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.BU I LOI NG PROJECT I DENT] FICATI ON
APPLICATION & PERMIT
- -
BUILDING — ELECTRICAL— PLUMBING — MECHANICAL
PERMIT NUMBER
871
a iLDINC
ADDRESS
Q �U>GH.� C tlti�j
OwN H'a n�/E
NAME /!
IM2A I 1 PHONE
P
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GTV '�i� x ♦tIS i I 41 _ t L
ELECTRIC PERMITI (tI„+bu 3FEE
PLAN CHECK VALIDATION
DATE OF APPLICATION
NgMEHAcrDRs
IL AA01A J*LV Llc. NO, 10
UTLETS-SWITCHES•RECEP 10,00/1.00
ILIGHTING FIXTURES 10.00/1.00
nouness TORS 'M
O 0 ' a ` PNONE • 1
PPLIANCES-RESIDENTIAL 4.00
PANELS 10,00
Aon,RCHITECT_
ENGINEER
tic. No.
PANELS (OVER 200 AMP) 20.001PLAN
CHECK FEE P.C. NO.
-
ISIGNS TRANS. 3.00
ADDRESS ENG.
ZIP
SPECIAL CIRCUIT 5.00
PERMIT VALIDATION
('
ISSUANCE DATA/
EMP. METER OR POLE INS. 20.00
APPLICANT'S�i..l
ADDRESS
MOTORS SEE FEE BCH,
SERVICE CHANGE 20.00
LICENSED CONTRACTORS DECLARATION
I hereby affairs that I um licensed u oder provisions of Chapter9
(commencing with Section 7000) of Division 3 of lite Business and
Professions Code a @y I''enu is in lull Parc • au feet
License Class—L_-Q.(1— Lic. Number��
L"e Calllra''taf
TEMP. POLE 30,00
BLDG.
ELECT.
PLG. MECH.
El
OWNER -BUILDER DECLARATION
1 hen al fin' lint I exempt from the Cantmcmri License
Law or the fallowing reason. (See. 7031.5, Busincssamd Professions
Code: An cit or count which resuiresu
Ye Y Y 1 Prior to is issuance, also
prior to its issuance, also
improve,sires demolish, or repair any stento lite
for such permit to file i signed statement Li that
fie sires thedp pursuant
ha is licensd 9 (commencing the provisions of the COmnatar s 3 Of H e
Urvismn om tit
Buw (ChapternProl Cod) or Benitic 7s exempt
Business and I'rolLsahons Code) or that he Is exempt Iherelrom and
the basis for the alleged exemption. Any violation of Section 7031 5
lora Permit dollars $500).he hcum "oacnvd penalty
by any more
of not marc woe lieu ire property,
rop dollars (my employees with re is as
❑ I, as owner at the will do ti or my, and (be
will (S the work, and the stmdure s not
their Safe r offered for
intended or offend for Luce (Sec. 7044, not Business and all Owner os
Code: The Conlrucmr's License Law docs not apply to un owner of
properly who builds or improves thereon, and who does such work
himself or through his own employees, provided that such improve
ments are not intended or offered for sale if, however, the building
or improvement is sold within one year of completion, the owner.
wilder will have the burden of proving that he did not build or int-
Prove for purpose of sale.).
0 I, as owner of the property, um exclusively contracting with
licensed contractors m construct the Rojecl (Sec. 7044, Business
and Professions Code: -rise Contractor's License Law docs not apply
m an owner of property who builds or improves thereon. and wlm
contracts for Such projects with a cuNfBClosso licensed pursuant It
the Contractor's License Law.
❑ I an, exempt under See. , B.6P.C. lor"hIL
reason
BUILDING PERMIT;�y%va!
- INFORMATION'yak'.+^g-;
!misc. — REFER TO OR
PERMIT ISSUANCE 1Q.00
VALUATION -
SIFT.
[LEC. CONTR. LIC. NO.
ELEC.
TOTAL
PERMIT TO
OTV : PLUMBING PERMITS* FEE`
• „`- '.: �' d I .5�
ALTER•DRAIN& VENT -WATER (EA.) 5.00
STORIES
TYPE CONSTR.
BACK F LOW PROTECT. DEVICE 4,00
OCC. GROUP
RES. UNITS
DRAINS -FLOOR, ROOF, AREA, COND. 5.00 04-
FIXTURES - PER TRAP".00
GAS - EA. SYSTEM -1 INC.4 OUTLETS 6,00
GAS - EA. SYSTEM -OVER 4 IEA,) 2.00
SQ FT. FLOOR AREA
TOTAL ACREAGE
BUILDING USE
RES IND CON PB Omer
INDUS TRI AL WASTE INTER. 30.00
LAWN SPRINKLERS- 1 INC 5 V.B. 6.00
ASSESSORS PARCEL NO.
LAWN SPRINKLERS - O A.) 1,00
SEWER•SANITARY-STO MEA.20 0.00
TRACT NO.
PARCEL NO.
WATER HEATER W/VkPj 9, L• 6.00
Owner Date
WATER SYSTEM\JX0
WORKERS'COMPENSATION DECLARATION
1 hereby affirm that I have a certificate of curse'" to xlGinsure,
or a certificate of Workers' Compenwtion Insurance, or a certified
copy thereof (See. 3800Comp.by— r!�At•!� P
Policy CnmpanY—
ACC. GATE
ACC FILE NO.
WATER TREATING EQUIP.. Pit U005 0-0
ZONING
ENG. SITE NO.
MISC. - REFER TO ORD.
-. '�'f
erl
Y0 Certified copy cop ishercby l will, rise
❑ Cetlified copy is tiled wish the lily inspection Division.
Applicant
FIRE SPRINK
Y ❑ No
ENERGY T-24
10 NE]
CRRTIFICA'TE of IiXGMPnON PROM WORKERS'
COMPENSATION INSURANCE
(This section neednot be completed if the permit is for one
hundred dollar (S 100) or .... )
I Lenity "hal in the Pufunnance of the work I'nr which this r
..it Is issued, I shall not employ 1 pe
P Y v Y person in any manner w as m
became subject to the Korkels' Cuntpensanon Laws of Celilornia.
DateApplicant
PERMIT ISSUANCE
FLOOD ZONE
Y N[D
A. L. U.C.
Y E) No
PLG. CONI R, LIC. NO.
PLG. O
TOTAL
-
j r
OTY MECHANICAL PERMIT +1 tM FEE`::
- 1'i rh; 1.
• 3 n .v
tV "FEE'SUMMARV;L
iv ✓,%E ,ll a 3Ee'a
.. ...
BUILDING
_
ALTER OR ADD TO MECH. 5.00
NOTICE TO APPLICANT: If, after making [his Certificate of E.-
s,mption, sou should become subject to the Workers Compensation
Provisions of the Labor Code, you must forthwith cmnply with
such provisions or this permit shall be deemed revoked
CONSTRUCTION LENDING AGENCY
I hereby affirm that there is a construction fending agency for
the performance of the work for which this permit is issued (Sec
3097, CiS.C.),
Lender's Name
Lenders Address
APPLIANCE 5.00
AIR HANDLING UNIT (TO 10,000GF.M) 4.00
PLAN CHECK
FEE
AIR HANDLING UNIT(OVER 10MC.F.M.) 6.00
SEISMIC FEE
EXHAUST HOOD (WITH DUCT) 5.00
MICROFILM
HEATING UNIT (TO 100,000 B.T.U.) 8.00
HEATI NG UNIT (OVER 100,000 B.T.U.) 9.50
ELECTRIC
I cettify that I have read this appliculion and slate that the above
information is mrrcct. I agree to comply with all oily and roun"y
ordinances and state laws relating "o building construction, and
hereby Autentiorixe representatives for ins of this city to enitt ppun [he
hervementionW property for inspection purposes, ts.
(We) allies, m vve, indilmnify and keep t.HRIca4 the City of
Cupertino against liabilities, judgments, costs, wul expenses whidh
may' in any way accrue against said City in 'OH.' unmC of the
grants of this peon t.
S'RY'
IaIUIL'ol, Ipicnl[ICUnt roe to, Dale
VENTILATION FAN (SINGLE) 4.00
BOILER-COMPI3 H.P. or 100,000 B.T. U.) 6.00
PLUMBING
W
��
BOILER -COMP l0var 100,000 BTU) SEE FEE BCH.
MECHANICAL
MISC. • REFER TO ORD.
PERMIT ISSUANCE 10.00
CONST. TAX
MECH. CONr. LIC. NO. MECH.
TOTAL
<(' TOTAL'"..t
l 22L"1WstL.1J/