4984APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALI. POINT PEN ONLY
' BUILDING PROJECT IDENTI FICATION
_
APPLICATION &PERMIT
BUILDING - ELECTRICAL_PLUMBING- MECHANICAL
PERMIIT NUMBR
9 8'4'
PLAN CHECK VALIDATION
ImILDING
ADDRESS I Cl9 zp 0`1Ia ao p"
OWNER'S y'L3Z:
NAme QR-y
- -�----------__--
DTV. ELECTRIC PERMIT FEE
' PHONE Cj
DTDns
NAME -
NAME
OUTLETS -SWITCHES -RECEP 5.00/1.00
LIGHTING FIXTURES - 5.00/1.00
'
rR GI, %_ uc. No.
\
CONTRACTOR
ADDRESS -
ADDRESS
APPLIANCES -RESIDENTIAL 4.00
PANELS 5.00
p l
Z30 �+� pJePRONE� O
DATE OF APPLICATION
ARCHITECTSIGNS
OR
ENGINEER
LIC -NO r
6,00
PLAN CHECK FEE P.C. NO,
SIGNS TRANS. '3.00
ARCH. OR ENG.
ADDRESS.
SPECIAL CIRCUIT 5,00
PERMIT VALIDATION
EMP. -METER OR POLE INS. -. 15.00
_
- - ZIP
APPLICANT'S: + -,
ADDRESS '
'MOTORS SEE FEE SCH.
SERV I CE CHANGE 10.00
-
' LICENSED CON"I'RACTO RS 1) EC LA RAT]ON
%I hereby affirm. l hat I am Ii Demand under provisions of Cha pier 9
(commencing with Section 7000) of Division 3 of the Business and
Professions Code n license is in full fou; utdgfli,
License Class Lie. Number �`-^"u'73I'
DateContractor
ISSUANCE DATE
-
+.
BLDG.
❑
ELECT. P.G. MECH.
•❑ ❑
'
BUILDING PERMIT
OWNER -BUILDER DIiCLARATION
affirm ing 1 am exempt bunt the C(antraBusinessact Pr Lssions
1 herebythe
Law fornycitllowingreywhch(Sec.
requires permittocnd Professions
to its issuance, also
Code: Any city or coy ntywhiny reyairesap prior
improve, demolish, or repair any structure, prior to its issuance, also
INFORMATION
MISC.- REFER TO ORD
VALUATION - .
$/FT.
PERMIT ISSUANCE 6.00
ELEC. CONTE. LIC. NO.
ELEC.
for such permit In fIFa signed statement that
the dp pursuant
requires ilicensed
heis licensed purstmnt to the provisions of the Contractor's License
_
TOTAL
PERMIT TO
pp
QTY. PLUMBING PERMIT FEE
1
Live (Chapter 9(commen6ing with Section 7000) of Division 3 ofthe
Business and Professions Code) or that he is exempt therefrom and
the basis for the alleged exenption. Any violation o f Seetim. 7031.5
Ci -
STORIES
TYPE CONSTR.
ALTER -DRAIN -WATER (EA.) 4.00
by any applicant for o permit subjects the applicant to a civil penalty
of not more than live hundred dollar, (4500).):
o I, as owner of the property, or my cmployecs with wages az
their sole Compensation; will do the work, and the structure is not
intended or offered for sale (Sec. 7044. Business and Pro ssions
BACK FLOW PROTECT. DEVICE 2.00
-
OCL. GROUP
REB. UNITS
,
DRAINS -FLOOR, ROOF, AREA, COND. 4.00
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 4.00
SO. FT, FLOOR AREA
TOTAL ACREAGE
himself or through his own employees, provided that such improve-
ntentaare not intended or offered for sale. H, however, the building
-
GAS - EA. SYSTEM - 1 1 PIC. 4 OUTLETS 4.00
r improvement is sold within one year of completion, the owner-
builder will have the burden of proving that he did not build or int
prove for purpose of saleJ.
'❑ 1, as owner of the property, am exclusively contracting with
licensed contractors to construct the project ISec 7044, Business
. ..
GAS - EASYSTEM -OVER 4'IEA) 100
BUILDING USE
RES IND CON PB Omer
❑ ❑ ❑ ❑ 0
INDUSTRIAL WASTE INTER. 20.00
LAWN SPRINKLERS - 1 INC 5'V.B. 5.00
ASSESSORS PARCEL NO.
and Professions Code: The Contractors License Law dies not apply -
to an owner of property who builds or improves thereon. anJwho
LAWNSPRINKLERS- OVER 5 (EA'.)'.' 1.00
Contracts for such projects with a contraclortzl licensed pursuant to
the Contractors Licinse Law,
' .
SEWER -SANITARY -STORM EA. 200ft/8.00
TRACT NO.
PARCEL NO.
WATER HEATER / - 4.00
❑ A lin exempt under -Sec. B:,@P.C.'lor��hii
lealon
DatL. OwnDr
WATER SYSTEM _. A 4.00
ACC. DATE
ACC. FILE NO.
WORK Ii RS'COM PENSA'I'I ONDECLARA'1'ION
WATER TRE QUI ^'� .I 4.00
1 hereby affirm (hat I have a certificate ofconsem to self -insure.
or a ceHificate of Workeri Compensation Insurance or a certified
ot_
ZONING
ENG. SITE NO.
copy thereof (See. 3800, Lah.C.)
Polfcy No. Com.��pany ;F=0}L0(7T ��
.❑ Certified copy is hereby furnished. -%/+U,)
❑ CertifiSg copy is filed P, the aty inspection Jmision,
1 r G E
CIeRTIFICA'I':OP P:X MPTION FROM WO "IiRS'
COMPENSATION INSURANCE
'IThis .,,end not be completed if the pernit is l'or on e
44
a
Ap
FIRE SPRINK
y� N�
•ENERGY T-24
Y N�
REFER TO ORD.
PERMIT ISSUANCE 6.00 �`
.- FLOOD ZONE
YE] NE)
A.L.u,c. -
Y,❑ NE]
PLG.CONTR:.' -LIC NO
- -
PLG.G'A'O
.
TOTAL a
QTY. MECHANICAL PERMIT FEE
FEE SUMMARY
hundred dollars(51001 or less) '
1 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
becenm subject to the Workers'Compensation Laws o(California.
Diuc Applicant
: BUILDING
ALTER OR ADD TO MECH. 4.00
f Ex-
NOTICIi TD APPLICANT: it, He, making this Certil'kmc lit'.
emption, you should become subject to the Workers' Compensation
cription,
provisions of the Labor Code, you must forthwith comply with
such provisions m this permit shall be drevmd revoked
-
APPLIANCE - 4.00 ;
PLAN CHECK
FEE
AIR HANDLING UNIT (TO 10=C.F.M.) 3.00
AIR HANDLING UNIT(OVER 10SMC.F.M.) 5.00
SEISMIC FEE ,
`coNSTRUC.PION LENDINGAGENCY
EXHAUST HOOD (WITH DUCT) 2.00
I hereby affirm that there is a construction lending agency for
' the performance of the work for which this permit is issued i Sec.
3097, Civ.C.l, -
MICROFILM
HEATING UNIT (TO 100,000 B.T.U.) 4.00
UNIT (OVER 100,000 B.T. U.)7.50 -
'ELECTRIC
'Lender's NameHEATING
Lender's Address
VENTILATION FAN (SINGLE) ' 3.00
PLUMBING
3�'�.
I certify that I have read this application and slate that the above
inforntiou is correct. I agree to comply with all city,and cotmly
ordinances and state laws relating to building construction. and
hereby authorize representatives of this city to enter upon the
'
BOILER -COMP(3 H.P.Or.100,000B.T.U.) 4.00
-BOILER-COMP (Over 100,000 BTU) SEE FEE SCH.
MECHANICAL
above-mentioned proRerty for inspe'c'tion purposes. , l
(We) agree w save, indenmify aud.kcep harmless the City of
Cupertino against liabilities, judgments, costs and expenses which
may in any way accrue ainst sai,,''(L.^^City in mseyuence of the
gr�nOf Ihis perm it// dY6G�
hTr�.u�/ff' &.�L/
1
MI SC. - - REFER TO ORD.
CONST. TAX
PERMIT ISSUANCE 3.00
MECH. CONT. LIC. NO.
MECH.
TOTAL
TOTAL
Signature of Applicant/Contractor Date
,OFFICE COPY