7173 APPLICANT TO FILL IN INFORMATION WITHIN REDLINES -.USE BALL POINT PEN ONLY
BU I LDI NG PROJECT I DENTI FICATION PERMIT NUMBER
BUILDINGAPPLICATION'& PERMIT
ADDRESS 717 3. -.
ADDRESS `
BUILDING-ELECTRICAL-PLUMBING-MECHANICAL
wNER'S - y ° " 4'i-. ..�i. PLAN CHEMVALIDATION
_� NAM E/ � ��� QTVe ' ' xEIECTRIC+PERMIT - "FEE':ky- '
�j PHONE
NAMERAcrons UTLETS-SWITCHES-RECEP 5.00/100
LIC.NO. 7 V4WLIGHTING FIXTURES 5.00/1.00
CONTRACTORS
Ao011RgW) yyjf. C9'/J APPLIANCES-RESIDENT
4.00
//`"'�; OxE PANELS PPLICATION
ARC ITECT 40 PLA EE P.C.NO.
OR SIGNS 6.00
ENGINEER
LIC.NO. SIGNS TRANS. 3.00 I•
AooH'E55 ENG. SPECIAL CIRCUIT 5.00 PNi MIT V TION
APPLICANT's ilp ' EMP.METER OR POLE INS. 15.00 City Of Cupertino
ADoREss DRESMOTORS SEE FEE SCH•
SERVICE CHANGE 10.00
o o LICENSED CONTRACTORS DECLARATION /r
a
an u I hereby affirm that 1 am licensed under provisions of Chapter 9
w<w (commencing with Section 7000)M Division 3 of the Business and '� ISSU CE DATE
D z Professions Code,an sdI m�license is in full force and effect BLDG. E PLG. MECH.
Vg
z0 to - License Class C(�Lic.Number%<39✓AP'
O N r w Date contractor ly� ElZ
¢ ¢ a OWNER-BUILDIiR DECLARATION BO DING PERMIT
w- °ii" MISC.- REFER TO ORD FORMAI ION
; m' 1 hereby alfinn That 1 am exempt from the Contractor's License VAL gTION
F LL o a Law for the following Reason.(Sec.7031.5,Business and Professions PERMIT ISSUANCE 9/FT.
Code:Any city or county which requiresa permil to construct,alter,
¢ or¢p improve,demolish,ar repair any Structure,prior in its issuance,also ELEC.CONTD. LIC.NO. ELEC. /�i
iiaO¢ requires the applicant for such permit to file a signed statement that %� TOTA
u w m n he is licensed pursuant to the provisions of the Contractor's License "Q� . E IT TO,
i
Law(Chapter 9(Cnmmeacing with Section 7000)of Division 3 of the ilf l 1')yk� ti ' .)s.'d,+hv r 'r
Business and Professions Code)or that he is exempt therefrom and QTLY. �PL'UMBING PERMIT ¢ y
f o o p ^R 9yh a 4 r 'rhM' mI� 1 '7^�. p Fg FEE .
¢r m the basis for the alleged exemption Any violation ofSectlon 7031 5 lq„ _ "Tt X!.a a�y "^ STORMTYPE CONSTR.
d1 2 by any applicant for u permit subjects the applicant to a civil Penalty ALTER-DRAIN -WATER (EA.) 4.00
of nal more than five hundred dollars($500).):
D 1,as owner of the property,or my employees with wages as BACK FLOW PROTECT. DEVICE 2.00 Oce.GROUP Res.UNITS
sole compensation,will do the well,and the structure is not
intended or offered for sale(Sec. 7044, Business and Professions DRAINS-FLOOR,ROOF,ARENCOND. 4.00
Code:The Contractor's License Law docs not apply to an owner of
property who builds or improves thereon,and who does such work F IXTUR ES-PER TRAP 4.00 50.FL FLOOR AREA TOTAL ACREAGE
himself or through his own employees,provided that such improve-
mentsarcmdintendedofofferedforsale.If,however,the building GAS-EA.SYSTEM-11NC.4 OUTLETS 4.00
s or impravemem is sold within one year of completion,the owner- GAS EASYSTEM OVER 4 (EA) -
builder will have file burden of proving that h - . - .
e did not build or im-. 1.00 BUILDING USE
prove for purpose of sale.). - - INDUSTRIAL WASTE INTER. 20.00 E IND CON PB Oer
❑ I,as owner of the property,am exclusively contracting with m❑ ❑ 1:1
.ad
contractors to construct the project(See. 7044,Business LAWN SPRINKLERS- 1 INC 5 V.B. 5.00 AElSSESgOflPARCEL NO.
and Professions Code:The Contractoi's License Luw does no[apply to an owner of property who builds or improves thcreou,and who LAWN SPRINKLERS-OVER 5(EA.) 1.00
contracts for such projects with a contractors)licensed pursuant to
f the Contractor's License Law. SEWER-SANITARY-STORM EA.200ft/8.00 TRACT NO. PARCEL NO.
❑ I:un exempt undar See. ',B.&I'.C:I'nr this , WATER HEATER W/VENT
reason 4.00
Owner Date - WATER SYSTEM 4.00 ACC.OATE ACC.FILE NO.
WORK Ii RS'COMPENSATION DECLARATION WATER TREATING EQUIP. 4.00
1 hereby affirm Ihul I hove a certificate of Consent to self-Maitre,
or a certificate of Workers'Compensatioq Insurance,or a certified ZONING ENG.SITE NO.
copy there f(q Sec.]800,L.h C.))..t +
Policy No.=447ompanyry{isbed.
O ❑ Certified Copy Is hereby Furnished.
z"Z K Certified Copy Is filer with the col,-inspection division. FIRESPRINK ENERGYT24
Applicam ��6f il f MISC.- REFER TO ORD. Y ❑ N❑ Y ❑ No
F rn PERMIT ISSUANCE 6.00
LU - CERTIFICATE COMPENSA EXEMPTION FROM WORKERS' FLOOD ZONE A.L.U.C.
W COMPIiNSA'fION INSURANCE PLG.CONTR. LIC.NO. PLc.
L O (This section need not he Completed if Ole permit is for one TOTAL Y❑ N❑ Y ❑ N❑
L Z hundred dollars IS 100)or less.) - _
U O 1 certify that in the performance of the work for which this per �'�"
Iy F +tot is isvhed,I shmll Ilat CII1PIny any Pl'rSnm many+Ilammer Y00910 OTV:; ;.MECHANICAL PERMIT FEE FEExSUMNIARY�r,
U. become subject to the Workers'.Compensation Laws of California. r
O 0. Date ApplicantALTER OR ADD TO MECHq00 BUILDING
>_ to NOTICE "r0 APPLICANT: If,after ranking this Certificate of Ex- . , '
Z cmption,you should become subject to the Workers'Compensation APPLIANCE 4.00 PLAN CHECK
provisions of the Labor Cndc, you Most forthwith comply with FEE
U
-such provisions or this permit shall be deemed revoked. AIR HANDLING UNIT(TO 10,000QF.M.) 3.00
CONSTRUCrION LENDING AGENCY AIR HANDLING UNIT(OVER 10=QF.M.) 5.00 SEISMIC FEE '
I hereby alfinn that there is a construction lending agency for EXHAUST HOOD(WITH DUCT) 2.00
the performance of the work for which this permit is issued(Sec. MICROFILM
3097,Civ.C.L HEATING UNIT(TO 100,000 B.T.U.) 4.00
Lender's Name HEATING UNIT(OVER 100,000 B.T.U.)7.50
Lender's Addle ELECTRIC
I certify that 1 have read this application and state that the above VENTILATION FAN (SINGLE) 3.00
information is correct. 1 agree to comply with all city and county PLUMBING
ordinances and state laws relating to building construction, and BOILER-DOW(3 H.P.or 100,000 B.T.U.) 4.00
h hereby authorise representatives of this city to enter upon the
h abovmmentimied property for inspection purposes. BOILER-COMP (over 100,000 BTU)SEE FEE SCH. MECHANICAL
(We) agree to save, indemnify and keep harmless the City of MISC.- REFER TO ORD.
Cupertino against liabilities,judgments, costs and expenses which PERMIT ISSUANCE 3.00 CONST.TAX
may in any way accrue against said City in consequence of the
grunting of this permit MECH.CONT. LIC.NO. . MECH.
TOTAL TOTAL
g ature 015ApplicantlUontractor 11EAc
OFFICE COPY .