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BUILDING PROJE T I DENT[ FICATION
APPLICATION & PERMIT
BUILDING -ELECTRICAL -PLUMBING -MECHANICAL
PERMIT NUMBER
8354
HURL ING t7z
i ADDRESSn
• LA�'Z30
owrvER's -a-
"AME « / �'T� ��✓`t,
Ti "ONE
- I k 1, i• ! sA
CITY.'live' a ELECTRIC PERMIT"' e!, �` t k,FEE n
i, % r a< 1.T a Lrp4t%rad S A7.i
PLAN CHECK VALIDATION '
DATE OF APPLICATION
NAM1EnRcroRs �a
ICPki ! u•La
{uf(y► L, C. NG Bra`
UTLETS,SWITCHES-RECEP 10,0011.00
LIGHTING FIXTURES 10.00/1.00
CONTRACTOR'S
Acton Ess
.d�3'�/�Y,OrvE(� $"SfO
PPLIANCES-RESIDENTIAL 4.00
PANELS 10.00
ORcnrtECT
ENGINEER'
uc. No.
PANELS (OVER 200 AMP) 20.00
PLAN CHECK FEE P.C. NO.
ISIGNS TRANS. 3.00
Roo css ENG. -
ZIP
SPECIALCIRCUIT 5,00
PERMIT VALIDATION
TEMP. METER OR POLE INS. 20.00
APPLICANT',
ADDRESS
MOTORS SEE FEE SCH.
SERVICE CHANGE 20.00�O/p-J✓
G
LICENSED CONTRACTORS IIECLARA'FION
TEMP. POLE 30.00
1 hereby aflinn that I am licensed under provisions of Chapter 9
(Commencing with Section 7000) of Division 3 of the Business and
Professions Code, ,.fad ppyyy �llicense is in full fort an resell.
License CI;Ls� fd T LiL. Number- ('�rI�✓_�/Fa�3 �
UaIC_ . J. -gC11111ri1el Or -1Cl����e�4
ISSUANCE DATE
BLDG. ELECT.
❑ ❑
PLG. MECH.
❑ ..e -s.
✓I"b1
a.rBUILDINO,PERM11�",S?•
4 ��
r•�Gnn
OWNER -BUILDER DECLARATION
MISC.- REFER TO ORD
1 hereby aflinn ng 1 am exempt from IIIc Cmvructor's Lice n>e
CodLawe:Ayckar Eric ylowiountywhin. Sec. 7031.5,ermit tucnd Prct,alon>
Code: Any city ar c0, rep which requirese permit lir, Construct,aheq
improve, demolish, Or repair any structure, prior W its issuance, also
requires the applicant to, such permit m file a signed statement than
he is licensed pursuant to the provisions TIE the Contractor's License
Law (Chapter 9(commencing with Section 7000)of Dlvlsio113 oI the
Business and Professions Code) or that he is exempt therefrom and
the basis for the alleged exemption Any violation of Section 70315-
,(Nrl,',�'-"NFORMATION t,4
VALUATION
$/FT.
SIFT.
PERMIT ISSUANCE 10.00
ELEC. CONTR. LIC. N0.
ELEC.
TOTAL
PERMITTO
GTY. - ,PLUMBING PERMIT IS! x'j. A is FEE.A`,
t v da vll'ISaa, a.'�4mti
STORIES
TYPECON6TR.
by any applicant for a permit subjects the applicant to a civil penalty
of not more than Five hundred dollars ($500).1:
- _
ALTER -DRAIN -WATER (EA.) 5.00
❑ I, as owner of the property, or my employees with wages as
their sok compensation, will do the work, and the structure s mm
BACK FLOW PROTECT. DEVICE 4.00
OCC. GROUP
RES, UNITS
DRAINS -FLOOR, ROOF, AREA, COND. 5,00
intended or offered for .Sale (Sec. 7044, Business and Professions
' -
Code: The Commctor's License Law don not apply to an owner of
property who builds or improves Ihercon, and who does such work
himself or through his own employees, provided that such improve-
mentsarenotintendedoroffered for is. If however, the building
FIXTURES - PER TRAP 5.00
GAS - EA. SYSTEM -1 INC.4 OUTLETS 6.00
SO, FT. FLOOR AREA
TOTAL ACREAGE
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-
prove for purpose of sale.).INDUSTRIAL
❑ 1, as owner of the property, am exclusively cunlmcling with
GAS EASYSTEM -OVER 4 IEA.) 2.00
- .
BUILDING USE
RE6 IND CON PB' Omar
❑ ❑ ❑ ❑ ❑
WASTE INTER. 30.00
licensed contractors to construct Dm project (Sec. 7044, Business
and Professioro Core: The Cont roc toe's License Law dues not 'apply
to an owner of property who builds or improves thereon, and who
LAWN SPRINKLERS - 1 INC 5 V.B. 6.00
ASSESSORS PARCEL NO.
LAWN SPRINKLERS - OVER 5 (EA.) 1.00
contracts for such projects with a contractions) licensed pursuant to
the Contractors License Law.
SEWER -SAN EA. 2001(/10.00
TRACT NO.
PARCEL NO.
❑ I am exempt under See.-, B.&P.C. for this
reason
WATER HEATER W/VENT 6.00
Owner Date
WATER SYSTEM 5.00
ACC. DATE
ACC. FILE NO.
WATER TREATING EQUIP. 5.00
WORK ERS'COMPENSATION DECLARATION
I hereby affirm that I have a certificale of consent m sell' -insure,
or a certificate of Workers' Compensation Insurance, or a certifier
ZONING
ENG. SITE NO.
Copy thereof (Sec. 3800, Lub.C.). II L✓00
Policy No. Company_p1OYU
FIRE 6PRINK
Y ❑ N ❑
ENERGY T24
V ❑ N❑
❑ Certified'copyuflcrebyfurnished.
Certified o is GI with the ity inspection division.
Applicant _p(Jy�1�
MISC. - REFER TO ORD.
CERTIFICATE 017 EX IPTION FROM WORKERS'
PERMIT ISSUANCE 10.00
FLOOD ZONE
AL.U.C.
COMPENSATION INSURANCE
(This section need not be completed if the permit is for one
Y ❑ N ❑
Y [3 N❑
PLG. CONTR. LIC. NO,
PLG.
TOTAL
hundred dollars (S 100) or ass)
I Certify that in the Perlurmence of the work for which OR, per
mit is issued. I shall nm employ any perwn in any manner aomw
become subject to the Workers Compemalion Lew, oI CHllfurnaa.
Date Applicant
I ••.r - Yr�r �_-s 4+ (
OTY. t w '. MECHANICAL PERMI'la }s - 4y FEE ,
ei r ' n,n.'. •�
Cq °� FEE SUMMARY, i.,
h
BUILDING
ALTER OR ADD T ECH: j
NOTICE TO APPLICANT: If, after making this Certificate of Ex-
APPLIANCE "- "5.00
AIR HANDLING UNIT 1 4.00
PLAN CHECK
FEE
emption, you should became subject to the Workers' Compemalion
provisions of the Labor Code, you must forthwith comply with
such provisions or this permit shun be deemed revoked.
AIR HANDLING UNIT (OVER 10=C. F.M. 6.00
SEISMIC FEE
CONSTRUCTION LENDING AGENCY
1 hereby affirm that there is a construction lending agency for
EXHAUST HOOD (WITH DUCT) 5.00
31ic 097 performance of the work for which this permit is issued (Sec.
MICROFILM
HEATING UNIT (TO 100,000 B.T.U.) 8.00
Lender's Neuse
LenderAddress
HEATING UN IT (OVER 100,000 B.T.U.) 9.50
ELECTRIC
I certify that l have read this applicatiml and State that the above
VENTILATION FAN (SINGLE) ,2
information is correct. 1 agree to comply with all city and county
ordinances and state laws relating to building construction, and
PLUMBING
BOILER- COMM H.P. or 100,000 B.T.U.) 6.00
BOILER -COMP (Over 100,000 BTU) SEE FEE bees.
MECHANICAL
Q ��
Imreby authorim representatives of this airy to enter upon the
bove-mentioned property for inspection purposea
MISC. - REFER TO ORD.
(We) agree to save, indemnlly and keep harmless the City of
Cupertino against liabilities, judgments Gusts and espcnsn which
may in a waY accrue against said City in cu asequence of the
granting IMS ern' .
CONST. TAX
PERMIT ISSUANCE 1D6B' 3 G"(�
MECH. CONT. LIC. NO.
I MECH.
77-7
lCD 1 Qr7
Signal re Of Applicant/Contractor Uale
I,I Q�OTAL
`^'� %'{(LN.ilrkl� (J1P
3
' TOTAL"''
OFFICE COPY