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APP ANT TO FILL IN INFORMATION WITHIN RED LINES -USE BALL POINT PEN ONLY
BUI LDI NG PROJECT I DENTI FICATI ON
APPLICATION & PERMIT
BUILDING - ELECTRICAL- PLUMBING - MECHANICAL
PERMIT NUMBER
5843
BUILDING
ADDRESS'
OWNER'S
NAME
D
���}qp� �4� -t
;) . "KTj� �1�� • ,
CT 1 aP.ERMIT•
QTY°9041111
a i•' gr'.'r:;0'518:'l
PLAN CHECK VALIDATION
DATE OF APPLICATION
CONTRACTOR'b
NA /��J �
2 /'Y!/F/- eLlc. No. ZB 1,71
UTLETS - SWITCHES -RECEP 5.00/1.00
LI GHTING FIXTURES 5.00/1.00
CONTRACTORS OW' -7Z7 7-
AODREb6
G �� S SOS
pp LIANCES-RESIDENTIAL 4.00
PANELS 5.00
ARCHITECT
OR
ENGINEER
' LIC. No,
SIGNS 600
PLAN CHECK FEE P.C. NO,
SIGNS TRANS. 3.00
ARCH. OR ENG.
-"' SS
ZIP
SPECIAL CIRCUIT 5.00
PERMIT VALIDATION
TEMP. METER OR POLE INS. 15.00
ADDRESS T
ADDRESS 3S
MOTORS SEE FEE SCH.
SERVICE CHANGE 10.00
09 v5' ,yam
/ O/
ISSUANCE DATE
t +R^hY;„LICENSED CONTRACTORS DECLARATION
',Y'`1 hereby affirm that 1 am licensed under provisions of Chapter 9
•
(commencing with Section 7000) of Division 3 of the Business and
Professions Code, and my license is in full (mc,,jnLa eel.
CI = (^T Lic. Number �j
BLDG.
❑
ELECT. PLG.
❑ ❑
MECH.
ElLicense
-
Dale' $_�L Contractor
,
OWNER -BUILDER DECLARATION.
MISC. - REFER TO ORD
1 hereby affirm That I am exempt from the Contractor's License
Law for the following reason.(Sm. 7031.5, Businessand Professions
Code: Any city Or county which rapidness permit to Construct, alter,
PERMIT ISSUANCE 6.00
A
yALUATION
D ` N
SIFT.
improve, demolish, or repair any structure, prior to its issuance, also
ELEC. CONTE. LIC.
J
requires; the applicant for such permitto file a signed statement that
he is licensed pursuant to the provisions of the Contractor's Ucensc
Law (Chapter 9 (commencing with Section 7000) of Division 3 of the
Rosiness and Profeaions Code) oothat he 1s exempt lhemfrom and
the basis for the alleged exemption. Any violation of Section 7031.5
_ - TOTAL
{ s
PERMIT TO
7'sJLL OV
r
STORIES
TYPE CONSTFL
by any applicant for a permit subjects the applicant to civil penalty
of not mom than five hundred dollars(5500).):'• -
-ALTER-DRAIN& VENT-WATER(EA.)4. u
8rt100
❑^. 1; as owner of the property, or my employees with wages as
their sole compenalion, will do the work, and the structure h not
BACK FLOW PROTECT. DEVICE 2,00 -
OCC. GROUP
-
RES. UNITS
1 DRAINS -FLOOR, ROOF, AREA,COND. 4.00
intended'oi"offered for sale (Sec. 7044, Basin. and Professions
Code: The Contractors License Law does not apply to an owner of
'property. who builds or improve lhemon, and who does such work
himself or through his own employees, provided that such improve
mentsamnotintendedoroffered for ale. If, however, the building
FIXTURES - PER TRAP 4.00
SCL FT. FLOOR AREA
- -
TOTAL ACREAGE '
GAS -EA. SYSTEM -1 INC.4 OUTLETS 4.00
or improvement is sold within one year of completion, the owner-
builder will have. the burden of proving that he did not build or im"
for purpose ofsaleJ. '' ' - -r' :
> ❑ I, as owner of the property, am exclusively Contracting with
. .1 .
GAS - EASYSTEM -OVER 4 IEA - 100
BUILDING USE
REB IND CON PB Cilia,
❑ ❑ ❑ ❑ ❑
INDUSTRIAL WASTE INTER. 20.00
licensed contractors to construct the project (See. 7044, Business
and Professions Code: The Contractor's License Law does not apply
to an owner of property who builds or improves thereon. and whoLAWN
LAWN SPRINKLERS- 1 INC 5 V.B. 5.00
SPRINKLERS - OVER 5 fEA.) 1.00
ASSESSORS PARCEL NO.
Contracts for such projects with a m ntraclor(s) licensed pursuant to
the Contractor's License Law.
SEWER -SANITARY -STORM EA. 200ft/8.00
TRACT NO.
PARCEL NO.
❑ I am exempt under Sec. ,BAP.C. for this
reason
WATER HEATER W/VENT 4.00
Owner Date
WATER SYSTEM 4.00
ACC. DATE
ACC. FILE NO.
WATER TREATING EQUIP. 4.00
. WORKERS'COMPENSATION DECLARATION
"
I hereby affirm That 1 have a Certificate ofconsenl to self -insure,
or a certificateof Woorrkke�rls' Comppeensation Insurance, or a certified
ZONING
ENG. SITE NO.
Polthem
No.* /BLalop'JfI -/AycJ?4 !i0?
icy
❑ Certif c9py is he�aall] dished P
ACer ie op)6 r ith t i spectijdon.
PP....
FIRESPRINK
y N
❑ ❑
ENERGY T 24
y N
❑ ❑
MISC.- REFER TO ORD.
TIFICATE OF EXEMPTION FROM WORKERS'
PERMIT ISSUANCE 6.00
FLOOD ZONE
A.L.U.C.
COMPENSATION INSURANCE
. (This clion need not be completed if the permit is for one
PLG. CONTR. LIC. NO. PLG.
I TOTAL
Y ❑ N ❑
Y ❑ N ❑
PT •-tI�' i rM t�,',p` ! ;'}meq
xis !+"-f4'
OTV. ;MECHANICAL PERMIT FEE
y) ap�+.+d , ay z
'Ne' ''3='" '^ ` K�I'I•A i " `"'
- ..w..•+ ,).
FEE SUMMARY'
BUILDING Zr tV
hundred dollars (S 100) or less.)
I certify that in the performance of the work for which this per.
mil is issuede I shell not employ any person in any mannero is to
become subject 10 the Workers' Compensation Laws of California.
Date Applicant
NOTICE TO APPLICANT: If, after making this six"
ALTER OR ADD TO MECH. 4.00
App LIANCE 4.00
PLAN CHECK
FEE
�� ^`
"1 90
Workers' Compensation
sa
em vision you should become subject m the Workers' Ccomply with
provisions io the labor Code, you must drevoke comply with
such provisions or this permit shall be deemed revoked.
AIR HANDLING UNIT (TO 10,000 GF.M) 3.00
AIR HANDLING UNIT (OVER 101000C.F.M.) 5.00
SEISMIC FEE
CONSTRUCTION LENDING AGENCY
1 hereby affirm that there is a construction lending agency for
EXHAUST HOOD (WITH DUCT) 2.00
the Performance of the work for which this permit is issued (Sec.
3097. CN.C.).
MICROFILM
HEATING UNIT (TO 100,000 B.T.U.) 4.00
HEATING UN IT (OVER 100,000 B.T.U.17.50
ELECTRIC
Lender's Name
Lender's Address
I certify that I have read this application and state that the above
information is correct. I agree to comply with all city and county
ordinances and state laws (elating to building construction, and
VENTILATION FAN (SINGLE) 3.00
PLUMBING
BOILER -OOMP(3 H.P. Or 100,000 B.T.U.) 4.00
BOILER -COMP (Over 100,000 BTU) SEE FEE SCH.
MECHANICAL
hereby authorize representatives of this city to enter upon the
above-mentioned property for inspection purposes.
MISC. - REFER TO ORD.
(WC) 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
PERMIT ISSUANCE 3.00
CONST. TAX
in Of thisper 1
I $
MECN. CONT. LIL. NO. MECH,
TOTnL
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4W�CTAt
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mire of scans/ cntrector Date
OFFICE COPY