8451PPL'ICANT°TO FILL 'IN'INFORMATION WITHIN RED LINES- USE BALL POINT PEN ONLY
:BUI LOI NG PROJECT I DENTI FICATION
APPLICATION & PERMIT
BUILDING-ELECTRICAL-PLUMBING-MECHANICAL
LL
'i'nv u't drat q.�l§ai Nk h�N• D 'e Y'ir'
CITY II 'I- 1 -ELECTRIC P,ERMIT,,1. 1 ��y FEE,
i ai'w .Y1R Jh',1J{ fA S '; Iw;} tY• I '�1,1 ,,.' N =
PERMITNUMBER
8451
PLAN CHECK VALIDATION
-
DATE OF APPLICATION
PLAN CHECK FEE .C. NO.
eaILOING ,..
'ADORE l^
T. N Gl/lI t 5
OWNER'S ��
"AME V�)/��
Ov IO V� I�S PHONE
CONTRACTOR'S
AME
LIC. No. ?j
UTLETS-SWITCHES-RECEP 10.00/1.00
LIGHTING FIXTURES 10,00/1.00
ro TRACToes -
ADDRESS
4-17 i �, PHONE T QI
ARCHITECT
PPLIANCES-RESIDENTIAL 4.00
PANELS 10.00
PANELS (OVER 200 AMP) 20.001
O .
ENR GINEER
LIC.. NO.
TRANS3.00
SIGNS .
ARCH. OR ENG.
ADDRESS
ZIP
SPECIAL CIRCUIT 5.00
PERMIT VALIDATION
EMP. METER OR POLE INS. 20.00
APPLICANTS
ADDRESS
MOTORS SEE FEE SCH.
SERVICE CHANGE 20.00
LICENSED CONTRACTORS UIiCLA RATION
TEMP. POLE 30.00
I hereby of HR that I am licensed rude, provisions of Chapter 9
(commencing with Section 7000) of Division 3 of the Business and
ISSUANCE DATE
B G. PLO J MECH.
Professions Code a d ny license is in full fns f • 1
LicenseC LIC. Number{�0
Dale fJConNuclur.ILYa_�' ( yFT�y,
bWNF.R-GUILDER DECLARATION
I hereby affirm that I am exempt lions the Contractor's License
Law for the following reason. (Sec. 7031.5, Businesaand Prolesaioos
Code: Any city of county whichreyuiresa permit tucoatruct.aller,
improve, demolish, or repair any atrucmli, prior to its issuance, also
requires the applicant fur such permit to Ilk a signed statement that
he Is licensed pursuant to the provisions of the Contractor's Llcena
Law (Chapter 9(conlmenclnµwith Sect I 17000)x1 Division 3ul (11
Business and 1'rolesssons Code) or that II Is enpl thercfrmn and
Ile basis for the atc,,cl exemption Any ( fon ul Beet ton 7031 5
by any applicant icor a permit sublet OLaIplleanl to a civil pcmaB3
of not mare Tom live hundred dollars ( S5001.):
❑ ❑
-
""`'1^'INFO ION''ii�j%''�fIA`.
MISC. - REFER TO ORD
TQQQN $/FT.
8>0
(/nvn
PERMIT ISSUANCE 10.00
ELEC. CONTR. LIC. NO.
ELEC.
TOTAL
.PERMIT TO
'
• I -
- ,� ',; Iy45'.
CITY. - PLUMBING u I ,' FEE'--
- t ', rr- t .
STORIES
8
TVP)`CONSTR.
.�I/7/�)v
07,
ALTER-DRAIN&VENT-WATER (EA.) 5.00
BACK FLOW PROTECT. DEVICE 4.00
OCC. GROUP
RES. UNrrb
❑ 1, as owner of the properly, or ay employees with wages as
their sole compensation, will do the work, and the structure Is not
intended or offered for sale (Sec. 7044, Buaincas and Professions
DRAINS -FLOOR, ROOF, AREA, COND. 5.00
Code: The Contractor's License Law does not apply to an owner of
property who builds or improves Ihercun, and who docs such work
himself or through his own employee, provided that such improve
mems are not intended or offered fur sale. If, however, the building
FIXTURES - PER TRAP 5.00
SO. FT. FLOOR AREA
TOTAL ACREAGE
TLETS fi.00
GAS -EA. SYSTEM-11N;ER4
-r improvement is Sold within one year of completion, the owner-
wilder will have the burdrn of proving that he Jid noI build m ins-
for purpose of sok.).
I, as owner of The property, am exclusively conflicting withEl
licensed contractors Io construct the project (See. 7044, BHfllleas
GAS - EA. SV STEM -OEA.) 2.00
BUILDING uSE
RE$ INDCON PB Omvprove
0
INDUSTRIAL WASTE I 30.00❑
LAWN SPRINKLERS - 1V.B. 6.00
ASSESSO ARCELNO,
and Professions Code- The Contractors License Law does not applyto an owner of properly who builds or improves thereon. and who
LAWN SPRINKLERS - 1EA.) 1.00contracts
fur such projects with a contructons) licensed Paruwlt In
the Contractor's License Law.
SEWER-SANITAR V -ST. 200ft/10.00
TRACT NO.
PARCEL NO.
WATER HEATER W/VENT 6.00
❑ I am exempt under See , 134P.C. for this
reason
Owner Date
WATER SYSTEM 5.00
ACC. DATE
ACC. FILE NO.
WORK ERS'COM PENSATION DECLARATION
WATER TREATING EQUIP. 5.00
I hereby xtfum that I have a cellduale of consent to sell-iRsrle,
or a certificate of Workers' Compensation Insurance, or a ectlil'icd
ZONING
ENG. SITE NO.
copy thereaftSec. 38130, Lab,C.l.-/
Policy No._Company.JY0Q7}T__V_L[GrQ
❑ Cetlilied ropy ishucby lunusheJ,
'-}"[Certified c p is ted with Ices tyf.,I" ""non d"Him.
A'(phcam 1.1t
FIRE$PRINK
Y o NE]
ENERGY T-24
Y ❑ N�
MISC.- REFER TO ORD.
CERTIFICATE 01° EXEMPTION FROM WORKERS'
PERMIT ISSUANCE 10.00
FLOOD ZONE
A.LO.C.
PLG. CONTR. LIF NO.
PLG.
TOTAL
COS114-NSATION INSURANCE
section need not be completed if the peanut is for one
hundred dollsrs(S]00)or less.)
I ccrtrfy that in the perfonnanee of the work In, .]rich this pis
mit Is issued, I shall not employ any person In any manner so as toU,
become subject to the Workers' Compensation Laws of Culilornia.
Dale Applicant
V N
V NE)
CITY.MECHANICAL PERMIT A = s `FEE.
""
-'fX.4+ FEE SUMMARY ?",^
BUILDING
3!
ALTER OR ADD TO MECH. 5.00
NOTICE TO APPLICANT: If, afar making this Certificate of Ex-
emption, you should become subject ID lire W'orkeri Colipenvation
provisions of the Labor Code, you amt lunhwilh comply with
such pfavisimet or this permit strait be deemed revoked.
APPLIANCE 5.00
PLAN CHECK
FEE
v
o
AIR HANDLING UNIT (TO IOAO0QF.M.) 4.00
AIR HANDLING UNIT (OVER 10=QF.M.) 6.00
SEISMIC FEE
3
CONSTRUCTION LENDING AGENCY
EXHAUST HOOD (WITH DUCT) 5.00
MICROFILM
I hereby affirm that Olen is a construction lending agency for
the performance of the work for which this permit is issued (Sec.
3097, Civ.C.).
HEATING UNIT (TO 100,000 B.T.U.) 8.00
HEATI NO UNIT (OV ER 100,000 B.T.U.)9.50
ELECTRIC
Leader's Name
Lender's Address
I certify that I have read this application and stale Ihm the above
information is correct. I agree to comply with all city and coumy
ordinances and stale laws relating to building construction, and
VENTI LATION FAN (SINGLE) 4.00
PLUMBING
BOILER -COMP 13 H.P. or 100,000 B.T.U.) 6.00
BOILER -COMP lOvar 100,000 BTU) SEE FEE SCH.
MECHANICAL
pereby author" representatives of this city to enter upon the
beve•mentioned properly for inspection purposes.
(WO agree m save, indemnify and keep harmless the City of
Cupertino against liabilities, jUdgnlenla, costa and expenses .'hich
may in any way accrue against said City in consequence of the
MISC. - REFER TO ORD.
CONST. TAX
PERMIT ISSUANCE 10.00
MECH. CONT. LIC. NO. MECH.
TOTAL
3:_TOTAC."
f Z
gran110 Wis email
�
�rllate
Signe reof Applicant/Contractor
OFFICE COPY