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APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN 9NLY
BUILDING PROJECT IDENTIFICATION
APPLICATION &PERMIT
BUILDING — ELECTRICAL— PLUMBING — MECHANICAL
PERMIT NUMBER
^ 79 A
BUILDING
A
9717A
r—
• awNER's - -
MEc4 r5•OIryw;.•EECTRIPERM3.2o_ONTRgCTOR'S[[OUTLETS-SWITCHES-RECEP
`d - ` ': -
PLAN CHECK VALIDATION
'
[NS
V m 41C No � 00
500/100
LIGHTING FIXTURES 5.00/1.00
DRER's -
ADDRESS
APPLIANCES - RESIDENTIAL 4.00
PANELS, 5.00
PHONE
DATE OF APPLICATION
ORHarTECT
ENGINEER
uc. No.
SIGNS 6.00
PLAN CHECK FEE - P.C. NO.
SIGNS TRANS. 3.00
ARCHLORADDRESS ENG.
SPECIAL CIRCUIT 5.00
PERMIT VALIDATION
EMP. METER OR POLE INS. 15.00
- zIP
�
APLICS
ADDfl
DDREE$$S
MOTORS SEE FEE SCH.
SERVICE CHANGE 10.00
���S �S
LICENSED CONTRACTORS DECLARATION.
I hereby affirm that l am license() under previsions of Chapter 1)
(commencing with Section 7000) of Division 3 of the Business andProfes
fla Cody, nSS1�h y license is in full jyyyy :}prj,c[fcy(.
Licence Inst Y�Con Nmnbe Y�
Lice
Ome�_��_ Conlruclor
ISSUANCE DATE
BLDG. ELECT.. ;PLG. MECH.
❑ ❑ ❑ ❑
— - 'N/,e iG LAK^
-
- -
OWNIi R -BUILDER DIfCLA RATION
I hereby artier that I am exempt from the Contractor's License
a, Businessto CO d Professions
Low for the following my w . (Sec. requires
/;ode: Any city or county which requiresapermitmconstma.alt,hp
IT
. IN s BUILDING.PERMdDN„
VALVA b/FT.
MISC. — REFER TO ORD
PERMIT ISSUANCE 6.00
ELEC. CONTR. LIC. NO. ELEC.
TOTAL
OT,V.: ,PLUMBING PERMIT' „- %FEE 2
.p - -
improve, demolish, or repair any structure, prior to its issuance, also
rumucs the apphcanl I'ot such permit In file a signed statement that
he Is licensed pursuant m lire provisions of the Contractor's LicenserviJ_
Law (Chapter 9 (commencing with Section 7000)ol Division 3 of the
Business and Professions Code) or that he is exempt therefrom and
the basis Int the alleged exenhp(mn. Any violation of Section 7031 5'
by any applicant fora permit subjects the applicanto a civil penalty
of not more than five hundred dollars ($500).):
V[�.
PE .. T
S
STORIES T ONSTR.
ALTER -DRAIN -WATER (EA.) 4.00
❑ Lwof the owner the property, or my employees with wages as
their sola towner at, will do the work, and the structure is not
BACK FLOW PROTECT. DEVICE 2.00
OCC. GROUP
RES. UNITS
DRAINS -FLOOR, ROOF, AR EA,CON D. 4.00
intended or 'offered for sale (Sec. 7044, Business and Professions
Cade: The Contractors License Law docs not apply to an owner of
FIXTURES - PER TRAP 4.00
GAS- EA. SYSTEM -1 INC. 4 OUTLETS 4.00
properly who builds or improves thereon, and who does such work
himself or through his own employees, provided that such improve
n epts are not intended or offered for sale. If, however, the building
Onlmprovenont is sold within -one year of completion, the owner
builder will have file, burden of proving that he did not build of im-
proveforpurposeofsale).
❑ 1, as owner of the property, am exclusively contracting with
$O. FT, FLOOR AREA
TOTAL ACREAGE
-
GAS - EA. SYSTEM -OVER 4 IEA.) 1.00
BUILDING USE
RES IND CON PB Om.,
INDUSTRIAL WASTE INTER. 20.00
licensed contractors to construct the project (Sec. 7044, BusinessLAWN
and Professions Cede: The Contractor's License Law does not apply
SPRINKLERS - 1 INC 5 V.B. 5.00
ASSESSORS PARCEL N0.
to agowocr of property who builds or improves thereon. and who
contractx for such projects with a contractons) licensed pursuant to
lire Contractor's License Law.
❑r l ant exempt under Sec. ,B.&P.C. for lits
reason
LAWN SPRINKLERS - OVER ( 1.00
SEWER -SANITARY -STORM ft/8.200
TRACT NO.
PARCEL NO.
WATER HEATER W/VE
Owner Date
WATER SYSTEM 4.00
_
ACC. DATE
ACC. FILE NO. -`
WATER TREATING EQUIP.
WORKERS'COMPENSATION DECLARATION
I hereby affirm that I have a certifcamaf consent m aelpi.ta m,
or a certificate of Workers' Compensation Insurance, or a certified
Rf
lar
ZONING
ENG. SITE NO.
MISC. - - REFER TO ORD.
copy tllcrcpl jSek. 3tl00�LA.C��
copPoliyNo.ere Car T
,
CI Certified copy is hereby fu Dished.bet 111 J4
CeHifi• opy is "fid the city inspection division.
Applicant..., (/1 � 3l1L:KN
FIRE SPRINK
Y E] NE]
ENERGY T-24
I Y ❑ NE]
PERMIT ISSUANCE 6.001,/FLOOD
CERTIFICATE OF E xEmprION FROM WORKERS'
" C'OMPIiNSA1'ION INSURANCE
1'I'In, Section need not be complete(] if the penial is for one
ZONE I
'
Y N�
A.L.U.C.
Y N�
PLG. cONTR. LIC. No.
pLG. yL
TOTAL
-
hundreddollarsthat in the perforor mance
I certify that m the perfornhanr.e o1 the work liar winch this 1 r
mit is Issued, I shall not employ any person in any manner so as to
s-�t'an*A>�
°OTV. "s MECHANICAL'PERMI, `"'"" iFEE
'r. va t� ,A'
't" k>4 FEE SUMMARY
BUILDING s
becom Inc{ the Workers' C pensah aw ] Cplifornia
Dat _S -p,} Applicant
NOI1 fi 0 APPLICANT: If, afle m ikmq Tfha Cert Game of Ex-
emption, 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.
. ;--�*
ALTER OR ADD TO MECH.4.00
APPLIANCE 4.00
AIR HANDLING UNIT (TO 10JMQF.M.) 3.00
PLAN CHECK
FEE
AIR HANDLING UNIT(OVER IQOOOC.F.M.) 5.00
SEISMIC FEE Jam'
CONS"FRUC-TION LENDING AGENCY
I hereby affirm that there is a construction lending agency for
the performance of Hire work for whichthispermit is issued (Sec
3097, Civ.C.L
EXHAUST HOOD (WITH DUCT) 2.00
MICROFILM
'
HEATING UNIT (TO 100,000 B.T.U.) 4.00
Lender's NamAddr
Lender's Address
HEATING UNIT (OVER 100,000 B.T.U.P.50
ELECTRIC
VENTILATION FAN (SINGLE) 3.00
BOILER-COMP(3 H.P. Of 100,000 B.T.U.) 4.00
I certify that Yhav, read (his applicatkm'and state that the above
information is correct. I agree to comply will, all city and county
ordin.mces and state laws relating to building construction, and
herebyauthorize representatives of this city to enter upon HhC
above-mentioned property for inspection purposes, -'
PLUMBING Q W
BOILER -COMP (Over 100,0008TU1 SEE FEE SCH.
MECHANICAL
MISC. - REFER TO ORD.
PERMIT ISSUANCE 3.00
(We) agree to save, indemnify and keep harmless the City of
Cupertino .,.just liabilities, judgments, costs and expenses which
may in any way occur, against said City jn consequence of the
granting of this pe 'L
f
i 7_
CONST. TAX
MECH. CONT" LIG NO. MECH.
TOTAL.
/
TOTAL (p
Signa u�of Applicant/Conhacmr Date
' OFFICE COPY