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APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
BU I LD ING PROJECT IDENTIFICATION
APPLICATION & PERMIT
BUILDING - ELECTRICAL- PLUMBING - MECHANICAL
PERMIT NUMBER
5788
BUILDING
a°nREBB i s GRee,K_
5 'S7eVCNS
OwNER's
NAME - / Dell
21 GSPNONE
6TV. < , ELECTRIC'PERMIT•1 y'. FEE,
PLAN CHECK VALIDATION
-
DATE OF APPLICATION
CONTRACTORNAME ` .,
H1/e62i G�e�2(G LIC, NO.
OUTLETS -SWITCHES -RECEP 5.00/1.00 -
LIGHTING FIXTURES 50D116011
CONTRACTOR
aoo
5UGH RlvoR 157 - .ONE" � IJ
PPLIANCES- RESIDENTIAL 4.00
PANELS S.00
ARCHITECT
ENGINEER
' LIC. No.
SIGNS 6.00
PLAN CHECK FEE P.C. NO.
SIGNS TRANS. 3.00
ADDRiSSSS E"D'
SPECIALCIRCUIT -5.00
PERMIT VALIDATION
EMP. METER OR POLE INS. 15.00 '
-ZIP
APPLICANT'S
ADDRESS
MOTORS0 E FEE SCH.
-
SERVICE CHANGP - 10.00
ZOO/
LICENSED CONTRACTORS DECLARATION
1 hereby affirm that I am licensed under provisions of Chapter 9
(commencing with Section 7000) of Division 3 of fit 1 •se anA
Professions CodepbIny license is in full forte/' yc'�
License Class 1. Lic. Number _1 I
ISSUANCE DATE
BLDG. ELECT. PLG. MECH.
Date Contractor
OWNFR-BUILDER DECLARAIIONBUILDING
ERMIT
-
MISC.REFER TO ORD
I hereby affirm that I am exempt from the Contractor's License
Law for the following reason.(Sec. 7031.5, Business and Professions
Cade: Any city or county which requires permit to construct, alter,
NFORMA�T110N.
PERMIT ISSUANCE 600
.
VALUATION S/FT.
ELEC.CONTR. LIC. NO.
ELEC. w711 1P
TOTAL / `--
improve. demolish, or repair any structure, prior to tsisseance, also
requires the applicant for such permit to file a signed statement that
he Is licensed pursuant to the provisions of the Contractors License
Law Where, 9(comnwncingwith Section 7000)TlfDivision 3ofthu
PERMIT TO '
Business and Professions Code) or that he is exempt therefrom and
QT+Y. - PLUMBING PERMIT
the basis for the alleged exemption. Any violation of Section 7031.5
by any applicant for a pemnit subjects the applicant to a civil penalty
of not more than five hundred dollars (8500).):
STORIES
TYPE CONSTR.
ALTER -DRAIN & VENT -WATER (EA.) 4.00
❑ I, as owner of the property, or my employees with wages as
their sole compensation, will do the work, and the structure is not
BACK FLOW PROTECT. DEVICE 2.00
OCC. GROUP
RES. UNITS
DRAINS -FLOOR, ROOF, AREA,COND. 4.00
intended or offered for sale (Sec. 7044, Business and Professions
Code: 'file Contractor's License Law does not apply to an owner of
FIXTURES - PER TRAP 4.00
GAS-EA.SYSTEM-11NC.40UTLETS 4,00
property who builds or improves thereon, and who does such work
himself or through his own employees, provided that such improve-
mentsarenotinlended or offered for sale. If, however, the building
SG. FT. FLOOR AREA
TOTAL ACREAGE
or Iniprovenlent is sold within one year of completion, the owner.
builder will have the burden of proving that h e did not build or im-
- . -.
GAS EASYSTEM OVER 4 IEA) 1.00
BUILDING USE
prove for purpose of sale.).
❑ 1, as owner of the property, am exclusively contracting with
RES IND CON PB Orn.,
❑ ❑ ❑ ❑
INDUSTRIAL WASTE INTER. 20.00
hecnsed contactors to construct the project (Sec. 7044, Business
and Professions Code:'I lie Contractor's License Law does not apply
to an owner of property who builds or improves thereon, and who
LAWN SPRINKLERS- 1 INC 5 V.B. 5.00
LAWN SPRINKLERS - OVER 5 (EA.) 1.00
- ASSESSORS PARCEL NO.
coutracts for such projects with a contracloos) licensed pursuant to
the Conimnors License Law.
❑ tum exempt under Sec.-, IL&P.C. for this
SEWER -SANITARY -STORM EA. 200ft/8.00
TRACT NO.
PARCEL NO.
WATER HEATER W/VENT 4.00
Owner Date
WATER SYSTEM 4.00
ACC.DATE
ACC. FILE NO.
WATER TREATING EQUIP. 4.00
WORKERS'COMPENSATION DECLARA'TON
'
1 hereby affirm that 1 have a certificate ofconsent to set Gin sure,
ZONING
ENG. SITE N0,
'
r u cerlificule of Workers' Coni Pens lion In'?,ounce, or a certified
Copy thereof ISce. 3800, Lab C.
Policy No. Company-
MISC. - REFER TO ORD.
❑ Certified cop is hereby furnished. ii f KA7� 7
Certified y is filcJ with the c y c i n dvl
i'Ml1T$t8 sfad.
Applicant
FIRE SPRINK
- v Q N ❑
ENERGY T44 -
v [] N�
CER1'IPICAT F EXEMPTION 'ROM WORKERS'
PERMIT ISSUANCE 6.00
FLOOD ZONE
A.L.U.C.
CO 'ENSA1'ION INS )RANCE
I'I'his section need not be completed if the permit is for one
PLG. CONTE. LIC. NO,
PLG.
TOTAL '
V N
Y N�
hundred dollars IS 1001 ar less.)
I certify that in the performance of the work for which this Per
mil is issued, I shall not employ any person in ;my manner so as to
become subject to the Workers' Compensation Laws of California.
Uwe ApplicantALTER
NOTICE. TO APPLICANT: If, after making this Certificate of lix-
°d;,•- a "v.'
MECHANICALeiRERMIT+.p , ,�'1 FyE E,,:
," FEE SUMMIARY
tK". . n4v
BUILDING
'
OR ADD TO MECH. 4.00
APPLIANCE 4.00
AIR HANDLING UNIT (TO 10=C.F.NU 3.00
PLAN CHECK
FEE
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.
AIR HANDLING UNIT(OVER 10=C.F.M.) 5.00
SEISMIC FEE
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, Cu,C.L -
EXHAUST HOOD (WITH DUCT) 2.00
MICROFILM
HEATING UNIT (TO.100,000 B.T,U.) 4.00
Lender's Name
Lender's Address
HEATI NG UN IT (OVER 100,000 B.T.U.)7.50
ELECTRIC
1 certify (hut I have read this application and slate that the above
VENTILATION FAN (SINGLE) 3.00
information is correct. I agree to comply with all city and county
ordinances and state laws relating to building construction, and
PLUMBING
BOILER• DOW (3 H.P. Of 100,000 B,T.U.) 4.00
BOILER -COMP (Over l00,o000TU)5EE FEE SCH.
MECHANICAL
hereby authorize representatives of this city to enter upon the
above-mentioned property for inspection purposes.
(We) agree to Ise, indemnify and keep harmless the City of
Cupertino aguins labilities, judgments, costs and expenses which
may in any cerue again . id City in consequence of the
granting ofS s miiL
MISC. - REFER TO ORD.
PERMIT ISSUANCE 3.00
CONST. TAX
MECH. CONT. LIC. NO. MECH.
TOTAL
TOTAL
-
Signature fppi 1 ontmc(or I Date
"VA
OFFICE COPY