C 8134A?.PCICANT TO FILLY IN INFORMATION WITHIN RED LINES'- USE BALL POINT PEN ONLY
^ ,BUILDING PROJECT IDENTIFICATION
APPLICATION & PERMIT
BUILDING ELECTRICAL PLUMBING MECHANICAL
:•1 1 f:"'' e'.7^lpl{ ulvE Y .t,j
OTY - )` ELECTRIC PE_RMITP %T 1 ti;'(u v FEE:h
' ITM. y,
PERMIT NUMBER
4
PLAN CHECK VALIDATION
.
DATE OF APPLICATION
gDIL�DINwG813
Ago`{J� �7jziGL''
OWNER' yy
"Af�lrE3
PHONV
roNTRACTOR5
AME
' LIC. NO
UTLETS-SWITCHES-RECEP 10.00/1.00
ILIGHTING FIXTURES 10.00/1.00
CONTRACTOR'S
ADDRESS
PHONE
[APPLIANCES - RESIDENTIAL 4.00
PANELS 10.00
ARCHITECT
OR
ENGINEER /�j,// �% G/�S
!r LI0. N0.
PANELS (OVER 200 AMP) 20,00
PLAN CMF K FEE P.C. NO.
SIGNS TRANS. 3.00
ARCH OR ENG.
ADDRESS #0rr1� n r �%
-,,b za, rtTEMP.
S.00
SPECIAL CIRCUIT:-:-
DATION
p n
APR - 1985
City of Cupertino
METER OR POLE INS. 20.00
APPLICANT'S
ADDR3U '/. C
MOTORS SEE FEE SCH.
SERVICE CHANGE 20.00
LICENSED CON TRACTORS DECLARATION
ITEMP. POLE 30.00
I hereby affirm That I unh licensed under pruvlslo s of Chapter 9
(commencing with Section 7000) of Division 3 of the Business and
ISSUANCE DATE
BLDG.
ELECT.
PLG. MECH.
Professions Code, and my license is in full force and effect.
License Class Lie. Number
❑
I
❑ ❑
Date Contractor
OWNER -BUILDER DECLARATION
I herebyaffirm that l ani exempt from the Comtr.cm,'s License
p
Law Code: the city following whin. heauiresa,Busit tocnstProfessions
er.
Code AOy City Or county WhiChrayuifesa permit tOCOmlmCl,altt4
prior t0 its issuance, also
requires, demolish, nt repair any Smit
_,BUILDING PERMIT;'hl ;, it
'• - "• INFORMATION'" . ,1.<„
MISC. - REFER TO ORD
VALUATION
} r
5/FT.
pERMIT ISSUANCE 10.00
ELEC. CONTR. LIC NO.
ELEC.
to statement enol
requires Ind applicant for such visit l0 file a
TOTAL
PERMIT TO
Cont)
r i
he is licensed pursuant to the provision of tire COnlmclor's License..
tic
Law (Chapter 9 (commencing with Section 7000).1 Division 3 Ofthe
Business and Professions Code) or that he is excm t therefrom and
the basis for the alleged exumpllon. Any viola for OBeCllao 7031.5
r
QTY. ,.. ,, PLUMBING PER t FEE
1 ? .,M, „{,., eo�l� N f
STORIES
TYPE CONSTR.
by any applicant lar a permit subjects the applicant too civil penalty
of not more than five hundred dollar (5500).):
ALTER -DRAIN& VENT -WATER (EA.) 5.00
BACK FLOW PROTECT. DEVICE 4.00
OCC. GROUP
RES. UNITS
❑ I, as Owner Of the property, or my employees with wages as
their sole compensation, will Jo the work, and the structure is nut
intended or offered for are (Sea 7044, Business and P utessions
DRAINS -FLOOR, ROOF, AREA, COND. 5.00
Code: The Contractor's License Law does not apply n an owner of
properly who builds or improves thereon, and who does such work
FIXTURES - PER TRAP 5.00
-Ya FT FLWR AREA
TOTALACREAGE
himself or through his own employees, provided that such improve.
menta are not intended or offered for sale. If, however, the building
GAS - EA. SYSTEM- 1 INC.4 OUTLETS 6.00
r improvement is Sold within one year of completion, the owner-
EGAS
wilder will have the burden of proving that he did not build or im-
prove for purpose of sale.).
I, as owner of the properly, ails exclusively contracting will,
licensed e.ntractors to construct the project (Sec. 7044, Business
- EASYSTEM -OVER 4 IEA.) 2.00
.
BW LOIrvG USE
RES IND GO PB Omer
❑ 1:1❑
INDUSTRIAL WASTE INTER. 30.00
LAWN SPRINKLERS -I INC 5 V.B. 6.00
ASSESSUKIS PARCEL NO.
and Professions Code: The Contractor's License Law docs no apply
to an owner Of property who builds Or improves fiction, and who
LAWN SPRINKLERS - OVER 5 (EA.) 1.00
contract, far such projects with a co ltractuds) licensed pursuant 10
the Commctor' icemse Law.
SEWER -SANITARY -STORM EA. 200ft/10.00
ACT NO.
,PARCEL NO.
WATER HEATER W/VENT 6.00
❑ tan exr_q n rSec. ,B.&I'.C. lar rot
reason
Owner }u� I 1`r/7]
woR'ERS' MIEN 1.ON UIiC'L;YT'fION.rWATER
WATER SYSTEM 5.00
[ACC,DATE
ACC. FILE NO.
TREATING EQUIP. 5.00I
hereby affirm Shat I have a certificate ofconsent to self -insole,
or a certificate of WorkersCompensation huurance, or a certified
ONING.
ENG. SITE NO.
copy Ihetof(Sec. 3800, Lab.C.L
Policy No. Cougwny.❑ CerlilieJ copy is hereby lumislmJ.
❑ Certified copy is filed with the city inspection division.
ESPRINK
y� NC]
ENERGY T-24
y� N[]Applicant
MISC.- REFER TO ORD.
CERTIVICATIi OI" EXI MPHON FROM WORKERS'
PERMIT ISSUANCE 10.00
FLOOD ZONE
AL.U.C.
PLG. CONTR. LIC. NO.
PLG.I
TOTAL
COMPENSATION INSURANCE
(This section need not be completed if the permit is fur one
Y N
V ❑ N
_ -
DTV.., . "1 �. MECHANICAL PERMIT ' t) /'} .FEE"
'
� 4+EE SUMMARYT* i!A'
hundred doll... ($100) or less)-
I certify that in the perfurnmnce of the work fur whish Ins p`
ter is issued, I >ball nor employ any person in any manner w as to
become subject to the Workers' Compensation Laws Of California.
Date ApplicantALTER
BUILDING
OR ADD TO MECH. 5.00
NO'ficr. 'f0 APPLICANT: If, after nmking this Certificate of Ex-
emption, you should become subject to the Workeri Compensation
APPLIANCE 5.00
PLAN CHECK
provisions of the Labor Code, you must lorlhwith comply with
such provisionsor this permit shall be Jeclned revoked.
CONSTRUCT ION LENDING AGENCY
FEE
AIR HANDLING UNIT (TO 10p00C.F.M.) 4.00
AIR HANDLING UNIT(OVER 10,000C.F.M.) 6.00
SEISMIC FEE
EXHAUST HOOD (WITH DUCT) 5.00
MICROFILM
1 hereby affirm that [here is a construction lending agency for
the performance of the work for which this paruit is issued (Sec.
3097, Civ.CJ. -
HEATING UNIT (TO 100,000 B.T.U.) 8.00
HEATING UNIT (OV ER 100,000 B.T.U.) 9.50
ELECTRIC
Lender's Name
Lender's Address
I ccrtlly that l have read this application and stale that dlt'above
information is correct. 1 agree to comply with all city and county
ordinances and state laws relating to building mnslruction, and
VENTILATION FAN (SINGLE) 4.00
PLUMBING
BOILER- COINED (3 H.P. or 100,000 B.T.U.) 6.00
BOILER -COMP (Over 100,000 BTU) SEE FEE SCH.
MECHANICAL
icreby authorize representatives of this city to enter upon the
eWvegnntlioncJ property I., inspectiwu purposes.
MISC. - REFER TO ORD.
CONST. TAX
(We) .gree to Save. indemnify and keep harmless the City of
upertino against liabilities, judgments, costs and expenses which
may in any wa accrue against said City in consequence of the
I's
PERMIT ISSUANCE 10.00
MECH. CONT. LIC. N0.
MECH.
TOTAL
;-TOTAL
-
ot,, t - s per IL
_
��-
al COI PP scant/Conte or I�)u
P1,11116Jfl'j/U/Cfi<!'2Gvr OFFICE COPY