13477. . APpIII ICANT TO FILL IN INFORMATION WITHIN RED LINES -USE BALL POINT PEN ONLY
10
BUILDING PROJECT IDENTIFICATION
APPLICATION & PERMIT
BUILDING -ELECTRICAL -PLUMBING -MECHANICAL
PERMIT NUMBER
13477
BUILDINGn
ADDRESS n
J�%E� I�a�'_�y/LOS$O?1 �V C,(%�
OWNER'S -
AME
414 olivo / PHONE
TV. ELECTRIC PERMIT FEE
PLAN CHECK VALIDATION
DATE OF APPLICATION
CONTRACTOR'S
NAME �p
(f'RC0�l C /?/Sr LIC. NO. zICY
+yp OUTLETS - SWITCHES -RECEP 10.0011.00,3d
0.00/1.00 Q(f'RC
0 LIGHTING FIXTURES 10.00/1.00
TOR$ f'
ARCBS gQg17.15
pj'
7p
?,-DO 4/AQ? ? I✓A 90'pHONE �6>'600
PPLIANCES-RESIDENTIAL 4.00
PANELS 10.00 t
ARCHITECT
OR
ENGINEER /.i�/�C+lJHTWC
sec. No.
PANELS (OVER 200 AMP) 20.00
PLAN CHECK FEE P.C. NO.
SIGNS TRANS. 3.00
ARCH. OR ENG.
ADO� ,",/� _
• 2.�' b�M6+�ie �i4pF ZIP 91f�7�
SPECIAL CIRCUIT 5.00
-RE55
PER MIT VALIDATION
�/ � )
q /VIZI�p '//
O
ISSUANCE DATE
BLDG. I ELECT. PLG. MECH.
EMP. METER OR POLE INS. 20.00
APPLICANT
/3L'oaj� �j}f A/�/�¢ 9�
MOTORS SEE FEE SCH.
SERVICE CHANGE 20.00
LICENSED CONTRACTORS DECLARATIONFl-
1 hereby affirm that I em licensed under provisions of Chapter 9
(commencing with Section 7000) of Division 3 of the Business anti.t
Professions Code n my license is in full force and effect.
License Class Lia Number
Date Contractor
OWNER -BUILDER DECLARATION
• 1 hereby affirm that I am exempt from the Contractor's License
Law for the following reason. (See, 7031.5, Business and Professions
Code: Any city or eau my which requirespermit to construct alter,alter,improve, demolish, or repair any structure, prior to its issuance, also
requires the applicant for such permit to file a signed alinement Ise
he is licensed pursuant to the provisions of the ) ofDmision License
Law (Chaplet9lassions Code)
Section is exempt
D ivision3 theand
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 ton civil penalty
of not more than five hundred dollars (8500).):
❑ I, as owner of the property, or my employees with'wages as
their sole compensation, will do the work, and the structure is' not
intended or offered far 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 awn employees, provided that such improve.
mems 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 in-
Prove for purpose of sale.).
❑ I, as owner of the property, am exclusively contracting with
licensed contractors to construct the project (See. 7044, BusinessLAWN
and Professions 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 B contractor(s) licensed pursuant to
the C'mdmcmr's License Law.
❑ I um exempt under Sec.., B &P.C. for This
reason
I
1
t \('j 1%
nU^e
(Lfir h
01
BUILDING PERMIT
INFORMATION
MISC.- REFER TO ORD
PERMIT ISSUANCE -10.00 _p
VALUATION'
$/FT.
ELEC. CONTR. LIC. NO.
ELEC.
TOTAL
PERMIT TO
ELS 7 -��
PLUMBING PERMIT FEE
STORIES
TYPEC STR.
ALTER -DRAIN -WATER (EA.15.00
BACK FLOW PROTECT. DEVICE 4.00
OCC. GROUP
RES. UNITS
DRAINS -FLOOR, ROOF, AR EA,COND. 5.00
FIXTURES - PER TRAP 5.00
GAS - EA. SYSTEM - I INC.4 OUTLETS 6.00
SO.FLFLOORAREA
TOTALACREAGE
GAS - EA. SYSTEM -OVER 4 IEA.) 2.00
- BUILDING USE
RES IND CON Pe Omer
INDUSTRIAL WASTE INTER. 30.00
SPRINKLERS- 1 INC 5 V.B. 600
.
LAWN SPRINKLERS - OVER 5 (EA.) 1.00
ASSESSORS PARGE: NO.
SEWER -SANITARY -STORM EA, 200ft/10.00
TRACT NO,
PARCEL NO.
WATER HEATER W/VE T 6.00
Owner Date
WATER SYSTEM 5.00
.1
WORKF:RS'COMPeNSATION DECLARATION
to
I botchy affirm that I have a Compensatateion
of consent L setfertifi d
co u certificate of Workers' L.b.C.). snion Insurue�a, Or a certified
copy thereof (Sec. Co pang ).&W.., .Lu.{i�
Policy Nrt Company
ACG DATE
ACC. FILE NO.
WATER TREATI EQUIPIZi,1 5.00
f.
ZONING
ENG. SITE NO.
�' e
❑ Certified Copy is hereby furnished.
❑ Caitiff coy fled wi the city inspection division.
ApplicuN_ -{/'f
,� O
MISC. - REFER TO ORD.
FIRE SPRINK
�.
V N�
ENERGY T-24
V � N C]
//��
CER'TIFICAT'E OF EXBMPI'IOMTROM WORKERS'
COMPENSATION INSURANCE
1'I'his section need not be completed if the permit is for one
hundred dollars IS 100) or Il
I certify that in the performance of the work for which this per
mit is issued, I shall not employ any person in any aware, so as tO
become subject to the Workers' Compensation Laws of California.
Date Applicant
PERMIT ISSUANCE 10-001&
FLOOD ZONE
Y ❑ N�
A.L.U.C.
VED N�
PLG. CONTR. LIC. NO.PLG.
�/�'rti
TOTAL (7.1 ---
MECHANICAL PERMIT FEE
FEE SUMMARY
BUILDING
ALTER OR ADD TO MECH. 5.00 Ste"
NOTICE TO APPLICANT: If, alter making this Certificate of Ex
emplion, you should become subject to the WorkersCompensation
provisions of the Labor Code, you must forthwith comply with
such provisions or this permit shall be deemed revoked.
CONS'T'RUCTION LENDING AGENCY
1 hereby affirm than 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
APPLIANCE 5.00
PLAN CHECK
FEE
AIR HANDLING UNIT (TO 10,000C.F.M.) 4.00
AIR HANDLING UNIT(OVER 10MC.F.M.) 6.00
SEISMIC FEE
EXHAUST HOOD (WITH DUCT) 5.00
MICROFILM
HEATING UNIT (TO 100,000 B.T.U.) 8.00
Lender's Address
I certify that I have ,cad 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
hereby authorize representatives of this city to enter upon the'
above-mentioned property for inspection purposes.
(Wa) agree to save, indemnify and keep harmless the City of
Cupertino against liabilities, judgments, costs and expenses whichme a
may in any way income ' at said City in consequence the
granting Oft' IL /�• y
y 4 P!
H EATI NG UNIT IDV ER l OQ000� .T.U.)B.50
ELECTRIC
xja hP
v
VENTILATION FAN (SINGLE) '4.00
BOILER-COMP(3 H.P.Or 100,000B.T.W.)-6.00
PLUMBING
3 S^w
BOILER -COMP Maar 100,9001TUISEE FE fJ.
MECHANICAL
/_2tti
.]
MISC. - �,fR EFR+TO D.
PERMIT ISSUANCE Y 10.00 .Q -�'
'x
CONST. TAX
MECH. CONT. LIC. NO. MECH.
TOTAL /S-`
'
TOTAL
���1
V�
L/
Signature of Applicant/ConDac - alp
OFFICE COPY