6024APPLICANT TO FILL IN INFORMATION WITHIN RED LINES'- USE BALL POINT PEN ONLY
BUILDING PROJECT I DENTI FICATION
APPLICATION &PERMITRRE5r4.4BUILDING-Et,ECTRICAL-'PLUMBING -MECHANICAL
PERMITNUMBER
24
IL.ING
[NAME
NER'/�/-,(1 Ir�r��j /�,,�a�p
Sifu� J �Lx `Y�'1�\
PHON 2Cl%3'�Q'�
A'ry, -
'yVi 0. Y
DTR,14iu�, is neo" ELECTR�IC.PERMIT +q'.' -, rFEE;7c
PLAN CHECK VALIDATION
DATE OF APPLICATION
CONTRACTORS
� LIC.('pyt c. N0.a 193
OUTLETS'-SWITCHES-RECEP 5.00/1.00
LIGHTING FIXTURES 5.00/1.00
ADDRESS ors
r noDREssLLp� y
s2,1 It r r - 1 PNONtU IV c f 10
PPLI ESIDENTIAL 4.00
PANEL - 5.00
ARCHITECT V-Q�
OR
ENGINEER
uc. No.
SIG 6.66
17,
PLAN CHECK FEE P.C. NO.
SI BANS. 3.00
ARCH. OR ENG.PERMIT
ADDRESS
SPEC 5.00
VALIDATION
./'. EM TER OR POLE INS.- 15.00 /f
' .. IIP
ADDRESS
•
MOTORS SEE FEE SCH.
SERVICE CHANGE 10.00
LICENSED CONTRACTORS DECLARATION
I hereby affirm that I am licensed under provisions of Chapter?
(commencing will, Section 7000) of Division 3 of the Business and
Professions Code, and my license is in full force and effect.
Class Lie, Number
ISSUANCE GATE
BLDG. ELECT. PLG. MECH.
El El El
Dale Contractor
OWNER -BUILDER DECLARATION
I hereby affirm that 1 am exempt from the Comracmr's License
Law for the following reason. (See. 703 1.5, Bolinessand Professions
Code: Any city or county which requires a permit to construct, alter,
BUILDING!PERMIT
v
"' INFORMATION 3
MISC.- REFER TO ORD
_
PERMIT ISSUANCE 6.00
VALUATION
S/FT.
'
ELEC. CONTR. LIC. NO. ELEC. ...�
TOTA
improve, demolish, or repair any st«mruC, prior to its issuance, also
tenures istic n edp pursuant t file roTlit is TIC a (Cont actor's i taloa
he is licensed 9(commencing
co fo the provisions of the Contractor's License
CngwiMSection 00) of Rte
Law(ChapterProfessions
'
PERMITTO
'7�s-7-7 �, t=7
Business and Professions Code) or that he is exempt caro n 70 and
is exempt therefrom
the
y:illbasis for the alleged forcexempOon.Any viappliontit) action malty
hy:myapplicantforaundrtsubjects 500).licantlnacivil penalty
: .
of not more than live the
dollars lmy
QTY. PLUMBING PERMIT - FEE
STORIES
TYPECONSTR.-
ALTER-DRAIN-WATER(EA.)4.00 .
❑ Las owner at the property, or my employees with wages as
property, em
their sole ion, will the work, and the is not
BACK FLOW PROTECT. DEVICE 2.00
OCC. GROUP
RES. UNITS
DRAINS -FLOOR, ROOF, AR EA, COND. 4.00
nd Proo
r offered
intended or offemJ 1r's rale (Sec. 7044, Business and Professions
(S
Cade: The Contractor's License law docs not apply to ori owner of
property who builds nr Improves Ihe,con, and w110 doe, Sancti work
himself or through his own employees, provided that such improve-
ments are not intended or offered For sale. If, however, the building
FIXTURES - PER TRAP 4.06
GAS-EA.SYSTEM-l1NC.40UTLETS 4.00
SD. FT, FLOOR AREA
TOTALACREAGE
is sob within one year of completion, the owner-
or Improvement will have
builder will have the burden of proving that he did not build or im-
prove for purpose ofsale.)..,
❑ I, as owner of tire property, amcontracting with
GAS - EA. SYSTEM - OVER 4 IEA.) 1.00
BUILDING USE
RES IND CON PS Other
INDUSTRIAL WASTE INTER. 20.00
_exclusively
licensed contractors to construct the project (Sec. 7044, BusinessLAWN
and Professions Code: The Contractor's License Law does not apply
toanownerol'property who builds or improves thereon, and who
SPRINKLERS- 1 INC 5 V.B. 5.00
LAWN SP,R INKLERS - OVER 5(EA.) 1.00
ASSESSORS PARCEL NO.
-
contracts for such projects with a contractor(s) licensed pursuant to
the Contractor's License Law.
❑ I am exempt under Ser,-, BAP.C. for this
reason4.00
SEWER -SANITARY -STORM EA. 200ft/8.00
TRACT NO.
PARCEL NO.
WATER HEATER W/VENT
Owner Date
WATER SYSTEM 4.60
ACC. DATE
ACC. FILE NO.
WORKERS'COMPENSATION DECLARATION
WATER TREATING EQUIP. 4.00
Vherehy affirm Oma I have a certificate of consent to self-ins.m,
ZONING
ENG. SITE NO.
or a certificate of Workers' Compensation Insurance,ora erlificd
copy thereoflSec. 3800,C.)� J
Policy No. CComp..panny..
13 Certified COp is hereby fume C
❑ Cerlil le tit t "y'
FIRE SPRINK
y N[]
ENERGY T-24Applicant
Y❑ NE]
MISC.- REFER TO ORD.
CERTIFICAI'I: OP EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
fl'his section need not be completed if lire tlemtil is for One
PERMIT ISSUANCE 6.00
FLOOD ZONE
N' ❑ NO
A.L.U.C.
V ❑ N�
PLG. CONTR. LIC. NO. PLG.
- I TOTAL
hundred dollars IS 100) or less,)
I certify that in the performance of the work for which this per
E`y �'t 5r ''- �-
btw k.. Su; « MECHANICAIL PERMIT ':FEE
tA� FEE SUMMARY
mit is issued, I shall not employ any person in any manner so as to
become subject to the Workers Compensation laws of California
k, x*
y - -
ALTER OR ADD TO MECH. 4,00
Dutc Applicant'
BUILDING
NOTICI: TO APPLICANT: If, after making this Certificate of liz-
APPLIANCE 4.00
AIR HANDLING UNIT (TO IOpODC.F.M.) 3.00
PLAN CHECK
FEE
enrplinn, you should become subject to the Workers'CompensutioIT
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.flM) 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, Civ.C.).
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 100,000 B.T.U.17.50
ELECTRIC
�/ -
VENTILATION FAN (SINGLE) 3.00
'1 Certify thus I have read this application and state that the above
information is correct, 1 agree to comply with all city and county
ordinances and state laws relating to building construction, and
PLUMBING
BOILER-COMP(3 H.P. or 100,000 B.T.U.) 4.00
BOILER -COMP (Over 100,000 BTU) SEE FEE BCH.
.MECHANICAL
hereby authorize representatives of this city to enter upon the
above-mentioned property for inspection purpows.
(We) ,gree to save, Indemnity and keep Immdess the City of
MISC. - REFER TO ORD. . .
Cupertino against liabilities, judgments, costs and expenses which
may in any way accrue against said �j'ty in consequence of the
grunt I, t this pennil����/�/
/�/�/u�///
PERMIT ISSUANCE 3.00
CONST. TAX
_
MECH. CONT. UG N0.
MECH.
TOTAL
TOTAL
Sign roof Applicant Driver Date'
r OFFICE COPY