1370.AEPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONL��1
BUI LDI NG PROJECT 1 DENTI FICATION -
1'
APPLICATION & PERMIT
(�.
ILDING - ELECTRICAL- PLUMBING - MECHANICAL
PE u HER
0
.
PLAN CHECK VALIDATION
BUILDING f
ADDRESS 10(41 30BR P^' ^
/Y- u13SlNY VFeI/l e, Ull'/
OWNER'S - -
NAMi
CITY. ELECTRIC PERMIT FEE
PHONE
-NameJAcr'oas1,I 1,-y
OUTLETS -SWITCHES -RECEP 5.00/1.00 eqlp
LIGHTING FIXTURES 5.00/1.00
� CV hJl uc vo.
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CONTRACTORS - -
ADDRESS
APPLIANCES 4.00
M
PHONE -444(
1' PANELS 5.00
DATE OF APPLICATION'
ARC TELT
OR
ENGINEER
'( .uc. No.%
SIGNS, 6.00
PLAN CHECK FEE P.C. NO.
SIGNS TRANS.3.00
ADDRESS ENG
SPECIAL CIRCUIT 5.0O
PERMIT VALIDATION'
•nP95i3/EMP,
METER OR POLE INS. 15.00
�1
APPLICANT'S
' ADDRESS
MOTORS IQ4{rP I �61+(� SEE FEE SCH. ''�.
SERVICE CHANGE 33 hip 10.00
LICENSED CONTRACTORS DECLARATION
I hereby affirm that I am licensed under provisions of Clmpter 9
(commencing with Section 7000) of Division 3 of the Business and
Professions Code and my license is in full force and effect.
Class_ (0 Lic. Number !36V311-_."
ISSUANCE DATE
-
BLDG.
ELECT.
I\
PLG. MECH.
El
Date Contractor
'IY'
OWNER -BUILDER DECLARATION
I hereby collo that I OR exempt from the contractor's License
Business and Professions
Law for the following reason. (Sec. requires
Code: Any mulish. oumy which structure permit to construct, alter, also
requires; demolish, or repair any structure; prior n its iateme t also
requires the applicant for such permit to file a signed statement that
he is licensed pursuant to the provisions of the Contractor's License
(commencingwithSection is 00) exemfttherefion oof the
w(Chand Professions
Business
Business and Professions Code) or that he is exempt therefrom and
BUILDING PERMIT
INFORMATION
MISC.- REFER TO ORD
VALUATION
SIFT.
PERMIT ISSUANCE 6.00 00
ELEG CONTR. LIC. NO.
TELEC
OTAL r1f
TOTAL J "
PERMIT TO
'
L6C7-
7T,
GT I r OF /� PLUMBING PERMIT FEE
STORIES
TYPE CONSTR.
the
nttSection
cora exemption. Any
C
nya applicant
by any applicant foraiLnd,c dollars the applicam toacivil penalty
tsthea applicantmalty
of not more than five hundred dollars 18500).1:
-
TER -DRAW NT-WATER(EA.)4.00
❑ I, as owner of the property, or my employees with wages as
their sole compensation, will do the work, and the structure is not
K FI,,9VJftqTECT. DEVICE 2.00
OCC. GROUP
RES. UNITS
DRAINS- FLOO , ROOF, AREA, COND. 4.00
intended or offered for safe (See. 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 does such work
himself or through his own employees, provided that such improve-
mems are not intended or offered for sale.' If, however, the building
F I -PER TRAP 4.00
90, FT. FLOOR AREA
'
TOTAL ACREAGE
GAS-EA.SYSTEM-1 INC.4 OUTLETS 4.00
or improvement is sold within one year of completion, the owner-
builder will have the burden of proving that Ise did not build or ins,
prove 1, aso nee of safe.).
❑ as owner of the property, exclusively contracting with
GAS - EA, SYSTEM -OVER 4 (EA.) 1.00
BUILDING USE
.RES IND CON Pe Omer
.0 ❑ 0 ❑ ❑
INDUSTRIAL WASTE INTER. 20.00'
he
licensed contractors to construct the project La does Business
d .704,
and Professions Code: The Contractor's License Law does not apply
to who an owner of property who builds or improves thereon, and who
LAWN SPRINKLERS- 1 INC 5 V.B. 5.00
LAWN SPRINKLERS -OVER 5 (EA.) 1.00
ASSESSORS PARCEL NO.
contracts for such projects with a contractors) licensed pursuant to
theContmctor'sLicense Law.
"SEWER -SANITARY -STORM EA. 200ft/5.00
TRACT NO,
PARCEL NO.
❑ I am exempt under Sec , BAP.C. icor this
reason
WATER HEATER W/VENT 4.00
Date Owner
WATER SYSTEM - 4.00
Ace. DATE
ACG FILE NO.
WATER TREATING EQUIP. 4.00
WORKF-RS'COMPENSATION DkLARATION,
1 hereby affirm that I have a certificate of consent to self -insure.
or a Certificate of Workers' Compensation Insurance, -or -a, certified
ZONING
ENG. SITE NO.
copy thereof(Sec. 38I0 0, Lab C.).
Policy No. Company �4
-
FIRE SPRINK
y E] N
ENERGY T24
y 0 -NE]
1 ❑ Certife 'oPY is hereby furnished.
Guthrie cJ�y(//�s�J{{jleG��r�h-t`te city inxpection division.
Adplcant.-�{;'
MtSC. - REFER TO ORD,
l
CERTIFICATE OP EXEMPTION PROM WORKERS'
PERMIT ISSUANCE 6.00
FLOOD ZONE
A.LU.C.
PLD. CONTR. , LIC. NO.
PLG.
TOTAL
COMPENSATION INSURANCE '
(This section need not be completed if the permit is far one
Y E] N
V ❑ NE]
CITY. MECHANICAL PERMIT FEE
FEE SUMMARY
hundred dollars (S 100) or less,)
I certify that in the performance of the work for which this per,
mil is issued, I slmll not employ any person in any manner so as to
BUILDING
-
become subject to the Workers' Compensation Laws of California.
Dale - Applicant
NOTICE TO APPLICANT: If, after making this Certificate of Ex-
ALTER OR ADD TO MECH. 4.00
APPLIANCE 4.00
PLAN CHECK
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.
FEE
AIR HANDLING UNIT (TO 10=11F.M.) 3.00
AIR HANDLING UNIT (OVER 10SWC.F.M.) 5.00
SEISMIC FEE
CONSTRUCTION LENDING AGENCY'
I hereby affirm that there is a construction lending agency for
EXHAUST HOOD (WITH DUCT) ,2.00
the performance of the work for which this permit is issued (Sec
3097, Civ,C.)..
Lender's Name
MICROFILM
HEATING UNIT (TO 100,000 B.T.U.) 4.00
HEATING UNIT (OVER 100,000 B.T.U.)7.50
ELECTRIC
Lender's Address
I, certify that I have read this application and state that the above
information is Correct. I agree to comply with all city and county
- ordinances and state laws relating to building construction, and
VENTILATION FAN (SINGLE) 3.00
PLUMBING
-
BOILER- COMP(3 H. P. or 100,000 B.T.U.) 4.00
BOILER -COMP (Over 100,000 BTU) SEE FEE SCH.
MECHANICAL
hereby authorize representatives of this city to enter upon the
above-mentioned property for inspection purposes.
MISC. - - REFER TO ORD.
CONST. TAX
" -
(We) agree to save, indemnify and keep harmless the City of
Cupertino against liabilities, judgments, costs anJ expenses which
may in any way accrue against said City in consequence of the
PERMIT ISSUANCE 3.00
MECH. CONT. LIC. NO,
TOTAL
TOTAL
'
"grajaftg-s thinn.
a���"ti
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Signat�reofA plicnnf/'ontragor etc
OFFICE COPY