16038APPLICANT TO FILL, IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
BU I LDING PROJECT I DENTIFICATI ON
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APPLICATION & PERMIT.
BUILDING = ELECTRICAL_ PLUMBING— MECHANICAL
PERMIT NUMBER -
1"
16038
aD ILDING - , ;
ADDRESS -
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OWNER'S
NAME
QTY.
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ELECTRIC PERMIT
FEE
PLAN CHECK VALIDATION
' HONE
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CD TIIaCTOR
VAIAC
JOUTLETS - 'SWITCHES -RECEP 10.00/1.00
LIGHTING.FIXTURES 10.00/1.00
uc. NO.
- -
TRACTOR'a
ADDRESS
PPLIANCES- RESIDENTIAL 4.00
PANELS 10.00
PHON 5"
DATE OF APPLICATION 1
ARCHITECT !
GINEER
uc. NO }�•
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PANELS (OVER 200 AMP). .20.00
PLAN CHECK FEE P,C; N0.
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-SIGNS
TRANS: - 3.00
ARCH. OR ENG.
ADCIFf ',
SPECIAL CIRCUIT 5.00
PERMIT VALIDATION
TEMP. METER OR POLE INS. Y 20.00
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811 \ }�el�
41
ADDRESS rS
ADDRESS
MOTORS'. SEE FEE SCH.
SkRKICE CHANGE ,20.00
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LICENSED CONTRACTORS DECLARATION
.
ELe L" OUC.
L
hereby uf(inn Illut'I um licvnsel under provlviane of Chupier 9
(emon"neing willr Seetiml 7000) of Divisions 3 of the Business and
Professions Code and my license is in full Corse and effect.
License class ie. N, ph, (_]
mUm
- ISSUANCE DATE
PLO. MECH.
010 o.
- BUILDING PERMIT
INFORMATION
OWNER - BUILDER DECLARATION _
,1 hereby affinu that I am exempt from Or Contractors License
Law l'or the following reason. (See 7031.5, Businessand professions
Code: Any city or county which requires a Permit to construct, alter,
improve, demolish, of repair any structure, prior to its issuance, also
regmres the applicant for such permit to tale a signed statement that
he is licensed persuent'lo the provisions of the Contractor's License
Law (Chapter 9 (empmmrcing with Scalier 7000) of Division 3 of the
usiness and Professions Code) or Omt he is escrom Iherefronn and
.
MISC.— REFER TO ORD
«,
PERMIT.ISSUANCE - 1
AO�— .
VALUATION
$ /FT.
ELEC. CONTR. LIC. NO.
ELEC.
TOTAL �.J�eL
PERMIT TO
-
'
S W /y,y %v4 t9
OTY.
PLUMBING PERMIT' t
FEE
tBhe basis fur the allege) exemption. Any violation of Section 7031.5
by any applicant for a permit subjects the app icanl Ina civil penalty
of not mom than five hundred dollars ($500),1:
STORIES
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TYPE CONSTR.
Q'U V/ !`r
ALTER-DRAIN (EA.1. 5.00'2
❑ I, as owner of the property, or my employees with wages as
their sale compensation, will do the work, and the st raefnre is oaf
/.
/
BACK FLOW PROTECT. DEVICE 4.00
Z'^
OCC. GROUP
RES. UNITS
/
DRAINS - FLOOR, ROOF,•AR EA,CON D. 500
- .
2��'•
pimpled or offered far sale (Sue 7044, Business and Professions
Code: The Contractor's License law does not apply to an owner of
'
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FIXTURES - PER TRAP 5.00
GAS- EA.SYST,EM -I INC.40UTLETS 6.00
property who builds or improves thereon, and who does such work
himself' or through his own employees, provided that such improve-
mentsarenotint ended or offered for sale If, however, the building
so. Er. FLOOR AREA
- roTaL ACREAGE
-
at improvement is sold within'one year of completion, the owner-
builder will have the harden of proving that he dill not build or, im-
prove,for purpose of sale.).
O I, as owner of the properly, um cxclusivuly contracting with
GAS - EA. SYSTEM'- OVER 4 (EA.)'' 2.00
BUILDING USE
RES IND CONY PB .other
Or . ❑ ❑• ❑ O
INDUSTRIAL WASTE INTER 3000
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licensed conlracton to construct the project (Sec. 7044, Business
and Professions Code: The Contractor's License Law does not apply
to an owner of property who builds or improves fiction. and with
LAWN SPRINKLERS: 1 INC 5 V.8. 6,00
LAWN SPRINKLERS =OVER 5 (EA.) 1.00
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ASSESSORS PARCEL NO.
,
contracts for such projects with p contractor(s) licensed pursuant to
the Contmctnr's License Law.
S EWER- SANITARY -STORM EA. 200ft /10.00
TRACT NO,
PARCEL NO.
. O I wn exempt under Sec. ,IIAP.C. for this
rcascm
WATER HEATER W /VENT 6.00
Owncr gate •
WATER SYSTEM: 5.00
ACC DATE
ACC. FILE NO.
WATER TREATING EQUIP.' - , 5.00
WORKERS'COMPENSATION DRCLARATION
I hereby affirm that I have a certificate ofennsunt to self - insure,
or a certificate of Workers' Compensalion Insurance, or a certified
ZONING
ENG. SITE NO.
copy thereof (Sec. 3800, Lab.CJ..
Policy No. Company
• Certified copy is hereby furnished. -
• Cmrli fah �npy I fit d wity( 1�yInspect' n division.
Applicam�.IL= G+6L,1 1.:1��_Ci�l..,.-�__—
FIRE $PRINK
Y�. NEI
ENERGY T-24
•' Y0 N�
MISC.- - REFER TO ORD.
C 17 RTI F [CA '11: O F EX Ii M 11 r 10 N FROM WORKERS'
PERMIT ISSUANCE a I&Qn
:—�
FLOODZONE
A.L.u, C.
COMP'ENSA'TION INSURANCE.
('Phis section need not be compleled if file ,permit is for one
Y N�
Y ❑ NE]
PLG.CONTR. LOC. NO.
PLO.
TOTAL OZQ
hundred dollars (S 100) or less.)
I certify that in the performance of tire work for which this per
mot is issued, I,shall not employ any person in any manner so as to
OTY.
MECHANICAL PERMIT
FEE
FEE SUMMARY
BUILDING
Q`O
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become subject to the Workers' Compensation Laws of California.
Date - Applicant
NO1'lCl: TO APPIACANT: If, after making this Certificate of fix-
ALTER OR ADD TO MECH. 5.00
APPLIANCE 5.00
AIR HANDLING UNIT (TO 10,000C.F.M.) 4.00
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PLAN CHECK '
FEE
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emptim , you should become subject to the Worker: Compensation
provisions of the Labor Code, you most forthwith comply with
such provisions or this permit shall be deemed revoked.
AIR HANDLING UNIT (OVER 10=C.F.M.) 6.00
.SEISMIC FEE
CONSTRUCTIONLENDINGAGENCY
I hereby affirm that there is a construction )ending agency for
EXHAUST HOOD (WITH DUCT)' 5.00
the performance of the work for which this,perinil is issued (Sec.
3097, Civ:C.).
MICROFILM
HEATING UNIT (TO 100,000 B.T.U.) 8.00
Lender's Name
Lender's Address
HEATING UNIT 100,000 B.T.U.
ELECTRIC
00
VENTILATION FAN (SINGLE)' 4.00
Lecrtify that l haremad thisappllcation and state that he above
inforoution is correct. 1 agree to comply with all city and county
9rdiminams and slate laws relating to building construction, and
PLUMBING,,
h
�. V J
BOILER- COMP (3 H.P. of 100,000 B.T.U.) 6.00
BOILER -COMP (Over 100,000 BTU) SEE FEE $CH.
MECHANICAL
hereby authorize representatives of this city to enter upon the
abovomentioned properly for inspection purposes.
' (We)r agree to save, indemnify and keep hafndens the City of
.- MISC-- ( REFER TO ORD.
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Cupertino against liabilities,, judge eau, costs and expenses which
.my in anylway aceme ogrifin fd City inconsequence of the
m Ijn Pthis permit.
a - PERMIT ISSUANCE - -
CONST. TAX
,I
MECH. CONT, _IC. NO. MECH.
TOTAL col
-° -
l
TOTAL
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Ignat.mol' Applicoilt/ ontraclor Date
OFFICE COPY