8283 ANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
JI LDI NG PROJECT I DENTI FICATIC' PERMIT NUMBER
LOING APPLICATION & PERF ^
ADDRESS OT rTv G
O 17.5 yANJ �' BUILDING-ELECTRICAL-PLUMBING- ECHANICAL
OiNNEH'S
NAME,-.C,J1 QV
T:�Lti+N I.¢n'TeIL OTY. ELECTRIC PERMIT FEE PLAN CHECK VALIDATION
PHONE
J • CONT ACT..
OUTLETS-SWITCHES-RECEP 10.00/1.00e..TE
M
�1 LC.NO, LIGHTING FIXTURES 10.00/1.00ADDRESSTORs APPLIANCES-RESIDENTIAL00PHONE PANELS 10.00 PLICATION
AHCHrtECi PLAN CHECK FEE P.C.NO.
OR PANELS (OVER 200 AMP) 20.00
ENCINEE I�(_
1 g Y141 I.C.NO, O SIGNS TRANS. 3.00
AARCH.OR DDRESS ENG. F� /*, 4 S�.M SPECIAL CIRCUIT 5,00 PERM l/y.pltr.,T10N
SR-�-fl�i��+q zIP9 7v EMP.METER OR POLE INS. 20.00 �L/
ADDRESS �.- /1NIInc/ MOTORS SEE FEE SCH. .'JUL
__5'-❑ri01 f2 J�'S'o$ SERVICE CHANGE 20.00
,00 LICENSED CONTRACTORS DECLARATION TEMP.POLE 30.00 ,City of Cupertino
c U I hereby affirm that I am licensed under provisions of Chapter 9 ISSUANCE DATE
y ¢ w (commencing with Section 7000)of Division 3 of the Business and B ELECT. PLG. MECH.
r z Professions Code,and my license is in full force and effect ❑ ❑ 1:1z a so - License Class Lia Number
o w - Date Contractor
a x s BUILDING PERMIT
¢ a OWNER-BUILDER DECLARATION
o a U INFORMATION
X ;LL I- I hereby affirm that I am exempt from the Contractor's License MISC.- REF1EELE
RD
F ¢0 J Law for the following reason.(Sec.703 L5.tlusinessand Professions PERMIT ISSUANCE 0.00 ,r�` yALUATION S/FT.
Code:Any city or county which requiresa permit to construct,alter, !/{I"`//// /
K G improve,demolish,or repair any structure,prior to its issuance,also ELEC.CONTE. LIC.NO. C.
¢ requires the applicant for such permit to file a signed statement that TOTAL PERMIT TO
he is licensed pursuant to the provisions of the Contractor's License
r z so Law(Chapter 9(commencing with Suction 7000)of Division 3 ofthe
E i o Business and Professions Code)or that he is exempt therefrom and QTY. PLUMBING PERMIT FEE `
¢ H e the basis for the alleged exemption.Any violation of Section 7031.5 STORIES T7nCONST .
by any applicant fora permit dollals $500).licum macivil penalty ALTER-DRAIN -WATER (EA.) 5.00
of not more than live hundred dollars(tiro applicant
.1:
❑ Las owner of the properly, my employees with wages as BACK F LOW PROTECTDEVICE 400 OCC..ROUP E5.UNITS
(heir sole compensation,will do thea work,and the structure is not . .
a�rJ
intended or offered for sale (Sec. 7044. Business and Professions DRAINS-FLOOR,ROOF,AREA,COND. 5.00
Code:The Contractors License Law does not apply to an owner of
property who builds or improves thereon,and who does such work FIXTURES-PER TRAP 5.00 SO,FT.FLOOR AREA TOTAL ACREAGE
himself re through his own employces.Provided that such improve-
ments
m building
or improv not it is sold or within
onefor
year
o If,howeveq(he the owner-
GAS-EA.SVSTEM-11 6.00 O
or improvement is sold within one year of completion.the owner. GAS-EA.SYSTEM-OVER 4 IEA.) 2.00
builder will have the burden of proving that he did not build or im- BUILDING USE
p vafmpurpose of sale.)' INDUSTRIAL WASTE INTER. 30.00 R IND 0 PB oma.
1,as owner of[he properly,am exclusively contracting withEl
li c sed contractors to construct the project(Sec. 7044,Business LAWN SPRINKLERS- 1 INC 5 V.B. 6.00 ASSESSORS PARCEL NO.
:uul 1'ro1'essiom Code:The Contra.bar's License Lnw docs not apply
to an owner of property who builds or improves thereon,and who LAWN SPRINKLERS-OVER 5(EA.) 1.00
contracts forsuch projectswith a contructoos)licensed pursuant to SEWER-SANITARY-STORM EA.200ft/10.00
the Contractors License Law. TRACT NO. PARCEL NO.
❑ l am exempt under Sec._ ,0.8 .C.for this WATER HEATER W/VENT 6.00
reason _
Owner ate WATER SYSTEM 5.00
AC .OA E ACC.FILE NO.
t M C . 6 ATI )IiCLARATION WATER TREATING EQUIP. 5.00
1 hereby affirm that I have a certificate ofconsenit.self-insure.
or a certificate of Workers'Compensation Insurance,or a certified ZONING ENG.SITE NO.
copy thereof(Sec.3800,Lab.C.).
Policy Na. Company
O ❑ Certified copy is hereby furnished. FIRESPRINK ENERGY T-24
Z Z ❑ Certified copy is fled with the city inspection division.
F O Applicant MISC.: REFER TO ORD. Y C] N❑ Y E] NC3
MN CERTIFICATEOFFXEMPIION('ROM WORKERS' PERMIT ISSUANCE 10.00 tBUILDING
A.L.U.C.
LU > COMPENSATION INSURANCE PLG.CONTE. LIC.NO. PLa.
a. Z ffhis section need not be completed if the permit is for one TOTAL NE] Y O N i]
hundred dollars($100)or less.)
L) O 1 certify that in the performance of the work for which this per- DTV. MECHANICAL PERMIT FEEMARY
l it is issued,1 shall not employ any person in any manner so as In
¢mne 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 fix- eanption,you should become subject Bs the Workers'Compensation APPLIANCE 5.00 2provisions of the Labor Code, you must forthwith comply with 'Ysuch provisions or this permit shall be deemed revoked. AIR HANDLING UNIT(TO 10=C.F.M.) 4.00CONSTRUCTION LENDING AGENCY AIR HANDLING UNIT(OVER IO,000QF.M.) 6.00
I hereby affirm that there is a construction lending agency for EXHAUST HOOD(WITH DUCT) 5.00
the perfnnnoncethe work Int w cob it is omit is issued(Sec. MICROFILM
3097,Civ.C.). ^ L HEATING UNIT(TO 100,000 B.T.U.) 8.00
Leader's Name 'TN •` N1,P_,LC[C.r`.
Lrnder'z Addre G ,A.'4 -4� HEATING UNIT(O VER 100,000 B.T.U.)9.50
1 certify that I have read this application and state that the above VENTILATION FAN (SINGLE) 4.00
information correct.I agree tcomply with all city and county PLUMB
ordinances and state laws relating to building construction, and BOILER-COMP(3 H.P.or 100,000 B.T.U.) 6.00
hereby authorize representatives of this city to enter upon the
above mentioned property for inspection purposes. BOILER-COMP (Over 100,000 BTU(SEE FEE SCM. MECHANICAL
(We) agree to save, indemnify and keep harmless the City of MISC.- REFER TO ORD. I�
Cupertino against liabilities,judgments, costs and expenses which CONST.TAX
may in any way accrue sainst said Cit in consequence of the PERMIT ISSUANCE 10.00
gra al t permit. MECH.CONT. LIC.NO. MECH.
e fA ;,i �� TOTAL TOTAL
S'ignamre ul'Applicunl/Contr:mtor Date
OFFICE COPY