4766 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
BUILDING PROJECT IDENTIFICATION PERMIT NUMBER
BUILDING � APPLICATION & PERMIT 4766
AOORRss ' yGV�� �k
BUILDING -ELECTRICAL-PLUMBING -MECHANICAL
OWNER'S - "s' PLAN CH ECK VALIDATION
"AME 9� QTY: ELECTRIC PERMIT,---.
O`� PHONE
GDNTRAciDFs
NAUTLETS-SWITCHES-RECEP 5.00/1.00
M
L/� C<J• UC.NO �h f7L LIGHTING FIXTURES 5.00/1.00
coNTRAcipes PPLIANCES-RESIDENTIAL 4.00
AODREss( L is �, PHONE2Z00-10 PANELS 5.00 DATE OF APPLICATION
ARCHITECT SIGNS 6.00 PLAN CHECK FEE P.C.NO. i
OR
ENGINEER
LIC.No. SIGNS TRANS. 3.00 '
ARCH,OR ENG. PERMIT VALIDATION
AODREss SPECIAL CIRCUIT 5.00 s
ZIP TEMP.METER OR POLE INS. 15.00
APPLCANTS MOTORS SEE FEE SCH.
ADDRESS
SERVICE CHANGE 10.00
o o LICENSED CONTRACTORS DECLARATION j
a 1 hereby affirm that I am licensed under provisions of Chapter 9 ISSUANCE GATE
H "' (commencing with Section 7000)of Division 3 ol'the Business andBEG
¢ BLDG. ELECT. PLG. MECH.
H O'^ Professions Code d my license is in full for
License au Lic.Number �CEl El
9 to r O Date !-:2177Contmctor City of Cupertino
a y f r WBUILDING PERMIT, -
¢ ¢ OWNER-BUILDER DECLARATION
s o v U .INFORMATION. '
X ; y I hereby affirm that 1 am exempt from the Contractor's License MISC.- REFER TO 200
RD
a Law for the following reason.(Sec.7031.5.Businessand Professions pERM1T ISSUANCE 6.00 VALUATION S/FT.
Code:Any city ar county which requires a permit to construct,alter,
ELEC.CONTR. LIC.NO.
X ¢ii improve,demolish,or repair any structure,prior[o its issuance,also ELEC �/
O¢ requires the applicant for such permit to file a signed statement that TOTALv PERMIT TO
F
he is licensed pursuant to the provisions of the Contractor's License _
H i
Law(Chapter 9(commencing with Section 7000)of Division 3 ofthe i, FM rs'. :
f i c Busineu and Professions Coital or that he is exempt therefrom and OTY.4 PLUMBING.PERMIT „..y +q.,y: #,y,FEE' L LC�� d G-�
¢ r$ the basis for the alleged exemption.Any violation of Section 7031.5 + ,' ' ' .�. -. ,v STORIES TYPE CONST .
a '; by any applicant for a permit subjects the applicant too civil penalty
ofnot more than five hundred dollars($5000.)
ALTER-DRAIN -WATER IEA.14.00
❑ I.as owner of the property,or my employees with wages as BACK F LOW PROTECT.DEVICE 2.00 OCC.GROUP RES.UNITS
their sole compensation,will do the work,and the structure is not
• intended or offered for Sale (Sec. 1044, Business and Professions DRAINS-FLOOR,ROOF,AREA,COND. 4.00
Code:The Contractor's License Law does not apply to an owner of
property who builds or improves thereon,and who does such work FIXTURES-PER TRAP 4.00 50.FT,FLOOR AREA TOTAL ACREAGE
himself or through his own employees.provided that such improve'
mentsare not intended oroffered for sale.If,however,the building GAS-EA.SYSTEM-I INC.4 OUTLETS 4.00
or improvement is Sold within one year of completion, the owner- GAS-EASYSTEM-OVER 4(EA) 100 BUILDING USE
builder will have the burden of proving that he did not build or im- . . . RES IND CON PB 011ier
Prove for purpose of sale.). INDUSTRIAL WASTE INTER. 20.00
❑ 1,as owner of the property,am exclusively contracting with E:] ED E:] ❑ ❑
licensed contractors to construct the project(Sec. 7044,Business LAWN SPRINKLERS-1 INC 5 V.B. 5.00 ASSESSORS PARCEL NO.
and Professions Code:The Contractor's License Law does not apply
to an owner of property who builds or improves thereon,and who LAWN SPRINKLERS-OVER 5 (EA.) 1,00
contracts for such projects with a comractosls)licensed pursuant to
the Contractor's License Lew. SEWER-SANITARY-STORM EA.200ft/8.00 TRACT NO. PARCEL NO.
❑ 1 i exempt under Sec.-.BAP.C.for this WATER HEATER W/VENT 4.00
reason
Date Owner WATER SYSTEM 4.00 ACC.OATE ACC.FILE NO.
WORK ERS'COMPENSATION DECLARATION WATER TREATING EQUIP. 4.00
I hereby affirm that 1 have a certificate of consent to self-insure, ZONING ENG.SITE N0.
or a certificate of Workers'Compensation Insurance,or a certified
I. copy thereof(Sec.3800,Lab.C- ?Lo 101 I> vo
Policy No. Company��II
0 ❑ Certified copy is hereby f rnished FIRE SPRINK ENERGY T 04
/ O Cerlifie 'o y Is fled ��yyI (/city Inspection division.
Z p Applicant !S MISC.- REFER TO ORD. Y ❑ N❑ Y ❑ N❑
Hy PERMIT ISSUANCE 6.00 FLOOD ZONE A.L.O.O.
LU CERTIFICATE EXEMPTION FROM WORKERS'
W >_ COMPENSATION INSURANCE PLG.CONTR. LIC.NO. PLG.
CL G (This section need not be completed if the permit is for one TOTAL Y❑ N❑ Y❑ N❑
0 Z hundred dollars IS 100)or less.) } i '+ '- - -
LJ O 1 certify that in the performance of the work for which this per. ' r r-- 3 ( teen rm '.{"I' � * + FEE SUMMARY k. r�.". T
H mit is issued, 1 shall not employ any person in any manner w as to QTY. ,.t MECNANICAL PERMITet e��Ia .kFEE 'i -.+?.. -
LL V become subject to the Workers'Compensation Laws of Califon ia. -'' .A w at'"/'*P"}"'v-°'+ ''•''` 1ac:L ''3'""
i Date ApplicantALTER OR ADD TO MECH. 4.00 BUILDING
} N NOTICE TO APPLICANT: If,after making this Certificate of Ex-
F Z emption,you should become subject to the Workers'Compensation APPLIANCE 4.00 PLAN CHECK
provisions of the Labor Code, you must forthwith comply with FEE
0 such provisions or this permit shall be deemed revoked. AIR HANDLING UNIT(TO 10MOC.F.M) 3.00
CONSTRUCTION LENDING AGENCY AIR HANDLING UNITIOVER 10=C.F.M.) 6.00 SEISMIC FEE
I hereby affirm that there is a construction lending agency for EXHAUST HOOD(WITH DUCT) 2.00
the 3097o.Clnce of the work for which this permit is issued(Sec. HEATING UNIT(TO 100,000 B.T.U.) 4.00 MICROFILM
,Ci
Lender's Name HEATI NG UNIT(OVER 100,000 B.T.U.P.50
Lender's Address ELECTRIC
I certify that I have read this application and state that the above VENTILATION FAN (SINGLE( 3.00
information is correct. I agree to comply with all city and county BOILER-COMP(3 H.P.or 100,000 B.T.U.) 4.00 PLUMBING
ordinances and stale laws relating to building construction, and
hereby authorize representatives of this city to enter upon the BOILER-COMP (Over 100,000 BTU)SEE FEE SCH. MECHANICAL
above-mentioned property for inspection purposes.
(We) agree to save, indemnify and keep harmless the City of MISC.- REFER TO ORD.
Cupertino against liabilities,judgments, costs and expenses which CONST.TAX
may in any way ccrue against sail�J.Cil�tyy��'p CO�jWen`'e�f PERMIT ISSUANCE 3.00
Q+astjl of sL KC(�¢ICI ' MECH.CONT. "NO-770E
IC NO. MECH. 9'J
// iii TOTAL
S ll�ApplHS/GY/14�V
S gnafure of pplicam/Contractor Date M.-,a„'> •... .'.r '�
OFFICE COPY