7225APPLICANT TO FILL IN INFORMATION WITHIN RED LINES -USE BALLPOINT PEN ONLY
' BUILDING PROJECT IDENTIFICATION PERMIT NUMBER
mnLoiNG APPLICATION & PERMIT
aonREss //
9s/s �05,_ GOSSO/N/ BUILDING - ELECTRICAL- PLUMBING - MECHANICAL 7225
OWNER'S
.:_>,V
I!
-J
r?
NAME �(�'I �f.r..
-s�So��
PHONE
CONTflACTOfl's
NwMe�-,,��jj /I
��%��G LIc.No.lJQ �y7K
T1r• ELECTRIC PERMIT FEE
'!F H'.3....
". ti'F ie' s. x'•1";"'
UTLETS-SWITCHES-RECEP 5.00/1.00
PLAN CHECK VALIDATION
'
GATE OF APPLICATION
PLAN CHECK FEE P.C. NO.
LIGHTING FIXTURES 5.00/1.00
CONTRACrOR'S
AooREss � 7"<3UT''
E 0 /
ARCHITECT -"
OR
ENGINEER
APPLIANCES -RESIDENTIAL 4.00
PANELS 5.00
SIGNS 6-00
SIGNS TRANS. 3,00
uc.rvo.
aRCH.OR ENG.
aooREss
SPECIAL CIRCUIT 5-00
PERMIT VALIDATION
•
ZIP
TEMP. METER OR POLE INS. 15.00
A
aDDHESS
oHEss
MQTQRS SEE FEE SCH.
SERVICE CHANGE 10.00
..J�•��
ISSUANCE DATE
w¢z
Hao LICENSED CONTRACTORS DECLARATION
a 0 w 1 herchy affirm that 1 am licensed under provisions of Chapter9
(commencing with See(ion,7000) of Division 3 or the Business and
H w 2 I iectee ons Cod an license is in full fU¢eypQ C[I2CI� n
o Z H w DateQ_ _ _ lice se
2 0 m - License CSI s Lic. Number-. 1T y
Zi/ JN
M i
E ¢ w OWNER-BUILDER DECLARATION
'
x 3 ' N I hereby affirm that I am exempt from the Contractor's License
HLLOj Law tirr the following reason (Sec. 7031.5, BusinessanJ Pro fessirns
iw>I Code: Any city of county which rcquiresapermit tocrosstruct,alter,
w Or eO improve, demolish, or repair any structure, prior m its issuance, also
- D ¢ rcyuires lhC applicant for such permit to lite a signed slatemem That
n w m " he is licensed pursuam m the provisions of the Contractor's License
H t a Law(Chaptur9(commencing with Section 7000)of Divislon3oC theall
i D Business and Pfolcssions Code) or thol he Is exempt 0mrefmm and
¢ H m the bastis for the alleged exemption. Any solation of Section 7031 5
ca 1.5
a�� hy;hny applicam fora permit subjects the opplic;mttoacivilpenatry
of sol more than five hundred dollars($500).): I
❑ 1, as owner of the properly, or my employees with wages as
lhei! sole compensation, will do the work, and the shuCture is sol
intended nr offered for sale (Sec. 7044, Business and
Code: The Contractor's License Law docs not apply to an owner oProfessions f
gKslf�i property who builds or improves thereon, and who does such work
'TS himself Or through his own d11pl0yel's, Provided (list suchInt prove.
men¢ are not intended or offered for sale. If, however, it,, building
ar improvement is sold within one year of completion, the owner-
'p(t-%.p:Fs'$�� builder will have the burden Ofproving that he did not build or am.
�4i1! prove tor purpose as owner of sale.).
❑ d as owner of the property, am exclusivCly contracting with
licensed contractors to construct [lie project (Sec. 7044, Business
End I'ro(essinns Code: The Contractor's License Law does not apply
to an owner of Property who builds or improves thereon. and who
contracts for suet, projects will, a conlraetor(s)Iicen50d pursuant to
the Cnntrclor's License Law.
❑ I am exemPl under See. ,B.&p.C. for the
reason
Owner Date
WORK F that I have Doted RATION
I hereby affirm that I have m certificate le oescre..l or selfeinsure,
c. a certificate of Workers' Compensation Insuruncc, or o certified
copyY hcre4 1.,,0, Lab,C.).
PUlic No. L ompany-FQJ. 00kO
O ❑ Cerified spy is here by C Imd.
z Z Ii1�Cerlifi y . filed it the 'it inx ecliOn division.
FO APphcan -
0- w CE RTI FICATE OI' EXI:Mleft ON FROM WO RK Ii RS'
L COMPENSATION INSURANCE
aJ p (I los sectma need sol be completed if [lie permit is for Ohl
U O hundred dollars IS 100) or less.)
certify that In the Performance of the work for which this per
LL F mit is tissued, I shall not employ any person in any manner an as to
O become subject to the Workers' Compensation Laws of California.
O ED y Date APPLICANT:
} m NOTICE: 'f0 APPLICANT: If, after making [his Certificate of Ex-
�. 2 emption, You shmdd become subject to the Workers' Compensation
Provisions of the Labor Code, you must forthwith comply with
U such provisions Or this permit shall be deemed revoked.
BLOC.
ELECT. PLG.
MECN.
_
BUILDING PERMIT
- s INFORMATION
MISC. - REFER TO ORD
PERMIT ISSUANCE__-6.00
6.00
VALUATION S/FT.
ELEC. CONT.. LIC..
LEC.
TOETA L
t-
OTjV: R,q ' PERMIT
c
ALTER-DRAIN (EA.)
BACK FLOW PROTECT. DEVICE 2.00
ROOA
DRAINS-FLOOR, F, REA, COND. 4.00
P RMIT TO
STORI
TYPE CONSTR,
-
OCC. GROUP
RES. UNITS
FIXTURES -PER TRAP 4.00
GAS-EA, SYSTEM-11NC.40UTLETS 4,00
GAS - EA. SYSTEM - OVER 4 (EA.) - 1.00
SD. FT. FLOOR AREA
TOTAL ACREAGE
BUILDING USE
RES IND CON PB Omar
❑ ❑ ❑ ❑ ❑
INDUSTRIAL WASTE INTER. 20.00
LAWWSPRINKLERS - 1 INC 5 V.B. 5.00
ASSE6 D PARCEL NO,
'
LAWN SPR IN KLERS - OVER (EA.) 1.00
SEWER-SANITARY-STORM EA. 200ft/8.00
WATER HEATER W/VENT 4.00
TRACT NO.
PARCEL NO.
WATER SYSTEM 4.00
ACC. DATE
ACC FILE NO.
WATER TREATING EQUIP. 4.00 "
ZONING
ENG. SITE N0.
-
FIRESPRINK
Y❑ N❑
ENERGY T-24
v❑ N❑
MISC.- REFER TO ORD.
PERMIT ISSUANCE 6.00
FLOOD ZONE
V N
❑ ❑
A.Lu.C.
V ❑ N❑
PLO. CONTR. LIC. NO.
PLG.
TOTAL
° p1;�,, R " w 't „,b+. `N w'
QTY $x' yMECHANICALPERMIT' t 'FEE"
a -
•'-k'f t:FEESUMM�ARR'
ALTER OR ADD TO MECN. 4,00
BUILDING
APPLIANCE'. 4.00
PLAN CHECK
FEE
AIR HANDLING UNIT (TO 10MOC.F.M.) 3.00
CONSTRUCTION LENDING AGENCY
I hereby affirm that there is a constriction lending agency Co!
the performance of the work for which this permit is issued (Sec
AIR HANDLING UNIT(OVER 10=0C.EM.) 5.00
SEISMIC FEE
EXHAUST HOOD (WITH DUCT) 2.00
MICROFILM
.
_ 3097, Civ.C.).
Name
HEATING UNIT (TO 100,000 B.T.U.) 4.00
6Lender's
I-endcr's Address
±'t':•(I I certify that 1 have read this application and state that the above
'nfannation is correct. I agree 10 comply with all city and county
rdimmees and state laws relating to building construction, and
hereby auth Grizc rcpres"antives m this City to enter upon the
abovc.inemioned property for inspection purposes.
agree to sive, indemnify and keep harmless the City of
Cupertino against liabilities, judgments, costs anWexpenses which
may in any way accrue against said City in c.nsegaence of the
gr a of this per
r (� MECH.
l7 -�rb
S,gltiuhrre o�APPIIeunr/s.on[rauor Date
HEATING UNIT (0111213 100,000 B.T.U.17.50
ELECTRIC
VENTILATION FAN (SINGLE) 3.00
BOILER-COMP(3H.P.Dr100,000B.T.U.) 4.00
PLUMBING
BOILER-COMP (Ove! 1 ,0 BTU) SEE FEE SCH.
MECHANICAL
7.00
MISC. - ER TO ORD.
CONST. TAX
-
PERM I ISSUA C 3.00
CONT. - LIC. NO.
44 Ns6FA
�if'/`r / Y�.ITTl1(��i p/ (� /I Q
MECH.
TOTAL
/.
p' •��IE+
^',Iw,M:L'
OFFICE COPY