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APPA \NT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
-DING PROJECT IDENTIFICATION
CATION & PERMIT
PERMIT NUMBER
dDILDINu
.REs
r, -L
(/,/
BUILDING -AEPLPELCITRICAL- PLUMBING MECHANICAL
4179
OwNEH'S/
NAIVE
jo-J a n , K , ,n 73�'
U/fY
-,. •,
nTv "'fw'1�" '.4u"�°ELECTRIC PERMITf�"� r a ° FEE,
Te:. :.. 4' 3^� �.cG t' 4K..::au..><tl r, t i"-• U e.,?{r?.M7.
PLAN CHECK VALIDATION
HOMER" T RS ,j
UTLETS-SWITCHES -RECEP 5.00I7.00
LIGHTING FIXTURES 5.00/1.00
Ic. No.[�LO l3/3
DATE OF APPLICATION
c NTRADTOR•s
MENTIAL
ADDRESSn
//IC, PHONE gyp{
i PPLIANCES-RESID 4.00
PANELS 5.00 g5.
ARCHITECT
OR
ENGINEER
LIC NO.
SIGNS 6,00
PLAN CHECK FEE P.C. NO.
SIGNS TRANS. 3.00
ARCH. OR ENG'
ADDRESS
SPECIAL CIRCUIT 5,80
PERMIT VALIDATION
TEMP. METER ORP S. 15.00
ZIP
�/� (�
7
APPLICANT
ADDRESS
a M Q
MOTORS SEE FEE SCH.
SERVICE CHANGE 10.00
LICENSED CONTRACTORS DECLARATION
1 hereby affirm that I am licensed under provisions of Chapter 9
ISSUANCE DATE
(commencing with Section 7000) of Division 3 of the Business and
Plofe cRonf Cod S[...��dn�d��QQlIy license is in full fare e�T [ f
License las �.LLL� Lic. Number O
BLDG.
❑
ELECT.
PLG. MECH.
❑ ❑
Date -A Contractor...
OWNER -BUILDER DECLARATION
I hereby affirm that 1 am exempt from the Contractor's License
Law fortheity following Professions
bounty whichequite .a perminess t to construct,
Anycity sh, or repair any structure permit o its mt mOe, lter,also
improve, demolish, or repair any structure. prior n its issuance, also
imprCodeove,
requires the applicant for such permit to Ole a signed statement That
he is licensed pursuant to the provisions of the Contractor's License
Law (Chapter 9(commencingwith Section 7000)of Division Sof the
Business and Professions Code) or that he is exempt therefrom and
the basis for the alleged exemption. Any violation of Section 7031.5t„'elrj'Gzlau<'a�1"
w?BUICDING PERMITit*ri'!'*,
�:^=�1'^INFORMATION'„,;;.L-wrS
MISC.- REFER TO ORD
VALUATION - $/FT.
PERMIT ISSUANCE 6.00 �
E EC. CONTR LIC. NO.
n
T�� /�
,<��, py
TOTAL
TOTAL 0( a{l
PERMIT TO
LEG,
Ye Y t Km YF t IVF
S1Y? i x., �'T.+IT+sLdy';7,s,) A ,9
�QTY.^�d' / „4',PCUMBING PEflM1T fi. 1,�,r °tFEEry,,
ia.:.a»s1 Es�tx?tns?.
STORIES
TYPE CONSTR.
by any applicant for a permit subjects the applicant toa Civil penalty
of not more than five hundred dollars (SSOO).):
gLTER-DRAIN-WATER (EA.) 4.00
❑ Las 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: 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
SD. FT. FLOOR AREA
TOTAL ACREAGE
himself or through his own employees, provided that such Improve-
ments1 arc not intended or offered for sale. If, however, the building
or improvement is sold within one year of completion, the owner-
builder will have the burden Of proving that he did not build or int-
prove for purpose of sale.).
❑ 1, as owner of the property, am exclusively contracting with
GAS - EA. SYSTEM -OVER 4 IEA.) 1.00
BUILDING USE
RES IND CON PB Olha,
❑ ❑ ❑ ❑ ❑
INDUSTRIAL WASTE INTER. 20.00
LAWN SPRINKLERS- 1 INC 5 V.B. 5.00
LAWN SPRINKLERS - OVER 5 (EA.) 1.00
ASSESSORS PARCEL NO.
licensed contractors to construct the project (Sec. 7044, Business
and Professions Code: The Contractor's License Law 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.
SEWER -SANITARY -STORM EA. 200ft/6.00
TRACT NO.
PARCEL NO.
❑ lam exempt under Sec.-. B.&P.C. for this
reason
WATER HEATER W/VENT 4.00
Date Owner
WATER SYSTEM 4.00
PCC. OATE
ACC. FILE NO.
WATER TREATING EQUIP. 4.00
WORKERS'COMPENSATION DECLARATION
I hereby affirm that 1 have a certificate of consent to self -insure,
or a certificate of Workers' Compensation Insurance, or a certified
ZONING
ENG. SITE N0.-
copy thereof fSec. 3600, Lab.C.).
Policy No. Company
D Ceslified copy is hereby furnished.
Certified copy is filed with the city inspection division.
Applicant
FIRE SPRINK
y N
❑ ❑
ENERGY T-24
y ❑ N ❑
MI. - REFER TO ORD.
SC
CERTIFICATEOF EXEMPTION FROM WORKERS'
PERMIT ISSUANCE 6.00
FLOOD ZONE
A.L.u.C.
PLG. CONTR. LSC. No.
PLG.
TOTAL
COMPENSATION INSURANCE
(This section need not be completed if the permit is for one
Y ❑ N ❑
- Y ❑ N❑
.-- '.•. ':.d -: - ., pt,�,'y,y --r, i(<
OTY:' - ,u MECHANICAL PERMIT- :Ia - FEE -
,1-:,,, I i, ,^
-' FEESUMMARY
hundred dollars ($100) or less.)
I certify that in the performance of the work for which this per
mil is issued, I shall not employ any person in any manner m ac to
BUILDING
become subject to the Workers' Compensation Lass of California.
Uste Applicant
NOTICE TO APPLICANT: If, after making this Certificate of Ex-
ALTER OR ADD TO MECH. 4.00
APPLIANCE 4.00
PLAN CHECK
emption, you should become subject to the Workers' Compensation
provisions of the Labor Code, yuu must forthwith comply with
such provisions or this permit shall be deemed revoked.
FEE
AIR HANDLING UNIT (TO 10=0C.F.M.) 3.00
AIR HANDLING UNIT (OVER IQOOOQF.M.) 5.00
SEISMIC FEE
CONSTRUCTION LENDING AGENCY
I hereby affirm that to... is a construction lending agency for
EXHAUST HOOD (WITH DUCT) 2.00
the perrormanec of the work for which this permit is issued (Sec.
3097, Civ.C.). A
MICROFILM
HEATING UNIT (TO 100,000 B.T.U.) 4.00
HEATING UNIT (OV ER 100,000 B.T.U.)7.50
ELECTRIC
1
dr 1
Lender's Name i/ �I
Lender's Address
I certify that I have read this application and state that life above
information is correct. I agree to comply with all city and county
ordinances and state laws relating to building construction, and
VENTILATION FAN (SINGLE) 3.00
PLUMBING
BOILER- COMP(3 H.P. or 100,000 B.T.U.) 4.00
BOILER -COMP (Over 100,000BTUI SEE FEESCH.
MECHANICAL
hereby authorize representatives of this City to enter upon the
above-mentioned property for inspection purposes.
MISC. - REFER TO ORD.
CONST. TAX
(We) agree to save, indemnify and keep harmless the City of
Cupertino against liabilities, judgments, costs and expenses which
may in any way areme against said City in consequence of the
PERMIT ISSUANCE 3.00
MECH.CO NT. - LIC. NO.
MECH.
TOTALt
L's:�'yx-lid^9Iw }
" TOTAL
gr gof lhispermit.
Sig lure of Applicant/Contractor Dale
OFF16E COPY