09727APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALLPOINT PEN ONLY
' BUILDING PROJECT TI �
C•+'
APPLICATION & PERI
BUILDING -ELECTRICAL -PLUMBING'- CHANICAL
PERMIr NUMBER
/�ADORES^
Ol I^-/7/
VI G I`
BUILDNG.�/�
;1;�DENTI
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Lrr
OWrvER' �"
NAME ,�J'/}�f'(PD�KIRSCH'i VOGL^
7
-
QTY. ELECTRIGPERMIT' FEE
PLAN CHECK (DATION
.2 7d I' -
2 (o �',
! o
7V
CONTRACTOR S
NAME
V06L .CoNsrRvc„r�on�..
uc. Na.
OUTLETS:-SWITCHES-RECEP 10.00/1.00 Q -
LIGHTING -FIXTURES 40.00/1.00?12
CONTRACTORS /�}�' (�' /��/�['[� ��//�,/
AGOREBS (O JJ /f46.q N0.J/"T ry/J-J
APPLIANCES` -RESIDENTIAL 4.00
^
(r+l .4
.,
PANELS 10.00 "
V'
DATE OF APPLICATION'
AR RITEC
oR �-Iou pl 4���/�/�^QN
ENGINEER h /�
uc. No.
PANELS (OVER 200`AMP) " 20.00
PLAN CHECK FEE P.C. N0:
" 1 _,pA� `
-
SIGNS TRANS.- 3.00
ARCH. OR ENG y
AooREas ni o, 8�4/QS%p'1•7
Lo ZIP7W
,-
SPECIAL CIRCUIT 5.00 -
�P� ITV LIDA C
IY UkQ/, jvj t '��Q�'7
rr pp JJ 7
`Z/f,
/CI`I - 1 p
J
EMP. METER OR POLE INS.. 20.00
!�P'L�TjO_ca,.
ACCRESS 6 /7 r�'R � Wg Y,
ADDRESS 114 R
MOTORS'' FEE SCH.
SERVICE CHANGE 20.00
LICENSED CON'T'RACTORS DECLARATION
TEMP. POLE 0.00
1 hereby offirm.lhat I ain licensed under provisions of Chapter 9
(commencing with Section 7000) of Division 3 of the Business andBLOG.
Pr host Cod d my license rs in full fort n c t.
Ln.ense floss Lie boor e,
Date r ri/SER 9'!-.
ISSUANCEDATE ,
jtljlQ
CD
ECH.
..
i BUILDINOPERMIT
t' {-':� INFORMATION F'
OWNER -BUILDER DECLARATION'
I hereby affirm that I am exempt from Ole Contractor's License
Law for the following reason. (Sec, uires a, Business antl Professions
Code: Any city or County which requitese permit to construct, alteq
-'.MISC.-" REFERTOORD
+pEflMIT ISSUANCE 10.00 d..
-
VALUATION "b/FT.
CONTR. LIC, NO. ELEC./"
TOTAL
,- y _
- '-
PLUMBING PERMIT FEE .
requiresthe applicant repair such anystructure,to file priorgir its issuance,alsoELEO
requires the applicant fiat such, permit to file o signed statement [plot
of the Contractor's License.
he Is Recused. pursuant n ing with Section
Lew(Chopter9(commencing with Section ]000)of Division of the
Business and Professions Code) or that he is exempt therefrom andQTY.
�('�V
PERMIT TO
p
SIAIC C.� /.•�
the basis for the alleged exemption. Any violation of Section 7031.5
by any applicant fora permit dolimts $5000.licant too civil penalty
-
of not more than five hundred dollars (try
STORIES
_ PE CONBTR.
ALTER -DRAIN -WATER IEA.) 5.00
em)'.
❑ I,'as owner of the property, or my employces'wilh wales as
their sole compensation, will do the work, and the structure isnot
intended or offered for sale (Sec. 7044, Business and Professions
Code: The Contractor's License. Law does nota pply to an owner of
- BACK FLOW PROTECT. DEVICE 4.00
OCC:GROUP ;
RES. UNITS
DRAINS -FLOOR, ROOF, AREA, COND. 5.00
FIXTURES - PER TRAP 5.00
-
'•GAS -EA. SYSTEM -1 INC.4 OUTLETS 6.00
property who builds or improves thereon, and who does such work
himself or through his own employees, provided that such impro
ments are not intended or offered for sale. If, howeve,r, thebaildingve-
sO. FT FLOOR AREA
I
TOTAL ACREAGE
or improvement is sold within one year of completion, rte owner-
builder will have the burden of proving that he did not build or air
prove for purpose of sale.).. I. . '•, ''
❑ I, as owner of the properly, "am exclusively contracting with
GAS - EA. SYSTEM -OVER 4 IEA.) 2.00
-
BUILDING USE
RES IND CON PB Omar
❑ ❑ ❑' ❑ -
INDUSTRIAL WASTE INTER. 30.00.
licensed contractors to construct the project (Sea 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 V.B. B4O0
-
ASSESSORSPARCEL NO.
-
LAWN SPRINKLERS - OVE ) 1.00
,out, Cis for such projects with a contractorls) licensed pursuant to
the OOIAmCtof s License Law.
❑'I am exempt under Sec. ,B.&P.C, I'nr this
reason
SEWER-SANITA O E OOft/10.00 d:
TRACT NO.
7�4�,
PARCEL N0.
WATER HEATER W/VENT 6.00
Owner Date
.,
" Rg
WATER SYSTEM 5.00
I
ACC. DATE
ACC. FILE NO.
-tWORKE-RS'COMPENSATION DECLARATION
WATER TREATING EQUIP. 5.00
1 hereby affirm that 1 have a certificate ofco nsenl to self -insure,
or a certificate of Workers' Compensation Insurance, or a certified
`, -
ZONING
ENG. SITE NO.
copy therf(Se 00, Lab.C.•�
Policy Nn(//� company)-FREHD�T /PP&&77
❑ Certified copy is hereby furnished. ' •
X Cerlifie y is Oled with the city' inspection.dis,non.
APPlieuntII11yQI[r✓-�I/-�i.6
;
-
E
FIRE SPRINK
Y-❑ N ❑
ENERGY T-24
.' Y ❑ N❑
MISC.' REFER TO ORD.
CERTIFICATEOF EXEMPT10N FROM WORKERS'
PERMIT ISSUANCE a ', 10.00 Q
FLOOD ZONE
A. L.L.C.
COMPENSAITON I NSURANCF.
f7hls section need not be completed if the permit is.for one
- Y ❑ N❑
-
Y ❑• N❑
PLC.CONTR. LIC. NO.
PLG.
TOTAL Qp2
hundred dollars ($100) or less.)
I certify that In the performance of the work for which this per -'CITY.
mit is issued, I shall not employ any person in any manner so as to
MECHANICAL PERMIT FEE
- FEE SUMMARY ;
- '
�`a d
become subject to the Workers' Compensation Laws of California.
Date Applicant -BUILDING
• '
ALTER OR ADD TO MECH., 5.00
NOTICE TO APPLICANT: If, after making this Certificate of
APPLIANCE - . 5.00
AIR HANDLING UNIT
PLAN CHECK -
FEE
emption, you should become subject In the Workers: Compensation
provisions of the Labor Code, you musBforthwl[h Comply with
such provisions or this permit shall be deemed revoked. '
AIR HANDLING UNIT (OVER IOAODC.F .) 6.00 -
SEISMIC FEE
/,O S�
CONSTRUCTION LENDING AGENCY
1 hereby affirm that there is a construction lending agency for
EXHAUST HOO H{(C 5.00
the performanceofthe work for which this permit is. issued (Sec
3097, Civ.C.).
Lender's Nam Q�L- CQNS�UC%AQ
Lender'sAddress
MICROFILMM '
-
HEATI NG. UN IT' 100,000 B.T.U.) 8.00
HEATING UNIT IO
.19.50 -
ELECTRIC`
- VENTILATION FA
- INGLE) 4.00
.l certify that l have read this application and state that the above
.information is correct. 1'agree to comply with all city and county
.ordinances add stale laws relating to building construction, and.
PLUMBING
/
/ a
-
BOILER- COMP I3 H.P. or 100,000 B.T.U.) 6.00 -
BOILER (Over 100,000 BTU) SEE FEE SCH.
'MECHANICAL
p (/V_
J ,�).
hereby authorize represenla[ives,of.this city to enter upon the,
above-mentioned property for inspection purposes.
- (We) agree to`save, indemnifyjand keep)harmless the City of
Cupertino against liabilities, judgrirents, cos /and expenses which
may, in- any way :Ccrue'agaius. said consequence of the granting Of a t': 7 1+ •
P!/
MISC.' + REFER TO ORD.
CONST. TAX
Oy
d
PERMIT ISSUANCE 10.00 Q u+
MECH. CONT. . 'LIC. NO. -
,
MECH.
TOTAL -t !�
aTOTAL
. '
/0(.
Sl OC Applicant/Contractor Date
OFFICE COPY