12031APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
BU LOI NG PROJECT I IDENTIFICATION,'
APPLICATION & PERMIT
BUILDING -ELECTRICAL- PLUMBING -MECHANICAL
PERMIT NUMBER
A ^O�A
I G I
BUILDING
ADDRESS 22273 Bahl
OWNER'S ..
NAME
Georga PDsada PHONE 24 � T69
OTV, ELECTRIC PERMIT FEE
PLAN CHECK VALIDATION
COME NTRacroRs
NOYE
UTLETS-SWITCHES -RECEP 10.00/1.00
LIGHTING FIXTURES 10,00/1.00
Atlas Heating- LIC.ND. 465266
,
DATE OF APPLICATION '
CONTRACTOR s
ADDREPPLIANCES
155 Commercial St. PHONE 739-0516
- RESIDENTIAL 4.00
PANELS 10.00
ARCHITECT Sunnyvale
OR
ENGINEER
- LIC. NO.
PANELS (OVER 200 AMP) 2000
PLAN CHECK FEE P.C. NO.
ISIGNS TRANS.. 3.00
AENG. `
HESs
ADDRESS
' ZIP
SPECIAL CIRCUIT 5.00
P jYLVALIDAT N
CC2 D
y*
j
'Y a �Q�
+
EMP. METER OR POLE INS. 20.00
APPLICANTS
ADDRESS
MOTORS SEE FEE SCH.
SERVICE CHANGE 20.00
N
LICENSED CONTRACTORS DECLARATION
I hereby affirm that I am licensed under provisions of Chapter 9
(commencing with Section 7000) of Division 3 of the Business and
Professions Co ltum license is in full fury, 6 8
License 1 Lic. Number YO GO
r
ISSUANCE DATE
BLDG. ELECT.
❑ 1:1
PLG. ,ME
❑
Date�� Contractor
JBU ILDIN,G PERMIT
' .INFORMATION'
OWNER -BUILDER DECLARATION
I hereby affirm that I am exempt from tjse Contracto'r's License
Law for the following reason. (Sec. 7031.5, Businessand Professions
Code: Any city or county which requires a permit to construct, a alter,
-
misc. - REFER TO ORD
PERMIT ISSUANCE 10.00
VALUATION
$/FT.
ELEC. CONTR. LIC. N0. ELEC,
TOTAL
improve, demolish, or fu any structure, prior its issuance, also
requires the applicant foror such permit to file a signed statement that
he is licensed the provisions of the Contractor's License
IT T
9 (commencing
en 3 ofthe
Law (Chapterand
Business and Professions Code) or that he is exempt therefrom and
Professions C de) Or Section is 00) exempt
DTV. PLUMBING PERMIT FEE
the basnyapor the a ora ermit subjects
by any applicant five hemi subjects the0).): am toacivil penalty
tsthAny ea plica tfo aclinn malty
of not more than five hundred dollars ($500).):
-
-DRAIN
STORIES
P CONETR.
ALTER -WATER IEA.) 5.00
❑ I, as owner at the property, or my employees with wages as
emp
their sole compensation, will do the work, and the structure is not
BACK FLOW PROTECT. DEVICE 4.00
OCC. GROUP
RES. UNITS
DRAINS -FLOOR, ROOF, AR EA, COND. 5.00
intended or offered for sale (Sec. 7044, Business and Professions
Code: The Contractor's License Law does not apply to an owner of
FIXTURES - PER TRAP 5.00
GAS-EA.SYSTEM-11NC.40UTLETS 6,00
SQ. FT. FLOOR AREA
TOTAL ACREAGE
'
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
or improvement is sold within one year of completion, the owner.
builder will have the burden of proving that he did not build or int-
prove for purpose of sale.).
❑ I, as owner of the property, am exclusively contracting with
I GAS - EA. SYSTEM - OVER 4 (EA.) 2,00
BUILDING USE
RES IND CON PB OIEe,
❑ ❑ ❑ ❑ ❑
INDUSTRIAL WASTE INTER. 30.00
licensed contractors 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 thereon. and who
LAWN SPRINKLERS -I INC 5 V.B. 6.00
ASSESSORS PARCEL N0.
LAWN SPRINKLERS - OVER 5 (EA.) 1.00
contracts for sumor(s) licensed pursuant to
such projects with a contra
sr
the COc s f or5 License Law.
SEWER -SANITARY -STORM EA. 200ft/10.00
TRACT N0,
PARCEL NO.
❑ I am exempt under Sec._, B,&P.C. for this
reason
WATER HEATER W/VENT 6.00
Owner Date
WATER SYSTEM11190
PCC. DATE -
'ACC. FILE N0.
WORKERS'COMPENSATION DECLARATION
WATER TREATIlJG EQUIP.
I hereby affirm that I have it certificate ol'cnnscm to self -insure,
or a certificate of Workers' Compensation Insurance, or a certified
ZONING
ENG. SITE NO.
copy theylIsf�p� 00, Lab.C.L '
Allied
p
Policy NZILVmpany pac
I
11Certified copy is' hereby furnished.
q. Certified pOfry j.�Blrtlewallheity inspection division.
APp v:ant tlai II L g
1
FIRE $PRINK
v ry
❑ ❑
ENERGY L24
❑ "❑
V N
MISC.- D.
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE.
(I his section need nal be completed if Ilm permit is for one
PERMIT ISSUAN 10.00
FLOOD ZONE
Y N
❑ ❑
A. L.U.C.
Y N
❑ ❑
PLG. CONTR. L 0'
PLG.
hundred dollars ($100) or It..)
I certify (hat in the performance of the work for which this perQTY.
mit is issued, I shall not employ any person in any manner so as to
" MECHANICAL PERMIT FEE
,.
FEE SUMMARY
'
BUILDING '
become subject to the Workers' Compensation Laws of California.
Date ' Applicant
-
ALTER OR ADD TO MECH. 5.00
NOTICE TO APPLICANT: If, after making this Certificate of Ex-
APPLIANCE 5.00
AIR HANDLING UNIT (TO 10,000CF.M.) 4.00
PLAN CHECK
FEE
emption, you should become subject to the Workers Compensation
provisions of (be Labor Code, you must forthwith comply with
such provisions or this permit shall be deemed revoked.
AIR HANDLING UNIT (OVER 10MC.FM.) 6.00
SEISMIC FEE
CONSTRUCTION LENDING AGENCY
I hereby affirm that there is a construction lending agency for
EXHAUST HOOD (WITH DUCT) 5.00
the performance of the work for which this permit is issued (Sec.
3097, Civ.CJ.
MICROFILM
HEATING UNIT (TO 100000 B.T.U.) � 8.00
,
Lender's Name
Lenders Address
H EATI N G U N IT (OVER 100,000 B.T,U.) 9.50
ELECTRIC
I certify that I have read this application and state (hat the above
VENTILATION FAN (SINGLE) 4.00
information is correct. I agree to comply with all city and county
mdinancesand state laws relating to building construction, and
hereby momnize representatives of this city to enter upon the
above-mentioned property for inspection purposes.
PLUMBING
-
BOILER-COMP(3H.P.or 100,000B.T.U.) 6.00
BOILER -COMP (Over 100,000 BTU) SEE FEE SCH.
MECHANICAL
'
(We) agree to save, indemnify and keep harmless the City of
Cupertino against liabilities, judgments, costs and expenses which
may in any way accrue against said City in consequence of the
granting of this permit.
MISC. - REFER TO ORD.
PERMIT ISSUANCE 10.00
CONST. TAX
MECH. CONT. LIC. NO. MECH,L
TOTA
AtlaB Heating 465266 $19.50
TOTAL
pli
Signature of Apcant/Contractor - Date
OFFICE COPY