2766APPLICANT TO FILL IN INFORMATION WITHIN REDLINES - USE BALI. POINT PEN ON
BUILDING PROJECT IDENTIFICATION'
APPLICATION & PERMIT
PE UMBER
2766
BUILDING
ADDRESS
U l.:
BUILDING - ELECTRICAL- - MECHANICAL
OWNER'$ -
NAME - _
G PHONE
_PLUMBING
QTY. ELECTRIC PERMIT FEE
PLAN CHECK VALIDATION
_
snmeATons
F/= L-ee�r"1�41c. No, e•y'1-� 797y
OUTLETS-SWITCHES-RECEP 5.00/1.00
LIGHTING FIXTURES 5.0011,00
CONTRACTORSC pej,�
AOOREss 5 e- /'
APPLIANCES -RESIDENTIAL 4.00
PANELS 5.00-
/6 Stn.,- V UtL PHONE 9,1-3(%C�
DATE OF APPLICATION
ARCHITECTSIGNS
OR
ENGINEER Lie NO
.
600
PLAN CHECK FEE P.C. NO.
SIGNS TRANS. 3.00
ARCH. OR ENG.SPECIAL
ADDRESS
CIRCUIT 5.00
PERMIT VALIDATION
EMP. METER OR POLE INS. 15.00
ZIP
Q
AS
ADDRESS
MOTORS SEE FEE SCH.
SERVICE CHANGE 10.00
0 '
LICENSED CONTRACTORS DECLARATION
-e-11,.-1-lit
1 hereby affirm that I am licensed under provisions of Chapter 91.
(commencing with Section 7000) of Division 3 of the Business and
Professions Code, and my license is in full fool oppit effec '[-
License Class_L4_ Lie. Number.SL9
Date (/- 9 Y' Contractor d/S�
a�C �, o
ISSUANCE DATE
L 1 V
BLDG.
❑
ELECT.
PILO. MECH.
❑ ❑
„
BUILDING PERMIT
INFORMATION
OWNER -BUILDER DECLARATION
I hereby affirm that I am exempt from the Contractor's License
La w for the following reason. (See. 7031.5, Businessand Professions
Code: Any city or county which requires. permit to
improve, demolish, or repair any structure, prior to its issuance, also
requires the applicant for such permit to file a signed statement that
Ise is licensed pursuant to the provisions of the Contractor's License
MISC. - REFER TO ORD
VA WATION
$/FT.
PERMIT ISSUANCE -
6.00 -construct,alter,
ELEC. CONTR. LIC. NO.
` -
f'v ���H(�, 33 797-1
ELEC.
TOTAL P�
PERMIT TO
CITY. PLUMBING PERMIT FEE
Law (Chapter 9 (commencing with Section 70000of Division 3 Of the
Business and Professions Code) or that he is exempt therefrom and
the basis for the alleged exemption. Any violation of Section 7031.5
STORIES
TYPE CONSTR.
by any applicant for a permit subjects the applicant to a civil penalty
of not more than five hundred dollars (S5001).
ALTER -DRAIN -WATER (EA.) 4.00
❑ I, as owner of the property, or my employees with wages us
their Sole compensation, will do the work, and the structure is not
BACK F LOW PROTECT. DEVICE 2.00
OCC. GROUP
RES. UNITS
DRAINS -FLOOR, ROOF, AR EA, COND. 4.00
intended or offered for sale (Sec. 7044, Business and Professions
Code: The Contractor's License Law does not apply to an owner of
properly who builds of improves thereon, and who does such work
F IXTUR ES - PER TRAP 4.00
SO. FT, FLOOR AREA
TOTAL ACREAGE
himself or through his own employees, provided that such improve
menus aremot intended or offered for sale. if, however, the building
GAS=EA.SVSTEM-11NC.40UTLET$ 4.00
I of 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.l.
❑ I, as owner of the properly, am exclusively contracting with
licensed contractors to construct the project (Sea 7044, Business
and Professions Code: The Contractor's License Law does not apply
to an owner of property who builds or improves thereon, and who
GAS- EA. SYSTEM -OVER 4 (EA.) 1.00
BUILDING USE
RES IND CON PB Orbe,
❑ ❑ ❑ ❑ ❑
INDUSTRIAL WASTE INTER. 20.00
LAWN SPRINKLERS, 1 INC 5 V.B. 5.00
LAWN SPRINKLERS - OVER 5 (EA.) 1.00
ASSESSORS PARCEL NO.
contracts for such projects with a contractors) licensed pursuant to
the Contractor's License Law,
SEWER -SANITARY -STORM EA. 200ft/8.00
TRACT NO.
PARCEL NO.
❑ I am exempt under Sec.-. B.&P.C. for this
VNATER HEATER W/VENT 4.00
reason
Date Owner
WATER SYSTEM 4.00
ACC.DATE
ACC. FILE NO.
WORK F:RS'COMPP.N'SATION DECLARATION
WATER TREATING EQUIP. 4.00
I hereby affirm that I have a certificate of consent to self -insure,
or a certificate of Workers' Compensation Insurance, or a certified
Copy the q//�i10QfLa}
Policy N J
ZONING
ENG. SITE NO.
,
eny -
Cl Certifieden py is hereby furnished
FIRESPRINK
ENERGY T 24
� Cetlif copy led with the city inspection Kvion.
,App calls
Y ❑ N❑
Y ❑ N❑
MISC.- REFER TO ORD..
CERT( FIC'A'FEOP EXEMPTION AI WORKERS.
PERMIT ISSUANCE 6.00
FLOOD ZONE
A.L.U.C.
PLG. CONTR. LIC. NO.
PLG.
TOTAL
COMPENSATION INS ANCF-
(This section need not be completed if the permit is for one
V ❑ N ❑
V ❑ N ❑
OTY. MECHANICAL PERMIT FEE
FEE SUMMARY
hundred dollars IS 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
BUILDING
become subject to the Workers' Compensation Laws of California.
Date Applicant
NOTICE TO APPLICANP: if, after making this Certificate of lix-
ALTER.OR ADD TO MECH. 4.00
APPLIANCE 4.00
PLAN CHECK
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.
FEE
AIR HANDLING UNIT (TO 10,000QRPA) 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, CN.C.).
Lender's Name
HEATING UNIT (TO 100,000 B.T.U.) 4.00
HEATING UNIT (OV ER 100,000 B.T.U.)7.50
ELECTRIC
Lender's Address
VENTILATION FAN (SINGLE) 3.00
PLUMBING
-
I certify that l have read this application and state that the above
information is correct. I agree to comply with all city and county
'ordinances Bad state laws relating to building construnion, and
BOILER- COMP (3 H.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
above-nsentioned property for inspection purposes.
MISC. - REFER TO ORD, .
CONST. TAX
(We) agree to save, indemnify and keep harmless the City of
Cupertino against liabilities, judgments, costs and expenses which
may in any way accrue against said City in consequence of the
PERMIT ISSUANCE 3.00
MECH. CONT. LIC. NO.
MECH.
TOTAL
TOTAL
I granting G sperm/
ie, f -'rL
natureofA plicam/Contralto Dale
OFFICE COPY '