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APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY ,/R
BUI LDI NO PROJECT I DENTI FICA I
APPLICATION & PEI T
BUILDING - ELECTRICAL - PLUMBING- MECHANICAL
PER T N ER
1 835
BUILDING
ADDRESS
6 � r
rv=ER S
PRONE 9G
]'S `,�
QTY:
' '- r - }' n Y - p Vy` '-
•ELECTRIC PERMITe,`y" ;• nx
i f
%?c: <y
rFEEP;
. {4 n%:
PLAN CHECK VALIDATION
DATE OF APPLICATION
CONTRACTORS �' _79
uc.NO.
UTLETS - SWITCHES - RECEP 5.00/1.00
N
LIGHTING FIXTURES 5.0011.00
ADDRESS TORS
PHONE
APPLIANCES - RESIDENTIAL 4.00
PANELS 5.00
ARCHITECT
on ENGINEER
uc. NO.
SIGNS 6,00
PLAN CHECK FEE C. NO.
R/D
SIGNS TRANS. 3.00
ARCH. OR END.
ADDRESS
ZIP
SPECIAL CIRCUIT 5.00
PERMIT VALIDATION
_O
/�� AIM
ISSUANCE DATE
BLDG. EDT, pLG. MECH.
❑
TEMP, METER OR POLE INS. 15.00
APPLICANTS
ADDRESS
/
MOTORS SEE FEE SCH.
§
SERVICE CHANGE 10.00
LICENSED CONTRACTORS DECLARATION
I hereby affirm that 1 am licensed under provisions of Chapter 9
(commencing with Section 7000) Of Division 3 of he Business and
ro fe ssions Cod =nd y lice is in lull fore (f�ect.
License Class / 1 ic, Number
Date a4j-7_ . Contractor dU15w�6
OWNER - BUILDER DECLARATION
I hereby affirm that 1 am exempt from the Contractor's License
Law for the following reason. (See, 7031.5, Business and Professions
Code'. An cif or count
Any y y it my structure permit isuanc alter,
improve, demolish, or repair Any structure, prior to its issuance, also
requires the applicant for such permit to file a signed statement that
he is (Chapter pursuanten the provisions of the )ofDicmT's License
Law (Chapter9( commenting with Section 70001 sfDivision3ol the
Business and Professions Code) ar that he is exempt therefrom and
the basis for the alleged exemption. Any violation of Section 7031.5
by any applicant fore permit subjects the 00.): am toacivil penalty
of not more than five hundred dollars (my employees ❑ Las owner of the property, or my employees with wages as
(heir 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 owner -
builder will have the burden of proving that he did not build or ma.
prove for purpose of sale.).
❑ L as owner of the property, floe exclusively contracting 704, with
licensed contractors : construct the project (Sec. 7044, Business
and Professions Code: The Contractor's License Law does not apply
to an
contracts for such projects with a coniraemrlsl licensed pursuant to
tr owner of property who builds tr improves thereon. and t to
the Contractor's License Law.
reaCl I am exempt under Sec. ,B. &P.C. (OT INS
son
r Te' -, BUILDING PERMIT,
' 'e ' INF,ORMATION " s+
` '
MISC. - REFER TO ORD
PERMIT ISSUANCE 6.00
gsy
VALUATION
S /FT.
ELEC. CONTR. LIC. NO.
�E
ELEC. J
TOTAL
PERMIT TO
"�� -
?:
OTY'.
-
^, ;a
: ° PLUMBINOPERMITfr`'
-
•p
`CFEE' -n
IFE
"'ip';
STORIES
/
TYPE CONSTR.
ALTER- DRAIN -WATER IEA.)4.00
BACK FLOW PROTECT. DEVICE 2.00
OCC. GROUP
RES. UNITS
DRAINS - FLOOR, ROOF, AREA, COND. 4.00
FIXTURES - PER TRAP 4.00
GAS - EA. SYSTEM - I INC.4 OUTLETS 4.00
SO FT. FLOOR AREA
TOTAL ACREAGE
GAS - EA. SYSTEM - OVER 4 (EA.) 1.00
BUILDING USE
RE� ❑N ❑ ❑
INDUSTRIAL WASTE INTER. 20.00
LAWN SPRINKLERS - 1 INC 5 V.B. 5.00
LAWN SPRINKLERS -OVER 5 (EA.) 1.00
ASSESSORS PARCEL NO.
OWWf::a///fff��� OW
SEWER-SANITARY-STORM EA. 200ft /6.00
T ADr NO.
PARCEL NO.
WATER HEATER W /VENT 4,00
Dace Owner
WORKERS'COMPF.NSATION DECLARATION
I hereby affirm that I have a certificate of consent to self- insure,
or a certificate of WorIs op�pe Iop,�pglya ce, or a certified
copy tftreul1 3/OOIZ�BI. J /Ia8
PoliljNo. ompany
WATER SYSTEM 4.00
.,°O�
ACC. DATE
Ace. FILE No,
^�
WATER TREATING EQUIP. 4.00
ZONIr�G
/
END. SITE N0.
❑ Certified copy is hereby fu shed.
�q, Certified p Ia fled with t it I pection division.
Applicant ,sl%�e'�/
FIRESPRINK
Y [] W
ENERGY T 24
Y>r N�
MISC. - REFER TO ORD.
I1(-(�
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(This section need not be compteted if the permit is far one
hundred dollars ($100) or lev.l
I certify that in the performance of the work for which this per-
red is issued, I shall not employ any.peraon in any manner so as to
become subject to the Worken' Compensation laws of California.
Date Applicant -
PERMIT ISSUANCE 6.00
FLOOD ZONE
Y 0
�wtere -�
PLC. CONTR. ❑C. NO.
pLG. �O
TOTAL
QTY:
.
�} - x MECHANICAL`PERMIT - -°' -
n '-
-
'FEED
n.S A.,{- FEE,SUMNIARY
BUILDING
�H
Ti
ALTER OR ADD TO MECH. 400
.
NOTICE TO APPLICANT: If, after making this Certificate of Ex.
emotion, you should become subject to the Workers' Compensation
provisions of the Labor Code, you most 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, Co.C.).
Lender's Name
APPLIANCE 4.00
AIR HANDLING UNIT (TO 10=C.F.M) 3.00
PLAN CHECK
FE
SEISMICFEE
012,
`-'�-
AIRHANDLING UNIT(OVER 10=11F.M.) 5.00
EXHAUST HOOD (WITH DUCT) 2.00
MICROFILM
HEATING UNIT ITO 100,000 B.T.U.) 4.00
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
herebym authorize
hereby authorize representatives of this city to enter upon the
property for representatives t this
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 consequence of the
gra this it. n
I-30-,AZ
HEATING UNIT (OV ER 100,000 B.T.U.)7.50
ELECTRIC
VENTILATION FAN (SINGLE) 3.00
BOILER - COMP (3 H.P. or 100,000 B.T.U.) 4.00
PLUMBING
w
, 6
BOILER -COMP (Over 100,000 BTU) SEE FEE SCH.
MECHANICAL
`
MISC. - REFER TO ORD.
PERMIT ISSUANCE 300
CONST. TAX
MECH. CONT. LIC. NO.
MECH.
TOTAL
-'T '-aL -•
•+'TOTML' '.
9'�j'�/
/ /
ignamre of Ap mono /Contractor
.,64 /L' /V or-, aLC47r Cp - I OFFICECOPY