR ADD TO MECH. 4.00 BUILDING $56.5
} to NOTICE TO APPLICANT: If,after raking this Certificate of I',-
F Z eprodon,you should become subject to the Workers'Compensation APPLIANCE 4.00 PLAN CHECK
provisions of the Labor Code, you ovist forthwith comply with FEE
U suCII provisions or Ilii,perndit,boll be deemed revoked.. AIR HANDLING UNIT(TO 10=C.F.M.) 3.00
CONS[RUCTION LENDING AGENCY AIR HANDLING UNIT(OVER 10SMC.F.M.) 5.00 SEISMIC FEE 5
I hereby At'Ino that there hs a eunstruction lending agency I'.. EXHAUST HOOD(WITH DUCT) 2.00
the performance of tire work for which this Permit G issued(Sec. MICROFILM
3097,Civ.C.). HEATING UNIT(TO 100,000 B.T.U.) 4.00
Lender's Name H EATING UNIT(OV ER 100,000 B.T.U.)7.50
Lender's Address ELECTRIC
I certify that l have read this application and state that the above VENTILATION FAN (SINGLE) 3.00
information is ,wheel. I agree to comply with all city and county PLUMBING
ordinances nod state laws relating to building .onstruction, and BOILER-COMP(3 H.P.or 100,000 B.T.U.) 4.00
hereby vuthorizc representatives of this city to enter upon the BOILER-COMP TO...100,000 BTU)SEE FEE SC[. MECHANICAL
above-mentioned property for Inspection purposes
(We) agree to sav indemnify and keep harmless the City'of MISC.- REFER TO ORD.
Cupertino against li bili ies.judgments, costs and espe es which PERMIT ISSUANCE 3.00 CONST.TAX
may in any way a cru o '' City in co yuc 'c of the
ti of this pern MECH.CONT. LIC.NO. MECH.
�I TOTAL TOTAL $93.7
Signature of pilicart ContrcUc Date
INSPECTOR COPY
\,