3290APPLICANT TO FILL IN LNFORMATION WITHIN RED LINES - USE BALI- POINT P.EN ONLY
1 'NG ' is • -
BUILDING PROJECT IDENTI FIC; 1N APPLICATION&PE IIT
am LmrvD ' 00 E z A B L
ADSS
DRE
GL0PEf:/1/0 CA BUILDING -ELECTRICAL- PLUMBING -MECHANICAL
PERMIT NUMBER
3290
.
OwNER'S E, :, zq Z •j .',-. .:.: .'w •x )�. fl"3-
"Ante - QTY'. ~".,ELECTRIC PERMIT' _: '`:3'1 ',FEE
PLAN CHECK VALIDATION
PHONE
GATE OF APPLICATION
PLAN CHECK FEE P.C. N0.
coNTRACTORS
NAME
THE KOHL '�L-IC. NO
UTLETS- SWITCHES -RECEP 5.0011.00
LIGHTING FIXTURES 5.00/1.00
CONTRACTOR'S 'GSI � 1' 5t�
ADDRESS C
$�� 65I - GA. 951'dlSr�.-
ARCHITECT
'TA E �!.
OW, V
PPLIANCES-RESIDENTIAL 4.00
PANELS S.00
SIGNS 6,00
SIGNS TRANS. 3.00
INpMCIR
sec. No.
ARCH 6p.tgC //
ADDRI:ss Z,(POO �, Bays IHKE Q
PALO AL7a Ch• el'zIo)a3
SPECIALCIRCUIT 5.00
PERMIT VALIDATION
1.
,/
/ �� 4,
1p('
EMP. METER OR POLE INS. 15.00
ADDRESS rs O ) c y I
ADDRESS
(a(0 OtINiOa< Cf-'f_J CA." 2
MOTORS SEE FEE SCH.
SERVICE CHANGE 10.00
LICENSED CONTRACTORS DECLARATION
I hereby affirm that I am licensed under provisions of Chapter 9
ISSUANCE DATE
(commencing with Section 7000) of Division 3 of the Business and
Professions Cade, and m li is in full force Slyeffect.
License ClasU�ic. Number
BLDG. ELECT.
❑ ❑
PLG. MECH.
I�
❑ I�
Da[erConlmctar �a.spp
OWNERBUILDER DECLARA•iID HANI CA
I hereby affirm that I am exempt from the Contractor's License
P
Law for thefollowing reason.(Sec:diness,Business and Professions
BUILDINGPERMIT'IY,TP
".'S'
MISC. - REFER TO ORD
ALUA IORMATION VF
VALUATION E/FT.
PERMIT ISSUANCE 6.00
countywhich structurep riort to construct. also
Code:e, demolish,
improve, demolish, or repair any structure, prior to its issuance, also
ELEC. CONTR. LIC. NO.
ELEO.
requires the applicant for such permit to file a signed statement that
he is licensed pursuant to the provisions of the Contractor's License
Law (Chapter 9(commencing with Section 7000) of Division 3 of t he
Business and Professions Codel or that he is exempt therefrom and
the basis for the alleged exemption. Any violation of Section 7031.5
TOTAL
�� PER T
^'� �' • - s •'."ly4 •^" i�
QTY: ' ' •-: PLUMBING PERMIT'S "w FEE J
.+.i a+, • i.. :P}n'•J "l•�t' «�:_
BTORIES
TYPE CONSTR.
by any applicant for a permit subjects the applicant to a civil penalty
of not more than five hundred dollars (S500).1:
ALTER-DRAIN&VENT-WATER (EA.),4.00
❑ 1, as owner of the property, or my employees with wages as
their sole compensation, will do the work, and the stntcture is not
intended or offered for sale (Sec. 7044. Business and Professions
BACK FLOW PROTECT. DEVICE 2.00
OCC. GROUP
RES. UNITS
OR,
DRAINS-FLOROOF, AREA, COND. 4.00
Code: The Contractor's License Law does not apply tD an owner of
property who builds or improves thereon, and who does such work
FIXTURES - PER TRAP 4.00
S(L FT. FLOOR AREA
TOTAL ACREAGE
himself or through his own employees. provided that such improve-
mens are no[ intended or offered for sale. If, however, the building
GAS -EA. SYSTEM -11NC. 4OUTLETS 4.00
or improvement is sold within one year of completion, the owner-
builder will have the burden of proving that he did not build or im-
prove for purpose of sale.).
❑ 1, as owner of the property, am exclusively contracting with
licensed contractors to construct the project (Sec. 7044. Business
GAS - A. SYSTEM -OVER 4 (EA.) 1,00
BUILDING USE
RES IND CON PS CO.,
❑ ❑ ❑ ❑ ❑
INDUSTRIALWASTE INTER. 20.00
LAWN SPRINKLERS - 1 INC 5 V.B. 5.00
ASSESSORS PARCEL NO.
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 - OVER 5 (EA.) 1.00
contracts for such projects with a contractods) licensed pursuant to
The Contractor's License Law.
❑ lam exempt under Sec.-. BAP.C. for this
SEWER -SANITARY -STORM EA. 200ft/8.00
TRACT NO.
PARCEL NO.
WATER HEATER W/VENT 4.00
reason
,
Date Owner
WATER SYSTEM 4,00
ACC.DATE
ACC. FILE NO.
I��RKERS5 COMPENSpptt��'[[Ipyypryry_DGc,LA RAT ION
I he by "a1TCnm That 14a a AIA: cam of consent to self-inrurc.
or a c4 ificate Of Workers' Compensation Insurance. or a cerlirQ
WATER TREATING EQUIP. 4.00
ZONING
ENG. SITE NO.
copy the ( ec. 3800, Lab.C.).
Policy No. Company Q G YA L ') B R I
❑ Certif..d coPy it hereby Fornishe
Certified copy is Bled with the city inspection division.
cant
FIRE SPRINK
V N❑
ENERGY T-24
YN❑
❑
MISC. - REFER TO ORD.C]Appl
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
section need not be completed if the permit is for one
hundred dollars 151001 ar less.(
I certify that in the performance of the work for which this Per-
mit is issued, I shall not employ any person in any manner so us to
become subject to the Workers Compensation Laws of California.
Date Applicant
NOTICE TO APPLICANT: If, after making this Certificate of Ex-
emption, you Should become subject to the Workers' Compensuion
provisions of the Labor Code, you must forthwith comply with
such provisions or this permit shall be deemed revoked.
PERMIT ISSUANCE 6.00
FLOOD ZONE
V❑ N❑
A.L.U.C.
Y❑ NC]
PLG. CONTR, LIC. NO. PLG.
TOTAL
'• H "sNs?a�'
QTY ., ?' . eMECHANICAL PERMIT S"'^ ''ts FEE A,
'#� fi _ lx . . I }L ,,/• a d - Fdl..i - s' h
4' FEE_'.SUMMARY'�-
! h.
7,T
`•^w +' '-�
BUILDING
ALTER OR ADD TO MECH. 4.00
APPLIANCE 4.00
PLAN CHECK
FEE
T =C.F.M.) 3.00
AIR HANDLING UNIT (O 10
zEz
AIR HANDLING UNIT (OVER IQOOOC.F.M.) 5.00 j
SEISMIC FEE
CONSTRUCTION LENDING AGENCY
EXHAUST HOOD (WITH DUCT) 2.00
MICROFILM
1 hereby affirm that there is a construction lending agency I'or
the performance of the work for which this permit is issued (Sec.
3097, Civ.C.).
Lenders Name
HEATING UNIT (TO 100,000 B.T.U.) 4.00
eL HEATING UNIT (OVER 100,000 B.T.U.P.50 I,j
ELECTRIC
PLUMBING
Lender's Address
1 certify that I have read this application and stale that the above
information is correct. I agree to comply with all city and county
ordinances send stale laws relating to building construction. and
hereby aulhon c representatives of this city to enter upon the
above-mentioned property for inspection purposes.
(We) agree to save, indemnify and keep harmless the City of
Cupertino against liabilities, judgments. Costs and expenses whichPERMIT
may in any way accrue against mid City in consequence of the
granting of this permit.
VENTILATION FAN (SINGLE) 3.00 3
BOILER-COMP(3 H.P. or 100,000 B.T.U,) 4,00
BOILER -COMP C., IW,000 BTU)SEE FEE SCH. 30
MECHANICAL
C
MISC. - REFER TO ORD.
CONST. TAX
i,>r.A'," v:;py",ar•y�aa
�
>'D TOTAL .o
- �._.e• "'`='•/"^'
ISSUANCE 3.00 .3
MECH. CONT. LIC. NO. TOTAL O
Polyfaf�E 273829 56
PfFCHA AIC0,L
Signature Dl ApplicantlCnnlmctor Date
OFFICE COPY