9204 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
BUILDING PROJECT IDENTIFICATION PERMIT NUMBER
BUILOING APPLICATION & PERMIT
LDDRE$ -J9 2 0 4
2211/ BUILDING -ELECTRICAL-PLUMBING-MECHANICAL
OWNER'S PLAN CHECK VALIDATION
rvAME d"7- pyTY. ELECTRIC PERMIT FEE
PHONE x PAID
CONTRACTOR'S
NA 2 //II/y G./ OUTLETS-SWITCHES-RECEP 10.00/1.00
Ct 61 4 k.C.No. LIGHTING FIXTURES 10.00/1.00 JUL 21985
CONTA ACTOR'S /' PPLIANCES-RESIDENTIAL 4.00
ADDRESS � Q J
,x/ fM PHONE arS-tH PANELS 10.00 DATE. F APPLAC4TION
ogcRITECT PANELS (OVER 200 AMP) 20.00 E P.C.No.
ENGINEER
Lie.No. SIGNS TRANS. 3.00
ADDRESS END. PER CIRCUIT 5.00 PERMIT VALIDATION
ZIP EMP.METER OR POLE INS. 20.00
APPLI DDRE55ESS
ADDRESS MOTORS SEE FEE SCH.
SERVICE CHANGE J 20.00 Q A
0 0 o LICENSED CONTRACTORS DECLARATION TEMP.POLE 30.00 OWL,
O. 1 hereby affirm that I am licensed under provisions of Chapter 9 ISSUANCE DATE
y a u, (commencing with Section 7000)of Division 3 of the BRSIRCSS and BLDG. ELECT. PLG. MECH.
H y z Professions Code d 1 license is m full fore• d - ❑ ❑ ❑
i o w - License C ns n Lic.Numher
0 w r we Uate Contractor
,Z s a BUILDING PERMIT
Icw OWNER-BUILDER DECLARATION INFORMATION
oAMISC.- REFER TO ORD
w y 1 hereby allino Ilett I am oxmnpt from the COntr'uctots License VALUATION $/FT.
HLL04 Law for the following reason.(See.7031.5,Business and Professions PERMIT ISSUANCE HY.fJ(f
Code:Any city or county which requires a permit to construct,alley _
ce u¢o improve,demolish,or repair any structure,prior to its issuance,also ELEC.CONTR. LIC.NO. ELEC. /
O LL requica the applicant for such porn.it to III.a Signed slalernedt that TOTAL 's PERMIT TO
A w$ he is licensed pursuant to the provisions of the Contractor's License �L.EC7
m
a Law(Chapter 9(comencingwith Section 7000)ol DivismF3 ofthe
Business and Professions Code)or that he is exempt therefrom and OTY. PLUMBING PERMIT FEE r
r p the basis for the alleged exemption.Any violation of Section7031.5 STORIES TYPE CONSTR.
a3 � by any applicant for a permit subjects the applicant to a civil penalty ALTER-DRAIN -WATER (EA.) 5.00
of not more than five hundred dollars(5500).):
❑ 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 sale(See. 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 docs such work FIXTURES-PER TRAP 5.00 SO.FT.FLOOR AREA TOTAL ACREAGE
• himselfor through his own employees,provided that such improve-
ments are not intended or offered for sale.If,however.the building GAS-EA.SYSTEM-1 INC.4 OUTLETS 6.00
or improvement is sold within one year of completion,the owner. GAS-EA.SYSTEM OVER 4 (EA.) 200
builder will have the burden of proving that he did not build o - . .
r im. BUILDING USE
prove for purpose ofsale.). INDUSTRIAL WASTE INTER. 30.00 RES IND CON PB oer
❑ 1,as owner of the property,am exclusively contracting with w❑ ❑ ❑ ❑ ❑
licensed contractors to construct the project(Sec 7044.Business LAWN SPRINKLERS- 1 INC 5 V.B. 6.00 ASSESSORS PARCEL No.
and Professions Code:The Contractor's License Law docs not apply
to an owner of property who builds or improves thereon,and who LAWN SPRINKLERS-OVER 5(EA.) 1.00
contracts for such projects with a contractions)licensed pursuant to
the Contractors License Law. SEWER-SANITARY-STORM EA.200ft/10.00 TRACT NO. PARCEL NO.
❑ I am exempt under Sec. .B.&P.C.for lhfs WATER HEATER W/VENT 6.00
reason
Owner Date WATER SYSTEM 5.00 ACC.DATE ACC.FILE NO.
WORK HRS'COMPFNSA1]ON DECLARATION WATER TREATING EQUIP, 5.00
1 hereby affirm that I have a certificate Of consent In self-insure. ZONING
or a certificate of Workers'Compensation Insurance,or a certified ENG.SITE NO.
copy thereof(Sec.3800,LAC I
A C.I / i/
Policy No. Con.pany� ^� !n
O ❑ Certified copy is hereby furnished. FIRE SPRINK ENERGY T-24
ZO / lt�I e c I In ection division.
Applicant }
MISC.- REFER TO ORD. Y ❑ No Y ❑ N❑
CC m CERT IFICATE OIs EXEMPTION PROM WORKERS' PERMIT ISSUANCE 10.00 FLOOD ZONE A.L.U.C.
LU �i, COMPENSATION INSURANCE- PLG.CONTR. ❑c.NO. PLG.
CL Z (This section need not he completed if 0¢ permit is for one TOTAL Y E3 ❑ Y❑ NE]N
hundred dollars(4100)or less)
U O I certify than in the performance Of the work for which this per- QTY. MECHANICAL PERMIT FEE FEE SUMMARY
U,_ U mit is issued, I shall not employ any person in any manner so as to
become subject to the Workers'Compensation Laws of Caft.nua.
y Date ApplicantALTER OR ADD TO MECH. 5.00 BUILDING
} W NOlIC17 TO APPLICANT; If,after making this Certificate of Ex-
(- ? emption,you should become subject to the Workers'Compensation APPLIANCE 5.00 PLAN CHECK
provisions of the Labor Code, you must forthwith comply with FEE
U such provisions or this permit shall he deemed revoked AIR HANDLING UNIT(TO 1OPMCF.M.) 4.00
CONSTRUCTION L17NDING AGENCY AIRHANDLING UNIT(OVER 10A000.RM.) 6.00 SEISMIC FEE
1 hereby affirm that there is a construction lending agency for EXHAUST HOOD (WITH DUCT) 5.00
le efforC.)nce of the work for which this permit is issued(Sec. MICROFILM
HEATING UNIT TO 100,000 B.T.U.) 8.00
a
Lender's Name NHEATING UN IT(OVER 100,000 B.T.U.)9.50 ELECTRIC �
Lender's NameAddress -t�
I certify that l have read this application and state that the above VENTILATION FAN (SINGLE) 4.00
• information is correct. I agree to comply with all city and county - PLUMBING
ordinances and state laws relating to building construction, and BOILER-COMP(3 H.P.or 100,000 B.T.U.) 6.00
hereby authorize representatives of this city to enter upon the BOILER-COMP love,100,000 BTU)SEE FEE SCH. MECHANICAL
above-mentioned property for inspection purposes.
(We) agree to save, indemnify and keep harmless the City of MISC.- REFER TO ORD.
Cupertino against liabilities,judgments, costs and expenses which PERMIT ISSUANCE 10.00 CONST.TAX
mayty way Scenic agains said City in consequence of the"anThis rmiL H.CONT. LIC.NO. .TOTALTOTAL,I ca Contractor ate u
f�F�_E COPY
ELECTRIC SERVICE NOTICE OFFICECOPY
BUILDING INSPECTOR'S NOTICE
CITY OF CUPERTINO
To
19a
You are hereby authorized to Connect electrical service for
Owner or Tenant /:—: 0 /,rtiG
At I ERS'%7P` p1?
No.of Wires Size of Wires
Size of Switch
Motor Load Voltage Phase
Heating Load . . . K.W. Voltage \/
/No.of Meters Light 110New Service Reconnect
Heat-120—Three Wire More Service
No.of Add.Meters Pawer ThreePhase Move Meter
ELECTRICAL I NSPECTOR
4
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