12224APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
BUILDING PROJECT 1 DENTI FICATION
APPLICATION &PERMIT
-'
BUILDING—ELECTRICAL—PLUMBING—MECHANICAL
PERMIT NUMBER
'
12224
BUILDING
aooREss \
21796 Hyannis Port Drive
OWNER'S
NAME
Louis Lau PHONE 257-6316
QTY.LECTRIC PERMIT FEE
PLAN CHECK VALIDATION
DATE OF APPLICATION
CONTRACTOR'S
NAME
Atlas Heating LIC.N0465266XTURES
ITCHES -RECEP 10.00/1.00
10.00/1.00
CONTRA
ADDRESS ons
155 Commercial St. PHONE 739-0516
-RESIDENTIAL 4.00
10.00
ARRCHITECT
ENGINEER-
LIC.No.
ER 200 AMP) 20.00PLAN
CHECK FEE P.C. NO.
S. 3.00
ARCH. OR ENG.
ADDRESS
ZIP
SPECIAL CIRCUIT 5.00
PERMIT VALID
/ C�
'�,,y/-1'p�
—1
ISSUANCE DATE
BLDG. ELECT. PLG. MECH.
❑ ❑ ❑
KEE
EMP. METER OR POLE INS. 20.00
ADDRESSTs
MOTORS SEE FEE SCH.
SERVICE CHANGE 20,00
LICENSED CONTRACTORS DECLARATION
1 hereby affirm that 1 am licensed under provisions of Chapter 9
(commencing with Section 7000) of Division 3 of the Business and
Professions Cod license license is in full toren mAefkGt.
Licens ys Contra for Atlas
Dale Contractor Atlas
_ -S-7
OWNER -BUILDER DECLARATION
I hereby affirm that I am exempt from the Contractor's License
Law for the following reason. (Sec. 7031.5. Businessand Professions
Code: Any city or county which Structure permit to construct, alter,
print to its issuance, also
improve, demolish, or repair any rmit to file
requires the applicant for such permit to file a signed statement that
he is licensed pursuant to the provisions of the Contractor's License
Law (Chapterand Professions therefrom the
Business and Professions Code) or that he is exempt therefrom and
odeng ) or Section is 00) exempt
the basis for he alleged exemption. Any violation of$ection 7031.5
by any applicant for a permit subjects the applicant to a civil penalty
of not mote than five hundred dollars (S500)J:
❑ 1, 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
Code: The Contractor's License Law does not apply to an owner of
property who builds or improves thereon, and who does such work
himself or through his own employees, provided that such improve-
ments are not intended or offered for sale. If, however, the building
or improvement is sold within one year of completion, the ownMer-
builder will have the burden of proving at he did not build or im-
prove for purpose of sale.).
❑ 1, as owner of the property, am exclusively contracting with
licensed contractors to construct the project (Sec. 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
contracts for such projects with a contractors) licensed pursuant to
the Contractor's License Law.
am exempt under Sea .&
,BP.C. for this
reason
son
BUILDING PERMIT
INFORMATION
MISC. — REFER TO ORD
PERMIT ISSUANCE 10.00
VALUATION
S/FT.
ELEC. CONTR. LIC. N0.
ELEC.
TOTAL
PERMIT TO
rJ
DTV. PLUMBING PERMIT FEE
ALTER -DRAIN & VENT -WATER (EA.) 5.00
STORIES
TYPE CONSTR.
BACK FLOW PROTECT. DEVICE 4.00
OCC. GROUP
RES. UNITS
DRAINS -FLOOR, ROOF, AREA, COND. 5.00
FIXTURES - PER TRAP 5.00 -
SO. FT. FLOOR AREA
TOTALACREAGE
GAS - EA. SYSTEM - i INC.4 OUTLETS 6.00
GAS - EA. SYSTEM -OVER 4 (EA.) 2.00
BUILDING USE
RES IND CON PB Omar
INDUSTRIAL WASTE INTER. 30.00
LAWN SPRINKLERS - 1 INC 5 V.B. 6.00
ASSESSORS PARCEL NO.
LAWN SPRINKLERS - OVER 5 (EA.) 1.00
SEWER -SANITARY -STORM EA. 200ft/10.00TRO.CTNO.
PARCEL NO.
WATER
WATER HEATER W/VENT 6.00
Owner Date
WATER SYSTEM 5.00
WORKERS'COMPF.NSATION DECLARATION
1 hereby affirm that I have a certificate of consent [.'self -insure.
or a certificate of Workers' Compensation Insurance, or a certified
copytherp�> r �o0, Lab.C.). Allied Pac'
Policy Ndy' ompany
ACC. DATE
ACC. FILE NO.
WATER TREATING EQUIP, 5.00
ZONING
ENG. SITE NO.
❑ Certified copy is hereby furnished.
L$ Certifieda py is tiled with the City inspection division.
APPlicant Ati aS Hea-t}}}�
MISC.- REFER TO ORD.
FIRE SPRINK
N�
ENERGY T-24
Y N�
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(This section need not be completed if the permit is for one
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
become subject to the Workers' Compensation Laws of California.
Date Applicant
NOTICE TO APPLICANT: If, after 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.
CONSTRUCTION LENDING AGENCY
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
Lender's Address
1 certify that I have read this application and state that the above
information is correct. I agree to comply with all city and county
ordinances and stale laws relating to building construction, and
hereby authorize repreuntatives of this city to 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 against said City in coD��"c
PERMIT ISSUANCE 10.D.
FLOOD ZONE
Y ❑ N[3
A.L. u.c.
Y N[3
PLG CONTR. LIC. NO.
JY�
PLC.
TOTAL
QTY. MECHANICAL PERMIT FEE
FEE SUMMARY
BUILDING
ALTER OR ADD TO MECH. 5.00
APPLIANCE 5.00
PLAN CHECK
FEE
AIR HANDLING UNI ( 0 10,000 $11A) 4,00
AIRHANDLINGUNIT IOV 40 ,F.M.) 6.00
.SEISMIC FEE
EXHAUST HO T DUCT)500
.
MICROFILM
ELECTRIC
HEATING UNI (TO 10 .U.1 8.00 .QQ
HEATI NG UN IT (0%% 0,000 B.T.U.) 9.50
VENTILATION FAN (SINGLE) 4,00
BOILER- COMPOH.P. or 100,000 B.T.U.) 6.00
PLUMBING
BOILER -COMP (Over LOg000 BTU) SEE FEE SCH.
MECHANICAL
/e QU
MISC. - REFER TO ORD.
PERMIT ISSUANCE 10001000gmnlingpp
CONST. TAX
MECH. CONT. LIC. NO. MECH.TOTALSignture
Atlas Heating 465266 $18.00
nnnv
TOTAL
of Appbonl
neuro