10220 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
BUI LDI NG PROJECT I DENTI FIC PERMIT NUMBER
BUILDING APPLICATION & PEWIT 10220 ADD.Ess 1` //��J^O 1� ��(( M1,vE BUILDING - ELECTRICAL-PLUMBING-MECHANICAL I O 2 2 O
°NAMERS D C& tMMWWF W
PLAN CHECK VALIDATION
QTY. ELECTRIC PERMIT FEE
c-,w',,�p PRONE
0Tt NARMERAcraRs .;4Ya� QQj UTLETS-SWITCHES-RECEP 10.00/1.00
Uc.Nc. 333 LIGHTING FIXTURES 10.00/1.00
CONTRACTOR'S
oOREss PPLIANCES-RESIDENTIAL 4.00
2 PRDrvE PANELS AID-1 0 00 DATE OF APPLICATION
ARCHITECT PLAN CHECK FEE P.C.N0.
OR PANELS (OVER 200 AMP) 20.00
ENGINEER
Llc.No. SIGNS TRANS. ( 3.ARCH.OR 00
ADDRESS ENG SPECIAL CIRC 5,00 PERMIT VALIDATION
APPLICANTzZIPEMP.METER O -
ADDRESS Q11{1 20.00
Sn
MOTORS SEE FEE SCH.
' SERVICE CHANGE 20.00
o ¢ i
Hoo LICENSED CONTRACTORS UIiCLA RATION TEMP.POLE 30.00 �+
¢ v I a z w hereby al'fnn that I am licensed underprovisions of Chapter 9 PAID
ISSUANCTE 'S
v,a A (commencing with ction 7000)of Division 3 of the Business and SLOG. ELECT. PLG. MECH.
H w i Professions Code,J5 my license is in full F. I
z i m.,-L/ License las Lin.N actor, BEQ 16 ^ ❑ . / ❑ ❑
m H w7. DBm � �Contraclor,
Q y i J
¢ ¢ re a OWNER-BUILDER DECLARATION BUILDING PERMIT
wi.LL y 1 hereby affirm that 1 am exempt from the Contractor's License MISC.- e'ty CUPOORTO ORD INFORMATION
u 0 j Law for the following reason.(Sec.7031.5,business and Profession VALUATION 3/FT.
H - PERMIT ISSUANCE 10.00
Code:Any edy"rcounty whiehrequrresupermit to construct,alter, U -
re ¢ 0 Improve,demolish,Or repair any Structure,prior to Its Issuance,also ELEG CONTR. LIC.NO. ELEC.
D LL requires the applicant for such permit t0 file a signed statement that TOTAL
n w m he is licensed pursuant to the provisions of the Contractor's License PERMIT TO
HiQLaw(Chapter 9(commemcing with Seclion 7000)of Division 3 ifthe
4o Business and Professions Coda)or that he is exempt Dmrefrom and
¢ H m the basis for the alleged exemption.Any violatiQTY. PLUMBING PERMIT FEE
on of Section]031.5 STORIES TYPE CONSTR.
Ate _ by any applicant for a permit subjects the applicant tua Civil penalty AL -TER -WATER (EA.) 5.00
of not more Ihan five hundred dollars(S500)J:
❑ I,as owner of the property,or my employees with wages as BACK FLOW PROTECT. DEVICE 4.00 OCC.GROUP RES.UNITS
their sole compensation,will do the work,and the structure is not
intended or offered for side (Sen. 7044, Business and Professions DRAINS-FLOOR,ROOF,AREA,COND. 5.00
Code:The Contractor's 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 or through his own employees,provided that such improve-
mentsarenotintendedorofferedforsxle.If,however,the building GAS-EA.SYSTEM-I1NC.40UTLETS 6.00
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. GAS-EA.SYSTEM-OVER 4 (EA.) 2.00 BUILDING USE
prove for purpose of sale.). RES IND CON PB Othv
❑ 1,as owner of the property,am exclusively contracting with INDUSTRIAL WASTE INTER. 30.00 0 El ❑ El
and
contractors to construct the project(Sec. 7044,Business LAWN SPRINKLERS- 1 INC 5 VB600 ASSESSORS PARCEL NO.
and Professions Code:The Contractor's License Law does not apply . . .
to in owner of property who builds or improves thereon.and who LAWN SPRINKLERS-OVER 5(EA.) 1.00
contracts for such projects with a contruclods)licensed pursuant to
the Contractor's License Law. SEWER-SANITARY-STORM EA.200It/10.00 TRACT NO. PARCEL NO.
C, I am exempt under Sec. ,B.&P.C.for this WATER HEATER W/VENT 6.00
Owner Date WATER SYSTEM 5.00 ACC.DATE ACC.FILE NO.
WORKFRS'COMPENSATION DECLARATION WATER TREATING EQUIP. 5.00
1 hereby affirm that I have a certificate ofconsent to self-insure,
or a certificate of Workers'Compeppssa t iog In umnec r a certified ZONING ENG.SITE NO.
copy thereof(Sen.3500,Lah.C.). CJ.-IO YID; �o
Policy No. Comp ,y
❑ Cer[ifiedpy i • ",--i.� FIRE SPRINK ENERGY T-24
Z Z VCertifiied Bw city inspcclion divisims.
F, O APndnant- o - MISC.- REFER TO ORD. 090 N� v [] IN
= w CIS RTI I'I CA'IT O I'Ii X FM PTI ON FROM WO RK Ii RS' PERMIT ISSUANCE 10.00 FLOOD ZONE AC.UG.
W > COMPENSATION INSURANCE PLG.CONTR. LIC.NO. PLG.
CL ❑ (This section need not be completed if the permit is for one TOTAL Y❑ IN Y❑ N❑
::) Z hundred dollars IS 100)TU less.)
U O 1 certify that in the perl'onnance of the work for which Otis per- QTY. MECHANICAL PERMIT FEE FEE SUMMARY
IL F mit is issued,I shall not employ any person in any manner so as to
U become suhject to the Workers'Compensation Laws of California.
¢.
Date-Applicant ALTER OR ADD TO MECH. 5.00 BUILDING
} w NOTICE TO APPLICANT: If,aper making this Certificate of Ex-
F ? emption,you should become subject to the Workers'Compcnsalion APPLIANCE 5.00 PLAN CHECK
provisions of the Cahn, Code, you most forthwith comply with
CJ such provisions or this permit shall be deemed revoked: AIR HANDLING UNIT(TO 10MC.F.M.) 4.00 '•t FEE
CONSTRUCTION LENDING AGENCY AIR HANDLING UNIT(OVER 10MC.EM.) 6.00 I SEISMIC FEE'
I hereby affirm that there is a conanctm.Icnding agency lir. EXHAUST HOOD (WITH DUCT) 5.00
the performance of the work for which this permit is issued(Sec MICROFILM
3097,Civ.C.). HEATING UNIT(TO 100,000 B.T.U.) 8.00
Lenders Name
Lender's Address HEATI NG UNIT(OVER 100,000 B.T.U.)9.50 ELECTRIC
1 certify that I have read this application and state that the above VENTILATION FAN (SINGLE) 4.00
m nnnation is correct. 1 agree to comply,with all city and mumty PLUMBING
ordinuntts and state laws relating to building construction, and BOILER-OOIx9POH.P.Dr100,000B.T.U.) 6.00
hereby authoriee representatives of this city to enter upon the BOILER-COMP 00ver 100,000 BTU)SEE FEE SCH. MECHANICAL
above-mentioned property for inspection purposes.
We) agree to save, indemnify and keep harmina the City of MISC.- REFER TO ORD.
C Ono against liabilities ' Igmunts, costs and expenses which CONST.TAX
any w y a -rue Buil 't said City in concqucnce of life PERMIT ISSUANCE 10.00
- r t T I, per u. MECH.CONT. LIC.NO. MECH,
TOTAL TOTAL
Signature of Applican onhantor ` U tc
OFFICE COPY
0 /
I
ELECTRIC SERVICE NOTICE OFFICE COPY
BUILDING INSPECTORS NOTICE
CITY OF CUPERTINO
2
ia - 2a 19 �
To
Yoa are hereby authorized to Connect electrical service for
1 o
'Owner or TenontAt � -
7 r 31/7
No.of Wires Slze of Wires Size of Switch )oil
Motor Load VOltage Phase
Heating Load K.W. Voltage
(1 LgN 110_—New Service " Reconnea
No.of Meters / J Heat 120Three Wlre More Service
No.of Add. Meters 111 Power Three Phase Move Meter
Q• ELECTRICAL INSPEC70R