5678 APPLICANT TO FILL IN INFOR TION WITHIN RED LINES - USE B POINT PEN ONLY
' PERMIT NUMBER
BUILDING PROJECT IDEN7I FICA APPLICATION & PER
BDILDII _ 5678
-`' AJOR ESS
T 100 ( 1- T tLL L 0 , BUILDING-ELECTRICAL-PLUMBING-MECHANICAL
OWNERS PLAN CHECK VALIDATION
NAME
ELECTRIC PERMIT FEE
OD( T PNONE
NAMERACTORL UTLETS-SWITCHES-RECEP 5.00/1.00 a
PGW _4N -LecTeDL sec.No LIGHTING FIXTURES 5.00/1.00 9
ro OERESS OR's PPLIANCES-RESIDENTIAL 4.00
ON`TRA r� '
AR05L3� PHONE �� PANELS- 5.00 O DATE OF APPLICATION
T PLAN CHECK FEE P.C.NO.
off SIGNS - 6.00
ENGINEER
LIC.NO SIGNS TRANS. 3.00
ARCH.OR ENG, PERMIT VALIDATION
AOORE55 SPECIALCIRCUIT } QAY 5.00
ZIP FEMP.METER OR POLE INS. 15.00
Ars
ADOROOR M MOTORS SEE FEE SCH.
Ess 11
1.139 eLo $% 12C �01 S.1 SERVIC E 10.00
o ¢ . s,
Foo LICIiNSED CONIRACI'ORS UECL RATION J
a U 1 hereby affirm that I am licensed ander provisions of Chapter 9 ISSUANCE DATE
G G (commencing with Section 7000)of Division 3,.f the Business and BLDG. ELECT. PLG. MECH.
F i Professi. Co ad my license is full force np d` _ El El
o i W License CI s Lic.Number C:.
o )ate " L contractor bhL
City of Cupertino BUILDING PERMIT
¢ sw a OWNER-BUILDER DECLARATION INFORMATION
wA H 1aw hereby affirm that I am exempt from the Contractor's License MISC.- REFER TO ORD
u O a Lfor the following reason.(See.7031.5,Business and Profen,ons VALUATION S/FT.
H - , PERMIT ISSUANCE 6.00
Code:Any city or county which requires a permit to construct,alreq
¢ ¢ ¢ iJ improve,demolish,Or repair any stn2ture,prior to its i,vuance,also ELEC.CONTn. LIC.NO. ELEC. /3 �[
a wO x requires the applicant for such p<mhil t.❑Ic a,igned smlcmcnr that TOTAL / PERMIT TO
m he is licensed pursuant to the provisions of the Contractor's License
F z s- Law(Chapter 9(co.mencing with Section 7000).(Division 3o fine EL'&r-7
¢ o Business and Prof.mns Code)or that he is cacmpt therefrom and QTY. PLUMBING PERMIT FEE
¢F the basis for the alleged eve.prion.Any vi.Utinn of Section 7031.5 STORIES TYPE CONSTR.
.w 3 - by any appliant for a permit subjects the applicant to a civil penalty -
ofnot more than five hundred dollamIS500).): ALTER-DRAIN Bt VENT-WATER (EA.) 4.00
❑ I,as..net.f the properly,Or in,employees with Wages os BACK FLOW PROTECT. DEVICE 2.00 OCs.GROUP RES.UNITS
their w1e compensation,will do the work,and the structure is not
intended or Offered for safe (See. 7044, Business and Professions DRAINS-FLOOR,ROOF,AR EA,CON D. 4.00
Code:T
he Contractor's License Law dors nod apply to an owner of
property who builds or improves thereon,and who docs wch work FIXTURES-PER TRAP 4.00 SU,FT.FLOOR AREA TOTALACHEAGE
• him.,If or through his own employe,,,provided that such improve- .
mems art not intended or offered dor safe.If,however,the building GAS-EA.SYSTEM-I INC.4 OUTLETS 4.00
or i.pr.veem is wld within one year of completion,the owner- GAS-EA.SYSTEM-OVER 4 (EA.) BUILDING USE
buim1,00
lder will have the burden of proving that he did not build or am. RES -IND CON PB 011ier
prove furs owner of,c)"), INDUSTRIAL WASTE INTER. 20,00
❑ L as owner of the omtruct he exclusively contracting with
IicensuJ contractors to construct rbc project Ser.7044,BusinessLAWN SPRINKLERS-1 INC 5 V.B. 5.DO ASS SSORS PARCEL NO.
and Professions Code:The Contractor's License Law dose not apply
I-un owns of prOpedy who builds or improves thereon,and who LAWN SPRINKLERS-OVER 5(EA.) 1.00 '
contracts for wch projects with a contomucrls)licensed pursuant to
the Conintetm,Licenl Law. SEWER-SANITARY-STORM EA.2001t/8.00 TRACT NO. PARCEL NO.
❑ 1am,xcmpt urid,r S,c. ,B.&P.C.for this WATER HEATER W/VENT 4.00
reason
Owner Date WATER SYSTEM 4-00 ACC.DATE ACC.FILE NO.
WORKERS'COMPENSATION DECLARATION WATER TREATING EQUIP. 4.00
I hereby affnn that I lave a cenilicale of,.E.nt to self-inwm, ZONING ENG.SITE NO.
or a cetifam of Workeri Compensation Insurance,or a certified
copy theumfiSee.3800.Iab,C.I QET
Policy No. Company r'fw�!
O' ❑ Certified copy is hereby fun i,hed. AIXA 18 FIRE SPRINK ENERGY T 24
z Z �CertiIt•d copy h 1 ty inspection division.
O Applicant- . � MISC.- REFER TO ORD. Y� N❑ Y � N�
CC w PERMIT ISSUANCE ' 6.00 FLOOD 20NE A.I_ll.C.
- CIiRT1EICA'fE OP ISXIiMPI'ION FROM WORKERS'
LU > COMPENSATION INSURANCE PLG.CONTH, sec NO. PLG.
CL O (This section need nod be completed if the permit c for one TOTAL vElNEI v N
Z hundred dollars(S 100)or IcV,)
U O 1 cerlify that in the performance of the work for which this eco- QTY. MECHANICAL PERMIT , FEE FEE SUMMARY. ""SL,
LL U mit is issued,I shallperson
not employ any in any mar.r so as to
become suhject to the Workers'Cnmperranion Laws of Calif.mia.
ECL.d Date Applivnt ALTER OR ADD TO MECH. 4.00 BUILDING
} w NOTICE TO AN-LICAN'I': 11,after nmking this Certificate of I... _
Z ..prion,youshould beconiembj,ct to the Workers'Compenvtiun APPLIANCE 4.00 PLAN CHECK I
provisions of the labor Code, you most forthwith comply with FEE
U such provisions m this permit shall be deemed revoked. AIR HANDLING UNIT(TO 10=r-F.M.) 3-00
CONSTRUCT ION LENIANG AGENCY AIR HANDLING UNIT(OVER 1Op00CERt) 5.00 SEISMIC FEE -
I hereby affnn that there is a construction lending agency for EXHAUST HOOD(WITH DUCT) 2.00
the pertonninre of the work for which this permit is issued(See. - MICROFILM
3097,Civ,C.), HEATING UNIT(TO 100,000 B.T.U.) 4.00
Lenderi Name HEATING UNIT l00,000B-T.U.)7.50 13 �_
Lender's Address ELECTRIC J /
l certify that l havereod lhisapplicationand state that theabove VENTILATION FAN (SINGLE) 3.00
information Is c.rrem. I ogres to comply with all city and county PLUMBING
ordimnces and stall laws relating to building construction, and' BOILER-COMP 13 H.P.or 100,000 B.T.U.) 4.00
hereby aulhonm repme nmtivice of this city to enter upon the BOILER-COMP (Over 100,000 BTU)SEE FEE SCH.
Amm-memioned property for inspection pmfoV,1. MECHANICAL
(We) agree to save, indemnify and keep harmleu the City of MISC.- REFER TO ORD.
Cupertino against Gabilifies,judgment.. costs and expenses which PERMIT ISSUANCE - 3.00 CONST.TAX
may in any way accrue agai sail City in consequence of the
g+' ling this Iet110e MECH.CONT. LIC.NO. MECH.
µ TOTAL TOTAL
i atumof Applicant/Contmctmr ale
OFFICE COPY