11509 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
s� PERMIT NUMBER
BUILDING PROJECT IDENTIFICATION APPLICATION & PERMIT -T
a°"°'"G 11509
auonitssO� l (��1f`ll.e4- �p BUILDING-ELECTRICAL-PLUMBING-MECHANICAL
earl.,. Owry ER's f I`'kL l �./ - PLAN CHECK VALIDATION
""'�'G " E CITY. ELECTRIC PERMIT FEE
ke C���er' PHONE
'CONTRACTOR 6 OUTLETS-SWITCHES-RECEP 10.00/1.00
NAME
O .15L-V#50111 �NG.383u1� LIGHTING FIXTURES 10.00/1.00
f.ONTRACTORS APPLIANCES-RESIDENTIAL 4.00
WL, 0Ia1&-J
Y PHON ita• voo PANELS 10.00 DATE OF APPLICATION
ARCHITECT .PANELS(OVER 200 AMP)
20,00 PLAN CHECKIFEE P.C.NO.
OR
ENGINEER
LIC NO. SIGNS TRANS. 3.00
AARCH.OR DDRESS ENG. SPECIAL CIRCUIT 5,00 PERMIT VALIDATION
ZIP TEMP.METER OR POLE INS. 20.000 )
AMOTORS SEE FEE SCH.
ADDRESS DREss
SERVICE CHANGE 20.00 ,,,r� /
w w o LICENSED CONTRACTORS DECLARATION ���7
a U u 1 hereby affirm that 1 am licensed under provisions of Chapter 9 ISSUA CE DATE
G 'u (commencing with Section 7000)of Division 3 of the Business and SLOG. ELECT. PLG. MECH.
Professions Cod d my license is in full a�e(
Z D 4 - Licte C{a Lic.Number Jul, ❑ ❑ ❑ ❑
g w Date '` - !_Contractor
a m f b ' BUILDING PERMIT
E M w Q OWNER-BUILDER DECLARATION INFORMATION
io A u MISC.- � O ORD
s g n I hereby affirm that I am exempt from the Contractor's License VALUATION $/FT.
-a.0 Law forthe following reason,(See.7031.5,Businessand Professions PERMIT ISSUANCE 10.00
rCode:Any city or county which requiresa permit to construct,alter,
Q Q Q 0 Improve,demolish,Or repair any Structure,prior to IIs Issuance,also ELEC.CONTR. LIC.NO. ELEC.
d - D, requires the applicant for such permit to file a signed statement that TOTAL 50, PERMIT TO
whe is licensed pursuant to the provisions of the Contractor's License
i TC
riLa. 9(commencing with Section 7000)of Division 3 of the %x-/J3, OL(z
i o Business and Professions Code)or that he is exempt therefrom and OTY. .PLUMBING PERMIT FEE
Fe I- Z the basis for the alleged exemption.Any violation of$ection 7031.5 STORIES TYPE CONSTR.
TR? by any applicant for a permit subjects the applicant fon civil penally ALTER-DRAIN&VENT•WATER IEA.) 5.00
of not more than five hundred dollars($500).):
O 1,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 (Sec. 7044, Business and Professions DRAINS-FLOOR,ROOF,AREA,COND. 5.00
.e: Code:The Contractor's License Law does not apply to an owner of
property who builds or improves thereon,and who does such'v odk FIXTURES-PER TRAP 5.00 So.FT,FLOOR AREA TOTAL ACREAGE
s himself or through his own employees,provided that such improve-
ments ore not intended or offered for sale.If,however,the building GAS-EA.SYSTEM-11 NC.4 OUTLETS 6.00
or improvement is sold within one year of completion,the owner. GAS-EASYSTEM OVER 4 (EA.) 200 BUILDING USE
builder will have th . - . .
e burden of proving that he did not build or im- RES IND CON PB Osner
prove for purpose of sale.). - INDUSTRIALWASTE INTER. 30.00 ❑ ❑ ❑ ❑ ❑
❑ d as owner of the property,he exclusively.744,contracting with
licensed contractors to construct the project La 7044,Business LAWN SPRINKLERS-1 INC 5 V.B. 6.00 ASSESSORS PARCEL NO.
and Professions Code:The Con tractor s License Law does not apply
to artowner of property who builds or improves thereon,and who LAWN SPRINKLERS-OVER 5(EA.) 1.00
contracts for such projects with:I coNracfods)licensed pursuant Io
the Contracmr's License Law. SEWER-SANITARY-STORM EA.200ft/10.00 TRACT NO. PARCEL NO.
0 lam exempt under Sec.-,B.&P.C.for this WATER HEATER W/VENT 6.00
reason
Owner - Date WATER SYSTEM 5.00 ACC.DATE ACC.FILE NO,
WORKERS'COMPENSATION DECLARATION WATER TREATING EQUIP. 5.00
1 hereby affirm that I have a certificate of consent toulf-insure, ZONING ENG.SITE NO.
or a certificate of Workers'Compensation Insurance,or a certified
copy thereof(Sec.3800_-
800,Lab.C.).
Policy No. Company
Q u0 Cu"
i fled copy is hereb 'urn' ad. FIRE SPRINK ENERGY T-Z4
Z < Certified w d 1 I the city inspec ibn division.
Applicant ms' s MISC.- REFER TO ORD. v❑ .N❑ Y ❑ N❑
~ mPERMIT-ISSUANCE 10.00 FLOOD ZONE A.L.u.c.
CC CERT MATE OF WM41ON FROM WORKERS'
_ COMPENSATION INSURANCE - PLG.CONTR. LIC.NO. PLG.
C' O This section need not be completed if the permit is for one TOTAL Y❑ N❑ v❑ N❑
D Z hundred dollars($100)or less.) -
U O 1 certify that in the performance of the work for which this Per. CITYMECHANICAL PERMIT FEE FEE SUMMARY
IL f mit is issued,I shall not employ any person in any manner oe as to
U become subject to the Workers'Compensation Laws of California.
0 OL Date Applicant ALTER OR ADD TO MECH. 5.00 BUILDING
DO NOTICE TO APPLICANT: If,after making this Certificate of Ex. -
Z emption,you should become subject to the Workers'Compensation APPLIANCE ' 5.00 PLAN CHECK
provisions of the Labor Code, you must forthwith comply with FEE
U such provisions or this permit shall be deemed revoked. AIR HANDLING UNIT(TO 10AO0C.F.M-) 4.00
CONSTRUCTION LENDING AGENCY AIR HANDLING UNIT(OVER 10p000.F.M.) 6.00 SEISMIC FEE
1 hereby affirm that there is a construction lending agency for EXHAUST HOOD(WITH DUCT) 5.00
the performance of the work for which this permit is issued(See. MICROFILM
3097,Civ.CJ. HEATING UNIT(TO 100,000 B.T.U.) 8.00
Lender's Name 3G 0-0
Lender's Address HEATING UNIT(0 100,000 B.T.U.19.50 ELECTRIC
.$.1� I certify that 1 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
y � ordinances and state laws relating to building construction, and BOILER•COMPI3 H.P.Or IO0,000B.T.U.) 6.00 '
\ hereby authorize representatives of this city In enter upon the BOILER-COMP IOver 100,000 BTU)SEE FEE SCH. MECHANICAL
above-mentioned property for inspection purposes.
(We) agree to save, fade nify and keep harmless the City of MISC.- REFER TO ORD.
Cupertino against liabilitie udgmenls, costs and ezpenus which CONST.TAX
M ay i way ue ainst said Ci y in consequence of the PERMIT ISSUANCE 10.00
run ' tis rn L MECH.CONT. LIC.NO. MECH.
TOTAL TOTAL
Si t p t [mclor Date
OFFICE COPY .
C^
ELECTRIC SERVICE NOTICE OFFICECOPY
BUILDING INSPECTOR'S NOTICE
fV(
CITY OF CUPERTINO
To
You are hereby authorized to Connect electrical service for
'Owner or Ienont f.l
At
s No.of Wires
Size of Wires Size of Switch
Major Load Voltage Phase
Heating Lood K.W. Voltage
New Service Reconnect
Light I10_
No.of Meters J r More Se.vice
`) Heor 170__Three Wire
No.of Add.Meters Power ree Phase Move Meter
Q• ELECTRICAL INSPECTOR