12314A;LICANT TO FILL IN INFORMATION WITHIN RED LINES - USE
1BALL POINT PEN ONLY
BUILDING PROJECT IDENTI WION
NU
APPLICATION & iVIIT;
BUILDING - ELECTRICAL- PLUMBING - MECHANICAL
PERMIT NUMBER
12314
aDILDwG
ADDRESS
�3(� S'7EuEfvS FREE �91A
OWNER'
NAME V E2TI No e�TY EN,yT�E $(7C
(1 P� ,D�.E�oriEo�S�7
O
'
DTV. ELECTRIC PERMIT PEE
PLAN CHECK VALIDATION
DATE OF APPLICATION
NAMENTRAcroRs
qq
R L CfEc )(_ Lie NO.2 76 72'8
UTLETS-SWITCHES -RECEP 10.00/1.00 0
I17ffLIGHTING FIXTURES 10.00/1.00
m Etsa 's c-io
)./03 Zr Nvg. S•Z;PHONE29 -33 q
APPLIANCES - RESIDENTIAL 4.00
PANELS 10.00
ARCHITECT-
OR
ENGINEER
LIC. No.
PANELS (OVER 200 AMP) 20.00
PLAN CHECK FEE P.C. N0.
SIGNS TRANS. 3.00
ARCH. OR ENG.
ADDRESS
• ;IP
SPECIAL CIRCUIT 5.00
PERMIT VALIDATION
,�1
`'I
ISSUANCE DATE
TEMP. METER OR POLE INS. 20.00
APPLICANTS
ADDRESS
3os L.�K VF r S, T, QSII (�
MOTORS PRn�,T- SEE FEE SCH.
SERVICE 20.00
LICENSED CONTRACTORS DECLARATION
I hereby affirm that I am licensed under provisions of Chapter 9DEC
(commencing with Svelion 7000) of Division 3 Of the Business and
Professions Codd, ul n license is o full fo e' a ff t
License Class Lin. Nuln be
Lice C (.'Onlra' p!
OWNER -BUILDER D: ARATION
I hereby affirm that I am exempt front the Contractor's License
Law forthefollowing reason. (Sec.7031.5,ermit tocodtruct,ssions
Code: Any city or county which structure permit to construct, otleq
improve, demolish, or repair any structure, prior to its issuance, also
requires the applicant for such revisit ns file a signed statement that
he is licensed pursuant to the provisions of the ) afD ivision License
D ivision 3 ofthe
Law (Chanter tr (commencing with Sect ion is exempt
Business and Professions Code) or that he is exempt echo 70 and
Any violation of Section malty
thebasisthe alleged exemption. subjects
by any applicant fore permit dollatstlteapplicanl toacivil penalty
of not more than five hundred dollars (8500).1:
❑ I, as owner of the property, or my employees with wages as
their sole compensation, will do the work, and the structure is not
intended or offered I'or sale (Sec. 7044, Business and Professions
Code: The Contractor's License Law does not apply to an owner of
property who builds or improves thereon, and who does such work
himself or through his awn employees, provided that such improve-
meatsarenolintendedorofferedforsale. If, however, the building
or improvement is sold within one year of completion, the owner,
builder will have the burden of proving that he did not build or ire-
prove for purpose of sale.).
❑ I, as owner of the property, am exclusively contracting with
licensed contractors to construct the project (Sec. 7044, Business
and Professions Code: The Contractor's License Law does not apply
to an owner of properly who builds or improves thereon, and who
contracts for such projects with a contractor(s) licensed pursuant to
the Contractors License Law.
❑ Iamexcmptundor Sec ,B.&P.C. for this
reason
2 91986
BLDG.
❑
ELECT.
PLG. MECH.
❑ ❑
n* of AD
call
�-.
BUILDING PERMIT
INFORMATION
MISC. fftiPe R TO ORD
VAW ATION
$/FT.
'
PERMIT ISSUANCE 10.00 N
ELEC. CE& LIC. NO.
Ri /C_ �1 z�� T
/%C 4 (J
ELEC. Z pG/ W
TOTALM O 0
PERMIT TO
FG
OTY. PLUMBING PERMIT FEE
STORIES
TYPE CONSTR.
ALTER-DRAIN-WATER(EA.) 5.00
BACK FLOW PROTECT. DEVICE 4.00
OCC. GROUP
RES. UNITS
DRAINS -FLOOR, ROOF, AREA, CONO. 5.00
FIXTURES - PER TRAP 5.00
SO. FT. FLOOR AREA
TOTAL ACREAGE
GAS-EA.SYSTEM-11NC.40UTLETS 6.00
GAS - EA. SYSTEM - OVER 4 (EA.) 2.00
BUILDING USE
RES IND CON PB Drier
❑ ❑ ❑ ❑ ❑
INDUSTRIAL WASTE INTER. 30.00
LAWN SPRINKLERS - 1 INC 5 V.B. 6.00
LAWN SPRINKLERS - OVER 5 (EA.) 1.00
ASSESSORS PARCEL NO.
--STORM EA. 200f1 .
SEWERSANITAR V 1000 /
TRACT NO,
PARCEL NO.
WATER HEATER W/VENT 6.00
Owner Date
WATER SYSTEM 5.00
ACG DATE
ACC. FILE NO.
WORK ERS'COMPENSAT ION DECLARATION
1 hereby affirm that I have a certificate of consent to set&insure'
or a certificate of Workers' Compensation Insurance, or a certified
Posey Nr. 'S afnpafiY i'� tA7loN -1 A/S,
WATER TREATING EQUIP. 5.00
-
ZONING
ENG. SITE N0.
❑ Cerlitiedc py ishcmbyfurppfished.
�Certifjd o y is flu 'll the city inspection division.
hpplicant ll� - (71 !" -
FIRESPRINK
y❑ N❑
ENERGYT-24
V❑ N❑
MISC.- REFER TO ORD.
CERTIFICATE OP EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
This vection need not be completed if ' the permit is I'or one
hundred dollars IS 100) or less.)
I certifythat in the performance of the work for which this per-
mit is issued, I shall not employ any person in any manner so as to
become subject to the Workers' Compensation Laws of California.
Date Applicant
PERMIT ISSUANCE 10.00
FLOOD ZONE
Y ❑ N ❑
A.L.U.C.
Y ❑ N ❑
PLG. CONTR. uC. NO.PLG.
TOTAL
OTV MECHANICAL PERMIT FEE
FEE SUMMARY
BUILDING
ALTER OR ADD TO MECH. 5.00
NOTICE TO APPLICANT: If, after making this Certificate of Ex-
emption, 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
CONSTRUCTION LENDING AGENCY
1 hereby affirm that there is a construction lending agency for
the performance of the work for which this permit is issued (Sec.
3097, Civ,C.). yy tCf1
Lender's Nam" �A/r\ B r �� E s
APPLIANCE 5.00
PLAN CHECK
FEE
AIR HANDLING UNIT (TO 10)000C.F.M.) 4.00
AIR HANDLING UNIT(OVER I0)000C.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 UN IT (OVER 100,000 B.T.U.) 9.50
ELECTRIC
Lender's Address- P TnAl - A6i�-mil l'-
I certify that l have read is application and stale Itlluaove
information is correct. I agree to comply with all city and county
ordinances and state laws relating to building construction, and
hereby authorise representatives -of this city In enter upon the
above-mentioned property for inspection purposes.
(We) agree to save, indemnify and keep harmless the City of
Cupertino against liabilities, judgments, costs and expenses which
may in y way accrue against said City in consequence of the
gmtitin f this permi �QC _ /� /
Y &,14 ' Y` j
/Je%-lZ
VENTILATION FAN (SINGLE) 4.00 '
PLUMBING
BOILER-COMP(3 H.P. or 100,000 B.T.U.) 6.00
BOILER -COMP (Over 100,000 BTU) SEE FEE SCH,
MECHANICAL
misc.- REFER TO ORD.
TAX
PERMIT ISSUANCE 10.001CONST.
MECH. CONT. LIC. N0. MECH.
TOTAL
TOTAL
E
Sign lue�Appllcant/ onlracior ar
OFFICE COPY