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APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
-6UILDINGPROJECT IDENTIFICAT
APPLICATION & PER&
BUILDING -ELECTRICAL- PLUMBING -MECHANICAL
PERMIT NUMBER
884 9
DDRE55
a°"°'"° ''
OWNER'5
ME
PHONE
QTY. ELECTRIC PERMIT FEE
PLAN CHECK VALIDATION
DATE OF APPLICATION
CONTRACTORS
naME (y
uC.no.4W 1 3
UTLETS- SWITCHES -RECEP 10.00/1.00 Q
LIGHTING FIXTURES 10.00/1.00
NAeas oRs`
PHONE
PPLIANCES-RESIDENTIAL 4.00
PANELS 10.00, 6
A CHIT",PLAN
DR l 7oS-e- 95113
S
ENGINEER
LIC. No.
PANELS (OVER 200 AMP) 20.00
CHECK FEE P.C. NO.
SIGNS TRANS. 3.00
goo 'ESS ENG'
ZIP
SPECIAL CIRCUIT 5.OB
PERMIT VALIDATION
ISSUANCE DATE
BLDG. ELECT. PLG. MECH.
E 0
EMP. METER OR POLE INS. 20.00
APPLICANTS
ADDRESS
MOTORS SEE FEE SCH. �-
-SERVICECHANGE 20.00'
LICENSED CONFRACfORS DECLARATION
1 hereby affirm that I am licensed under provisions of Chapter 9
(commencing with Section 7000) of Division 3 of the Business and
Prof -scions CotlC�n license is in full forpya�,d'i3
License Class _S.e= Lic. Numhcr L,�iP-
Date f coltlmcmARArjO:1.d_�_d �- L
an
�rebya prat this Iam x iR t from
I hereby affirm that I um exempt (mm the Conlmetors License
Law for the following reason. (Sea 7031.5, Business and Proflxsions
Code: Any city or county whichrequiresupermit to construct, alter,
improve, demolish, or repair any st ruct Lira, prior to its issuaneo, also
requires the applicant for such permit In file a signed statement that
he is licenwd pursuant to the provisions ot'the Contractor's License
Law (Chapter 9 (commencing with Sect ian 7000) of Division 3 of the
Bminea and Professions Cade) or that he is exempt theretront sodOTV.
the basis for the alleged exemption. Any violation of Section 7031.5
by any applicant fore permit subjects the applicant toecivil penalty
of not more than five hundred dollars (5500).500),):
O I, as owner of the property, or my employees with wages
sole compensation, will do the work, and the stage s as
rture is not
intended or offered for sale IS,, 7044, Business and Professions
Code The Contractor's License Law does not apply to an owner of
property who builds or improsm thereon, and who does such work
himself Or through his Own cmpl°yeas, provided that such on prove-
ments are not intended or offered for sale. If, howeser, the building
or improvement is sold within one year of completion, the owner -
builder will have the burden of proving that he did not build or am-
prove for purpose of sale.).
❑ I, as owner of the property, am exclusively contracting with
licensed contractors to construct the project (Sec. Business
and Professions Code: The Contractor's License Law does does not apply
to owner of property who builds or improves thereon, and who
contracts for such projects with a contrtracrorlsl licensed pursuant to
them License Law.
laexe
❑ lam exempt under Sec.., H.&P.C. for this
mason
TEMP. POLE 30.00
p
F1
BUILDING IN ORMATIONT
�a
MISC. - C1L7 RD
PERMIT ISSUANCEVALUATION
10.00 U�
$/FT.
ELEG CONTR. LIC. NO,
ELEC, Q
TOTAL -2,07-
-
PERMIT TO
�L'7
PLUMBING PERMIT FEE
STORIES
TYPE LONSTR.
ALTER-DRAIN-WATER(EA.) 5.00
BACK FLOW PROTECT. DEVICE 4.00
OCC. GROUP
RES. UNITS
DRAINS -FLOOR, ROOF, AREA, COND. 5.00
FIXTURES - PER TRAP 5.00
GAS-EA.SYSTEM-11NC.40UTLETS 6.00
GAS - EA. SYSTEM - OVER 4 (EA.) 2.00
56 FT. FLOOR AREA
TOTAL ACREAGE
BUILDING USE
RES IND CON PB OMar
El ❑ El 1:1 El
INDUSTRIAL WASTE INTER. 30.00
LAWN SPRINKLERS - 1 INC 5 V.B. 6.00
LAWN SPRINKLERS -OVER 5 (EA.) 1.00
ASSE RS PARCEL NO.
SEWER -SANITARY -STORM EA. 2001t/10.00
TRACT NO.
PARCEL NO.
WATER HEATER WNENT 6.00
Owner Date
WORKIiRS'COMPENSAT'ION DECLARATION
1 hereby affirm that I have a certificate of consent to self -insure.
or a eertif t of Workers' Compcn lion Insurance, or a certified
copy (her 00, Lah.C.).� �r / /k ' `�
Policy N nmr eny �, 10[J a'1
WATER SYSTEM 5.00
ACC. DATE
ACC. FILE NO.
WATER TREATING EQUIP. 5.00
ZONING
ENG. SITE NO.
❑ Certified copy is hereby furmsheJ'
Ceru/f�uq %p_y� is �flet,� /yI the city 'nspection wision.
Applican/'---rJ"T4L
FIRE SPRINK
Y(] IN
ENERGY T-24
Y1] Nf7
MISC.- REFER TO ORD.
=1-s .�/
CERTIFICATE OF Ii X17MPTION I7ROM WORKERS'
COMPENSATION INSURANCE
(This section need not he completed if the
n ncrmiI is for ons
hundred doll... IS 100) or less.)
I certify that in the perfo.m.oce of the work for which this per-
mit is issued, I shall not employ any parson is any manner so as m
become subject to the Workers' Ccmpenmlmm Laws of California.
Data Applicant
NOTICE. TO APPLICANT It, after making ()lis Cerlificate of Ex-
emption, you should become subject to the Workcrs'C,N,,Rtatioo
provisions of the Labor Code, you most forthwith Comply with
such provisions or this permit shall be deemed revoked.
CONSTRUCTION LENDING AGENCY
1 hereby affirm that there is a construction lending agency for
the performance of the work tot which this permit is issued (Sec.
3097, Civ.C.).
Lender's Name
PERMIT ISSUANCE 10.00
FLOOOZONE
V N�
A.L.U.C.
V N�
PLG.CONTR. LIC. NO.
TOTAL
DTV. MECHANICAL PERMIT FEE
FEE SUMMARY
BUILDING
ALTER OR ADD TO MECH. 5.00
APPLIANCE 5.00
PLAN CHECK
FEE
AIR HANDLING UNIT (TO 10=12-F.M.) 4.00
AIR HANDLING UNIT (OVER 10=C.F.M.) 6.00
SEISMIC FEE
EXHAUST HOOD (WITH DUCT) 5.00
MICROFILM
HEATING UNIT (TO 100,000 B.T.U.) 8.00
Lcndcr's Address
1 certify that I have read this application and state that the above
information u c.rrvcl I nice to comply with all city and county
ordirunces and state laws relating to building construction, and
hereby authorize representatives of this city es 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 which
may in any way accrue i mm said City in consequence of the
g ting flhispermil'
HEATI NG UNIT (OVER 100,000 B.T.U.) 9.50
ELECTRIC p
VENTILATION FAN (SINGLE) 4.00
BOILER-COMP(3 H.P.Or 100,000B.T.U.) 6.00
PLUMBING
801 LER-COMP (Oxer 100,000 BTU) SEE FEE SCH.
MECHANICAL
MISC. - REFER TO ORD.
PERMIT ISSUANCE 10,00
CONST. TAX
MECH.CONT. LIC. NO, MECH.
TOTAL
'
TOTAL
Signature of Applinnl/Contractor Daze^
OFFICE COPY