11558APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
BUILDING PROJECT IDENTIFICATION
APPLICATION & PERMIT
BUILDING —ELECTRICAL— PLUMBING —MECHANICAL
PERMIT NUMBER
11558
BUILDING
ADDRES10_11r
D 4 ! S �L U•> -r TREE �,�:
OWNER'S
NAME
G, E. ' /AMPSOAS DNEas�'4t74
OTY. ELECTRIC PERMIT FEE
PLAN CHECK VALIDATION
DATE OF APPLICATION
CONTRACTOR
NAME / /� 7�
/
4p.Lm. NO. 49ryC/fG
UTLETS-SWITCHES -RECEP 10.00/1.00
LIGHTING FIXTURES 10.00/1.00
CONTRACTORS
ADDRESS n
y'yaAle,K15f 2p-'PHONE92q-4;
APPLIANCES -RESIDENTIAL 4.00
PANELS 10,00
ORCRITECTPANELS(OVER
OR
ENGINEER A /
LIC. NO.
200 AMP) 20.00
PLAN CHECK FEE P.C. NO,
SIGNS TRANS. 3.00
ARC K OREND.
ADDRESS
ZIP
SPECIAL CIRCUIT 5,00
PERMIT VALIDATION
Q
a1f c A Y
ISSUANCE DATE
ITEMP. METER OR POLE INS. 20.00
ADDRESS
ADDRESS
'
MOTORS SEE FEE SCH.
SERVICE CHANGE 20.00
LICENSED CONTRACTORS DECLARATION
I hereby affirm that I am licensed under provisions of Chapter 9
(commencing with Section 7000) of Division 3 of the Business and
Professions Code atIq my license is in full force a d effect.
License C�a7�-_�.f7„. Lic. Numbese G f
Dale 7911---L��XI1::G�w---ntractor _i.�.2lGe-t
OWNER.BUILDER DECLARATION
I hereby collo that 1 on exempt from the Contractor's License
Professions
Law fmthe followingreason(Sec.uires Business to construct,
Code:
e,dmcity sh cot my which requitersp riort umnsuancalter,
or repair any structure, tore, e a prior n Its issuance, also at
improve, he applicant
requires the applicant for such permit to file a signed statement that
he is licensed pursuant m the provisions ol'the Contractor's License
Law (Chapter 9 (commencing with Section 70001 of 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
by any applicant for a permit subjects the applicant ma civil penalty
of not more than five hundred dollars (S500)J:
❑ I, as owner of the property, or my employees with wages as
their sole compensation, will do the work, and the Sinaloa! 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
properly who builds or improves thereon, and who does such work
himself or through his own employees, provided that such improve-
mcnisarenotintendedoruffered for sale. IL however, the building
or 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.)
❑ 1, as owner of the properly, am exclusively contracting with
licensed contractors to construct the project (Sec. 7044, Business
and Nmfesslans 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.
❑ 1 am exempt under Sec. , B.&P.C, for this
reason
BLDG.
❑
ELECT.
1:1
PLG. MECH.
11Co
BUILDING PERMIT
INFORMATION
MISC.— REFER TO ORD
VALUATION
$/FT.
PERMIT ISSUANCE 10.00
ELEC. CONTR. LIC. NO.
ELEC,
TOTALPERM
TO
me
CITY. PLUMBING PERMIT FEE
STORIES
TYPE CONSTR.
ALTER -DRAIN -WATER IEA.) 5.00
BACK F LOW PROTECT. DEVICE 4.00
OCC. GROUP
RES. UNITS
DRAINS -FLOOR, ROOF, AREA, COND. 5.00
FIXTURES -PER TRAP 5.00
SO. FT. FLOOR AREA
TOTAL ACREAGE
GAS-EA.SYSTEM-11NC.40UTLETS 6,00
GAS - EA. SYSTEM - OVER 4 IEA.) 2.00
BW )DING uSE
RES IND CON PS Omar
❑ ❑ ❑ ❑ ❑
INDUSTRIAL WASTE INTER3000
. .
I LAWN SPRINKLERS- 1 INC 5 V.B. 6.00
LAWN SPRINKLERS - OVER 5 (EA.) 1.00
ASSESSORS PARCEL NO.
SEWER -SANITARY -STORM EA. 200ft/10.00
TRACT NO.
PARCEL NO.
WATER HEATER W/VENT 6.00
Owner Date
WATER SYSTEM 5.00
ACC.DATE
ACC. FILENO.
WORK Ii RS'COMPENSATION DECLARATION
1 hereby affirm that I have a certificate of consent to selfinsure'
or a certificate of Workers' Compensation Insurance, or a certified
copy thereof(Sec. 3800, Lab.C.). r
Policy No. CompanyCGL/ItZe+>%
❑ Certified copy is hereby furnished, cg7 -,,r.r !LI
❑ Certifip� pop Is filed with the cit/y �Inspection vision.
Applicant_f lfelfrL�F�iK�s�1'`s'« CO��—
WATER TREATING EQUIP. 5.00
ZONING
ENG. SITE NO.
FIRE SPRINK
Y ❑ IN❑
ENERGY T-24
V ❑ N❑
MISC. - REFER TO ORD.
CE RTI F I CATE OF EX I7M PTI ON FROM WOR K Ii RS'
COMPENSATION INSURANCE.
(This section need not he completed if the permit is for one
hundred dollars IS 100) or less. )
I certify that in the performance of the work far which this per-
.it is issued, 1 shall not employ any person in any manner so as to
become subject to the Workers' Compensal ion Laws of California.
Date Applicanl
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
PERMIT ISSUANCE 10.00
FLOOD ZONE
Y ❑ N ❑
A.L.U.O.
Y ❑ N ❑
PLG. CONTR, LIC. NO.
PLG.
TOTAL
DTV. MECHANICAL PERMIT FEE
FEE SUMMARY
BUILDING
ALTER OR ADD TO H. 5.00
APPLIANCE (' fJJ 5.00
PLAN CHECK
FEE
AIR HANDLING UN O 1Op00OF.M.) 4.00
AIR HANDLING UNITIOVE
Qf 6.OD
SEISMIC FEE
EXHAUST HOOD IV
UCT) 5.00
MICROFILM
HEATING UNIT (TO 100,000 B.T.U.) 8.00
H EATI N G U N IT I OV ER 100,000 B.T.U.) 9.50
ELECTRIC
Lender's Address
I 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 state laws relating to building construction, and
this city es enter upon the
hereby auihoriee representatives ins' inspection
above-mentioned properly forinsp ofpurposes.
(We) agree to save, indemnify and keep harmless the City of
Cupertino against liabilities, judgments, costs and expenses whichPERMIT
may in any way accrue against mid City in consequence of the
gram gofthisperntit
?
VENTILATION FAN (SINGLE) 4.00
PLUMBING
BOILER-COMP(3H,P.Gr100,000B.T.U.1 6.00
BOILER -COMP IOver 100,000 BTU) SEE FEE SCH.
MECHANICAL
MISC, - REFER TO ORD.
CONST. TAX
ISSUANCE 10.00 Q "
MECH.
MECH.0 NT. LICAGA
_ d� f - I TOTAL ��
E
TOTAL
ignature of Applicant/ ntra o Date
OFFICE COPY