C 5856OFFICE CORY - '
APPLICANT TO FILL IN INFORMATION WITHIN RED LINES —. USE. BALL POINT PEN ONLY
.•Iy'�. AU I LDINGPROJECT I DENTIFICATION .. .r � '- � '., ,•, PMO` NUMBER ,
v UILDING APPLICATION &'PERMIT
O23o �sTEver/VS C7��� BUILDING ELECTRICAL-PLUMBING—MECDERESS HANICAL t 5856
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NAMEEH'a o F5hV/y`,J . I.,
PHONE f.
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QTYELECTRIC PERMIT FEE
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F HECKVALIDATION
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I bYIID V
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DATE OF APPLICATION
4
CONTRACTORSNAME
/oM Heogowlag4Ic.,O o 8622
OUTLETS-SWITCHES-RECEP 5.00/1.00
LIGHTING FIXTURES y 5.00/1.00
CONTRACTORS ♦.
aoovsss.r, ''
57/ N &-7 SRuJO� ONE
APPLIANCES RESIDENTIAL 4.00.•.
PANELS, 5.00 _
ARCHITECT
OR
ENGINEER uc. Na..
SIGNS . 6.00
PLAN CHECK FEE P.C. NO.
-
" SIGNS,TRANS. •'r 3.00
•
NDDRESSENG. -
•' $P ECIALCIRCUIT . S;OO
PERMIT VALIDATION
rrEMP. METER OR POLE INS • 1500
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appLlcaNr's -- -'
AOOH LA -
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MOTORS'' SEE.FEE,SCH.
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10.00"
SERVICE CHANGE .j"1000
LICENSED CONI'RACIORS DECLARATION
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I herchy affnG Tom Jr.. licensed under uovisinns of Clm,no 9
(commencing with Section 7000) of Division 3 of the Ilusiness and
Pnilesvons Cod ,Ayy I license rc m full force nd��ef}}'�klc
Li Cl s_G:LicNumber�n'ia22
Une �b _Contractor
• OWNFR-BUILDER DECLARA-ZION
-
-'I. hereby, affinu that am exempifroni lite COnl moor', License`'
Law for the following reason. 7031.5, Business and Professions,
Code: Any city or County which requires permil to construct alter,
in prove, demolish, or repair any strumom, prior to its issuance, also
21hires Ille applicant for $licit permit to file a signed Statement that
'fie Is licensed perstunt to the provisions of the Contractors I.ICCnse
.l-liw(Cliapter')(CO111menLingwllli Seetiol17000)of Dlvisioil3bitI,cOL/K'/f
Business and 1'rt'essions Code) or that he is exempt therefrom and
the basis for The allegedlexemption-Any violation Of Section 7031.5
by any applicant for a permit subjects the applicant to a civil penalty
of not more than five hundred dollars ($500).):
ISSUANCE GATE
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',61tECT.
L�
PLG. MECH.
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�• - A
�BUIL'DING PERMIT
INFORMATION
MISC. — ', . -REFER T&ORD
-:
'PERMIT ISSUANCE 6'00
VALUATION
ty of Cupertino
WT.
ELEC. CONTR. LIC. NO.
ELEC.
TDTAI.
PER fvll TO
DTV, a 'PLUMBING PER FEE
- `
STORIES
i
TYPE CON
ALTER -DRAIN -WATER (EA.)
❑' I, as owner of the.property, or my employees with wages as
their Side nprensnlion,'will An the work, and tire structure is not
BACK FLOW PROTECT. DEVICE 2.00
OCC. GROUP
RES. UNITS
DRAINS -FLOOR, ROOF, AREA, COND. 4.00
intended or offered for sale (See. 7044, Business and Professions
-
®'-'
Code: 'The,Cmn(rador's License Law does not apply to an owner of
Property who hvidds or improves thereon: and who does Such work.
himself or through his own employees, provided that such improve-
mems are not intended or offered for sale. If, however, The building
-
'
FIXTURES - PER TRAP 4.00 _c
SQ FT. FLOOR AREA
TOTAL ACREAGE
GA$ - EA. SYSTEM - I INC. 4 OUTLETS 4.00•-
or improvenront is sold wilhinlone year of completion, lite owner-
builder will have Ilse burden of proving that he did not build or im-
prove for purpose ofsale.).i
❑ > I, as owner of the property, am exclusively contra with
GAS - EA. SYSTEM -OVER 4 (EA.I .• " 1.00
- BUILDING USE -
RES IND' CON PB' Other
❑ ❑ ❑ ❑. ❑
INDUSTRIAL WASTE INTER. •20:00
licensed contractors to construct the project (Sec. 7044,,limbaess
uad I•ro(essions Code. The Contractor's License Law does not apply
to mi owner of properoi It,, builds or improves thereon, and who
LAWN SPRINKLERS - 1 INC 5 V.B. ' 5.00
ASSESSORS PARCEL NO. -
'
-
LAWN SPRINKLERS -OVER 5'(EA.) 1.00
'SEWER
contracts for such projects with a c.Hturtonsl licensed pursuant to
tire Contractor's LicenseLaw.
-SANITARY -STORM' EA..200ft/8.00.
TRACT NO.
PARCEL NO.
•
. ❑ l am exempt under Sec. `; BA P.C. for this
rcoson'
WATER HEATER W/VENT
,y
Owner Date
WATER SYSTEM 4.00
ACC. DATE
ACC. FILE NO.
WAT,ERTREATING EQUIP, 4.00
-
'WORK '!RS'COMPI:NSATION,DIiCLARATIONI'
`
I hereby affirm'hut I have a certificate ofnmsent bi seR�mwoe,
or a certificate of Workers' Compensation Insurance, or a certified
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-
ZONING
ENG. SITE NO.
'copy thereof f5ec 3800 iLub,C�
com Bcg
policy No
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ID Cetld
❑ Cerli6•.
1ppl
ieer-c t
ran' division.
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FIRESPRINK
V ❑ IN E]
ENERGY T24 "
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p
MISC.- REFER TO ORD.
RTI
z 'ICAO E OF'LXIA7 N ION '-ROM WORKERS'
COMPENSA71(1N INSURANCI
T his section. need not be completed if the IT is for one
PERMIT ISSUANCE 6.00
FLOOD ZONE
Y ❑ N ❑
A.L.U.C.. -
Y [:]IN❑
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0
_PLG. CONTE. .LIC. NO:
PLG.
TOTAL
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O
F
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y
WNOTICE
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hundred dollars (E 100) or less.)
1 certify that in the performance of the work foi.which this per-
mit is issued, I shall not employ any person in any manner m as to
. become subject hl the Workers'Compensation Laws of California.
'Dale to .- Applicant'- ''"
' -
QTY. MECHANICAL PERMIT FEE
FEE SUMMARY
-BUILDING"
PLAN CHECK
ALTER•OR'ADD TO MECH. 4.00
a
APPLIANCE 4.00
TO APPLICANT: If, afler making this Certificale of Ex-:''
emptiun, you should become subject to the Workers' Compensation
—
provisions of the Labor Code, you must forthwith comply with
such provisions or This permit shall be deemed revoked.
AIR HANDLING UNIT (TO 10,000C.F.M.) 3.00
FEE
AIR HANDLING UNIT(O 10 C.F.M.15.00
SEISMIC FEE
. CONSTRUCTION LENDING AGENCY ,
'I' hereby affirm tier there is .'construction lending agency for
EXHAUST HOOD (WITH DUCT) '.2.00
•MICROFILM
lire performance of the work for which this permit is issued (Sec.
3097, Civ.C.).
-
HEATING UNIT (TO 10 , 0 .T:U'.) -4.00 _
Under's Name
HEATING UNIT (OVER 100,000 B.T.U.)7.50
ELECTRIC
Lenders Address
I certify flim l have read this application rind state that lire above
VENTILATION FAN (SINGLE) 3.00'
information is correct. I agree to comply with.all'city andcounty,
orlin:umes and slate-laws•relming to buildingconnrumi In. and
PLUMBING
•r
BOILER -COW (3 H.P. or 100,000 B.T.U.) 4.00
BOILER-COMP(Over 100,0008TUI SEE FEE SGH.
— -
•.MECHANICAL.
-
V
Iau
ereby lanin, representatives of this city .H enterupon the
above-mentioned properly (orinspeclion purposes'. i
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' (We) agree m save, indemnify and keep harmless fire City of
Cupertino against liabilities, judgments, costs and expenses which
may Gn any way accrue against said City in consequence of the
MISC. - Z, O S ' REFER TO'ORD.
CONST. TAX
'
-
'PERMIT ISSUANCE . "3.00
gmnlIng o this permit.
' 1�' '�J'fo B5.
MECH. CONT. LIE. NO. MECH.
OTAL
/ 7
TOTAL
Vi`
Signa eof ApplicatrlCon Vdflor. Date,
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OFFICE CORY - '