5643APPLICANT TO FILL IN INFORMATION WITHIN. RED LINES .USE BALL POINT PEN ONLY
BU I LDING PROJECT IDENTIFICATION
_
APPLICATION'&PERMIT
••
BUILDING— ELECTRICAL_PLUMBING — MECHANICAL
PERMIT NUMBER
S
BUILDING.
ADDRESS
27, 3AtV 2
OWNER'S -
NAME //ff
PHONE
"' •-,
QTp�V.' MELECTRICPERMIT
rV&$�W&M4il.ID.
PLAN CHECK VALIDATION
.• '
"
DATE OF APPLICATION
CONTRACTOR'S- "
N � .
P. t: r eters �- ,c: Ho. `e
UTLETS :SWITCHES b.R ECEP 5.00/1.00
LIGHT,ING FIXTURES '-5.00/1.00
ADDRESS ,Rs
ZGSY +S}0✓11M ljbie PHONPy1J1#fyO
APPLIANCES -RESIDENTIAL : 4.00 •
PANELS 5.00
OR ^
ENGINEER.'•-
Nod
SIGNS ' 6.00 ,
SIGNS
.PLAN CHECK FEE P.C. NO.
'
SIGNS TRANS.'- 3.00 };'
ADDRESS END
ilp .. F
SPECIAL CIRCUIT 5.00
'PERMIT VALIDATION
EMP: METER OR POLE INS - - 15.00
APPLICANT -
ADDRESS � - +'
-MOTORS SEE FEE SCH.
SERVICE. CHANGE --10.00
p
0
LICENSED CONTRACTORS DECLARATION
t
-
I hereby affirm Thal 1 am licensed under provisions of Chapter 9
(commencing with Section 7000) of U vi tan 3 01 the Bus peri and
'mfessrons Code ,/� n y license Is In full for an f�t.
¢enssJ���4- • Lic. LI . mb Nuer
Date u
J
ISSU/ E DATE
BLDG. ELECT. PLG.' -MECH.
❑
-
-
• OWNER -BUILDER DECLARATION �
I hereby affirm that I turn exempt from tire Cntractor's License'
Law for the following reason.'(Sec. 7031.5, Business and Professions
Code: Any city or wanly which construct,requireso permit to
_ - • �
A 4• +
B,�:IILDINGRER IT"
4a6 ��P R ATED�Iy, -
MISC. — REFER TO ORD
- PERMIT ISSUANCE .. 6.00
VALUATION $/FT.
ELEC. CONTE. LIC. NO: ELEC.
�• TOTAL
f.%&
DTllV 4 +g PLUMBING PEEMIT #fi b + AF
TIN ^ e, � Ss` -7o,
x% x _ .. 9 F i a w
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 lire provisions of the ContnmLicense
Law(Chapter9(commencingwdll Seelion7000)of Division3oflhe
Business and Professions Code) or that ImJx exempt therefrom and
the basis for the alleged' exemption. Any violation of Section 7031 5
by any applicant fora permit subjects ihcapplicantioacivilpcnulty
of not more than five hundred dollars($500):): " �••� •
"•
PERMIT TOtor:s
g�N
STORIES
5.,;�
TYPE CONSTR.
'
ALTER-DRAIN-WATER(EA.)4.00
_
❑ I, as owner of the properly, or my employees, with wages as
their sole compensation, will do the work, and the structure is not
BACKFLOW PROTECT. DEVICE 200
,
OCC. GROUP
RES. UNITS
DRAINS -FLOOR, ROOF, AREA, COND: 4.00
intended or offered for sale (Sec: 7044, Busineea'and Professions
Code: The Contractor's License Law does not apply to an owner of
property who builds or improves thereon, and who docs such work
himself on -through his own employees, provided that such improve-
meets are notintended or offered for sale. If, howeveq the huilding
/ FIXTURES -PER TRAP - - 4.00
- - -
GAS-. E_A. SYSTEM -1 INC.4 OUTLETS 4.00.
so. Pr. FLOOR AREA
". TOTAL ACREAGE
-
or, improvement is sold within one year of completion, the owner-.
builder will have the burden of proving that he did not build or ire-
Prove for purpose of sale.).
U as Owner of the properly, am exclusively contracting with
-
GAS'- EA.•SV STEM - OVER 4 (EA.) 1.00
BUILDING USE
RES. IND CON. PB Other
❑ ❑ ❑.•. ❑ ❑'.
INDUSTRIAL WASTE INTER. 20.00.
d
licensed contractors to construct the project (Sec. 7044, Business
. 7044,
0 License Low does not apply
and Professions Code: The who
to of propertywho buildstr improves thereon,and who
LAWN SPRINKLERS- 1 INC 5 V.B. 5.00
-
- .LAWN SPR IN KLERS - OVER 5(EA.) 1.00
.
ASSESSORS PARCEL NO.
frowner
the Cont for such projects with u wmraclorts) licensed pursuant to
the 1 an, tore License Law.
❑ I am exempt under Sec. ,B.&P.C. for this
reason
SEWER -SANITARY -STORM EA. 200fiI8.00
,TRACT NO.
o.
PARCEL NO. .
WATER HEATER W/VENT 4.00
Owner Data
WATER SYSTEM , 7 4.00
• ACC. DATE
ACC. RLE No.
''WORKF.RS'COMPFiNSAT10N DECLARATION
"
WATER TREATING EQUIP, - 4.00
I hereby affirm that I have a certificate of consent to self-irsure,
ZONING
ENG. SITE NO.
oza certifiwtu oLWorkcrs' Coinpenea[ion Insumuce,yr n certified
copy llu4�ree����qpp��jj$$ppQQJJ..a1, C.).//''
Policy NtJ y_A GZI th4runy !'r`A lN+ne,l""'e
. ❑ Certified'ally is hereby famished. -
❑' f.'erl, '�j Cnpy IS d II I(y Inspection diVxio11.,
APPliaint Vr"`',-���_
-
MISC.- PREFER TO ORD.
-.FIRE SPRINK
Y❑ N❑
ENERGY T 24
Y❑ N❑
CFRTIFICA1FOF EXEMPTION FROM WORKERS'
' COMPENSATION INSURANCE
(I [its section need not he completed if the permit Is for one
PERMIT ISSUANCE 6.00
FLOOOZONE
Y ❑ N ❑
A.L.U.C.
•Y ❑ N ❑
PLG. CONTE.' v LIC. NO.-
Call
TOTAL'
hundred dollar (S 100) or less.)' -
I certify shat in the erformance.ol' the work for which this er
y p y p y p
ITT Is Issued, I shall oot employan person in an manner so as to
become subieet to it,, Workers' Compensation Laws of California
A8rv4r gSwF, a $ }Awa"in1,Ag ar 5 ay' q,
4 u y "' Vd+a ,'f`- k
QTYb. F �MECIHANICAL'sP,RMIT '$• 9o- FE
m a m., . w k NA {, 9 p 5.
f e - e A a 4 '145OmTNI . s A'�a n'
V,
y ` FE
MMAvF0
Ate.
ALTER OR ADD TO MECH. 4.00
Dame -Applicant
NOTICE. TO APPLICANT: if, after making this Certificate of Ex-
BUILDING
APPLIANCE - 4.00
AIR HANDLING UNIT (TO 1Q000C.F.M.) 3.00
PLAN CHECK
'FEE
emption, you should'become subject to the Workers'Compensation
provisions of the Cabot Code,:you must forthwith comply with
such provisions or this'pennit shall beldeemed revokod.
AIR HANDLING UNIT(OVER 10PWC.EM.)5.00 _
SEISMIC FEE
CONSTRUCTION LENDING AGENCY
EXHAUST HOOD (WITH DUCT) 2.00
I herehyuffirnl that there is a construction lending agency for
the .performance of it,, work for which this permit is issued (Sec.
3097,Cie C.).
MICROFILM
-
HEATING UNIT (TO 100,000 B.T.U.) 4.00
Lender's Name
Lender's Address
HEATING UNIT 100,000 B.T.U.)7.50
,ELECTRIC
I certify that I have read this application and state that the above
information is correct. 1 agree m comply with all city and county
ordinances and state laws relating to building Iioustruclion, and
hereby authorize representatives' of this city to ad c, upon the
above-mentioned property for inspection purposes. -
VENTILATION FAN (SINGLE) - 3.00 -
PLUMBING
BOILER-COMPI3 H.P. Dr'100,000 B.T.U.) 4.00
So LERIOver t00,000BTU) 'SEE FEE SCH.
-.MECHANICAL'
_
(We) agree. to save; Indemnify and keep harmless the City of,
Cupertino against liabilities, judgments costs and ekpenses which
wayaccrgssaid City,in consequence of theof
MISC.,-'` -- REFER TO ORD:
PERMIT ISSUANCE !;' 3.001CONST.
TAX
paany
thpit /�
MECH. CONT. LIC,NO.
MECH:TOT
Q'aiTALR 4
0, Applicant ontr r/' —�
J i. OFFICE -COPY