5092Ar PLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINLP\E(,
BUILDING PROJECT I DENTI FIC! 'N
r
APPLICATION & PE`. .IT
BUILDING - ELECTRICAL- PLUMBING -MECHA
PERMIT UMBER5092
aoILDING SI,
ADDRESS
QOO, �. DE'AN� 8L1�•i�'
OWNER' ,1
"nMF 9'vzA /"L A'>t�y cECfy�
-ti� :.- _
DTV. ' ELECTRIC PERMIT FEE''
PLAN CHECK VALIDATION
VCOk.L- CO • PHONE 'buGO
"f''
CONTRACTORS
NAME
IC* UTLETS- SWITCHES-RECEP 5.00/1.00 p
1L LIGHTING FIXTURES 5.00/1.00
44-il-eq C6EC71LV_ LIC.No.C_40 P"
DATE OF APPLICATION
PLAN CHECK FEE P.C. No,.
POOREss TORS %IST
2442,S LeAr.RlCiI.y V Li PHONE E -S7 26
2
ARCHITECT
OR
ENGINEER
uc. No.
APPLIANCES -RESIDENTIAL 4.00
Q PANELS S.DD L��
SIGNS 6.00
SIGNS TRANS. 3.00
ARCH. ORENG,
SPECIAL CIRCUIT 5.00ADDRESS
PERMIT VALIDATION
TEMP. METER OR P 15.00
ZIP
4 J
APPLICANT'S
ADDRESS
tO MOTORS SEE FEE SCH.
SERVICE CHA 10.00
+4'ZS C.EGi'E062_A ST• hLT• 1t161A! Ch
/( -
LICENSED CONTRACTORS DECLARATIONO-DO
CL Upe IRB 19;.t7
I hereby affirm that I am licensed under provisions of Chapter 9
(commencing with Section 70001 of Division 3 of the Businessand
Professions Code, ani d Wicense is in full forcq...• •rrrrl\.p
License Class 61.! Lin. Number �1`'J G GtO
ISSUANCE DATE
E Li2�- L+�
BLDG. ELECT.
❑
PLG. MECH.
Date Contractor _k(hLL t51
OWNER-BUILDER DECLAI✓ TfOhr -'
I hereby affirm that I am exempt from the Contractors License
Law for the following reason. (See. 703 LS, Businessand Professions
Code: Any city or county which requires permit to construct. alter.
improve, demolish, or repair any structure. Prior to Its issuance, also,
requires the applicant for such permit to file a signed statement that(-tU\)_L
he is licensed pursuant to the provisions of the Contractor's License
Law (Chapter 9(commencing with Section 7000) of Division 3 of the
Business and Professions Code) or that he is exempt therefrom and
the basis for the. alleged exemption. Any violation of Section 703 LS
J`"---INFORMATIBUILDING N _Z'
�� W..t.,„,INFORMATION `-'
MISC. - REFER TO ORD
vgLlannDN 5/FT.
PERMIT ISSUANCE 6.00 (7•(70
ELEG CONTR. LIC. NO. LQ E �*
�1 TA 3�a�J
AtJ_ (,-W�
PERMIT TO
EG� T
/ /
- ., ., _
OTV. PLUMBING PERMIT) \ j" ;;' I I FEE"..
- s-� ?`: - ('
STORIES
TYPE CONSTR.
by any applicant for a permit subjects the applicant to a civil penalty
of not more than five hundred dollars 155001.1:
ALTER -DRAIN & VENT -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
intended or offered for sale (Sec. 7044. Business and Professions
IBACK F LOW PROTECT. DEVICE 2.00
OCC. GROUP
RES. UNITS
DRAINS -FLOOR, ROOF, AREA, COND. 4.00
Code: The Contractor's License Law does not apply m an owner of
property who builds or improves thereon, and who does such work
FIXTUR ES - PER TRAP 4.00
SM FT. FLOOR AREA
TOTAL ACREAGE
himself or through his own employees, provided that such improve-
ments are not intended or offered for sale. If, however, the building
GAS- EA. SYSTEM - 1 INCA OUTLETS 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.).
El as owner of the property, am exclusively contracting with
`licensed contractors to construct the project (Sec. 7044. Business
GAS - EA. SYSTEM -OVER 4 IEA.) 1.00
au1LDING uSE
RES IND CON PB Om.r
[] C] E] C] E)L
I IN DUST RI A L WASTEINTER. 20.00
LAWN SPRINKLERS - 1 INC 5 V.B. 5.00
ASSESSORS PARCELNO.
and Professions Code: The Contractors License Law does nor apply
to an owner of property who builds or improvesthereon, and who
LAWN SPRINKLERS - OVER 5 IEA.) 1.00
contracts for such projects with a contmctoRs) licensed pursoan, to
the Contractor's License Law.
SEWER -SANITARY -STORM EA. 200ft/8.00
TRACT NO.
PARCEL NO.
WATER HEATER W/VENT 4.00
❑ I am exempt under Sec... BAP.C. for this
reason
Date Owner
WATER SYSTEM 4.00
ACC. DATE
ACC. FILE NO,
WORK ERS'COMPENSATION DECLARATION
WATER TREATING EQUIP. 4.00
1 hereby affirm that I have a certificate of consent to sell -insure.
or a certificate of Workers' Compensation Insurance, or a certified
ZONING
ENG. SITE NO.
copy the pL T.5ab.C.). ?a C.'
Policy N mpany
❑ Serll(md copy \shere (YrnlShe
FIRE SPR INK
ENERGY T-24
erI d with D cil®.-vatiQn division.
ApPliCanr 7 Yj
V N ❑
Y N
❑
MISC.- REFER TO ORD.
PERMIT ISSUANCE 6.00
FLOOD ZONE
A.L.U.C.
CERTIFICATE OF EXEMPTION FROM WORKERS'
PLG. CONTR. LIC. NO.
PTDTLG.AL
COMPENSATION INSURANCE
(This section need not be completed if the permit is for one
hundred dollam($100) or 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 as to
become subject to the Workers' Compensation Laws of California.
Date Applicant
NOTICE TO APPLICANT: If, atter making this Certificate of Ex
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.
Y ❑ NE)
Y NC]l
OTY ,\ MECHANICAL PERMIT~ s FEE+
- r -
}",4t�F�EE SUMMARYv_,hy
BUILDING
ALTER OR ADD TO MECH. 4.00
APPLIANCE 4.00
PLAN CHECK
FEE
AIR HANDLING UNIT (TO 10A000.F.M.) 3.00
AIRHANDLING UNIT(OVER 10=C.F.M.) 5.00
SEISMIC FEE
CONSTRUCTION LENDING AGENCY
EXHAUST HOOD (WITH DUCT) 2.00
MICROFILM
I hereby affirm that there is a construction lending agency for
the performance of the work for which this permit is issued (Sec
3097, Civ.C.).
Lender's Name
HEATING UNIT (TO 100,000 B.T.U.) 4.00
HEATING UNIT (OVER 100,000 B.T.U.)7.50
ELECTRIC
y
Lender's Address
I certify that I have read this application and stale that the above
information is correct. 1 agree to comply with all city and county
ordinances and ]'late laws re'l'ating to building c,lnstruction. and
VENTILATION FAN (SINGLE) 3,00
PLUMBING
BOILER -COMP(3H.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
abovc-mentioned property for inspection purposes.
(We) agree to save, indemnify and keep harmless the City of
Cupertino against lixbilitie. 1 d encs, costs and expenses which
may y-Iw: rue aid City in consequence of the
IT Ing IR pe IL
/ ft.r
MISC. - REFER TO ORD.
CONST. TAX
PERMIT ISSUANCE 3.00
MECH. CONT. LIC. NO.
MECH.
TOTAL
� •-'-„• 'FF'P may:
'f•'a:TOTAL•,::
„f"->se'�
Sign ora eplicant(Contmctor Do0.•
OFFICE COPY