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PPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
BUILDING PROJECT I DENTI FI ON
APPLICATION & AIT
BUILDING - ELECTRICAL- PLUMBING - MECHANICAL
PERMIT NUMBER
13471
ADORE LC+Z
7-7 SS
OWNER'S
NAME
PHCNE�.V a �
TY. ELECTRIC PERMIT FEE
PLAN CHECK VALIDATION
DATE OF APPLICATION
CONT�N
NAME c aR-
NAME `
,N1 0L C. No. _
OUTLETS - SWITCHES -RECEP 10.00/1.00
LIGHTING FIXTURES 10.00/1.00
CONTRACTOR'S rfgA^ 1
ADDRESS
O �{ PRONF
APPLIANCES - RESIDENTIAL 4.00 --
a PANELS 10.0 -
AROHITCT
OR
N IN L .o
PANELS (OVER 200 AMP) 20.00
PLAN CHECK FEE P.C. NO.
SIGNS TRANS. 3.00
ARCH, OR ENKE-
ADDRESS
Del LI a,.. N 6 I P
.w/SP ECIALCIRCUIT 5.00
PERMIT VALIDATION
9/-/4/f 17
UU //
ISSUANCE DATE
�- EMP. METER OR POLE INS. 20.00
APPLI
ADDRESS
'
MOTORS SEE FEE SCH.
-SERVICECHANGE 20.00
LICIiNSEU CONTRACTORS DECLARATIONr
I hereby affirm that I am licensed under provisions of Chapter 9
(commencing with Section 7000) of Division 3 of the Business and
Professions CoA. anQ m license is in full fore d f
Numh)rw..7J.�/'r
Date Convac
OWNER -BUILDER DE A t{'/oirTyk' (
A'MO
1 hereby affirm (hal I am exempt from tireMISC.-
Contractor's License
Law for the following reason. (Sec. 7031.5, Business and Professions
Code: Any city or county which requires a permit to construct, 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 licensed pursuunt to lire provisions of the Contractor's License
Law (Chapter 9 (commencing with Section 7000) of Division 3 of the
Business and Professions Code) or that he is exempt therefrom and
the basis for the alleged exetnpton. Any violation of Section7031.5
by any applicant for a permit subjects the applicant toa civil penalty
of not more than five hundred dollars (5500).):
❑ I, as owner of the property, or my employees with wages as
their sole compensation, will do tire work, and the structure is not
intended or offered for sale (Sec. 7044, Business and Professions
Code: The Contractor's License Law docs 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 -
Hunts are not intended oroffered for sale. If, however, the building
Crimprovement is sold within one year of completion, the owner-
builder will have the burden of proving that he did not build or am-
prove for purpose of sale.).
❑ I, as owner of the property, am exclusively contracting with
licensed contractors to construct the project (Sec. 7044, Business
and Professions Code: The Contractor's License Low 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.
❑ lam excmpl under Sec. ,B.&P.C. for this
reason
, 1 �U r
_
-
BLDG.
❑
ELECT.
PLG. MECH,
❑ ❑
p y V
01 p
BUILDING PERMIT
INFORMATION
REFER TO ORD
VALUATION
$/FT.
PERMIT ISSUANCE 10.00 Q+-
ELEC. CONTR. LIC. NO.
ELEC.
TOTAL /S__(0PERMIT
TO
CITY. PLUMBING PERMIT FEE
STORIES
TYPE CONSTR.
ALTER -DRAIN -WATER (EA.) 5.00
BACK FLOW PROTECT. DEVICE 4.00
OCC. GROUP
RES. UNITS
DRAINS -FLOOR, ROOF, AR EA, COND. 5.00
FIXTURES - PER TRAP 5.00
50. FT. FLOOR AREA
TOTAL ACREAGE
GAS-EA.SYSTEM-11NC.40UTLETS 6.00
GAS EASYSTEM 00
- . - OVER 4 (EA.) 2.
BUILDING USE
RES IND CON PB Omer
❑ ❑ ❑ ❑ ❑
INDUSTRIAL WASTE INTER. 30.00
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 N0,
PARCEL N0.
WATER HEATER W/VENT 6.00
Owner Date
WATER SYSTEM 5.00
WORKERS'COMPENSAT10N DECLARATION
1 hereby affirm that I have a certificate of Consent to self -insure,
or a certificate of Workers' Com �Gt,�qmcc. or a certified
copythereof f Sec. 3800•ipm,) }
Policy o. is here ny_ e
edified copy is hereby fur1
Certi d c py I fi Gil wisp gt ivislon.
��-�4.(r/
CER A .'cSLMlei7 MWORKERS'
COMPENSATION INSURANCE
(This section need not be completed if tire permit is for one
hundred dollars ($100) or less.)
I certify that in the performance of tire work for which this Per-
mit is issued, 1 shall not employ any person in any mummer so as to
become subject to the Workers' Compensation Laws of California.
Date Applicant
ACC. DATE
ACC. FILE NO.
WATER TREATING EQUIP. 5.00
-
ZONING
ENG. SITE NO.
FIRE SPRINK
V ❑ N❑
ENERGY T-24
V ❑ IN E]
MISC. - REFER TO ORD.Appllc:Int'A1X_Q'
PERMIT ISSUANCE 10.00
FLOOD ZONE
Y ❑ No
A.L.U.C.
Y ❑ N❑
PLG. CONTE, LIC. NO.
PLO.
TOTAL
OTY. MECHANICAL PERMIT FEE
FEE SUMMARY
BUILDING
ALTER OR ADD TO MECH. 5.00
NOTICE TO APPLICANT: If, idler making this Certificate of I'x-
emptier, you should become subject to the Workers' Compensation
provisions of the Labor Code, you most forthwith comply with
such provisions or this permit Strait be deemed revoked.
CONSTRUCTION LENDING AGENCY
I hereby affirm that there is a construction lending agency for
the performance
rfo C ince of the work for which this permit is issued (Sec.
Lender's Name
APPLIANCE 5.00
PLAN CHECK
FEE
AIR HANDLING UNIT (TO 10/1000F.M.) 4.00
AIR HANDLING UNIT (OVER 10=C.F.M.) 6.00
SEISMIC FEE
EXHAUST HOOD (WITH DUCT) 5.00
MICROFILM
HEATING UNIT (TO 100,000 B.T.U.) 8.00
HEATING UNIT (OVER 100,000 B.T.U.)9.50
ELECTRIC
Az 0`10Lender's
Address
I certify that I have read this application and slate 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.
(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
grand of this permit,
A,d v.� $
VENTILATION FAN (SINGLE) 4.00
PLUMBING
130ILER-COMP(3H.P.or100,000B.T.U.) 6.00
BOILER -COMP (Over IOQ000BTU) SEE FEE SCH.
MECHANICAL
MISC. - REFER TO ORD.
CONST. TAX
PERMIT ISSUANCE 10.00
MECH. CONT. LIC. N0. MECH.
TOTAL-`
J I to of Applicant/Con ctor ate
OFFICE COPY