17688aPf LICANT TO FILL IN INFORMATION WITHIN RED LINES -USE BALL POINT PEN ONLY
* 'V&tlLDING PROJECT IDENTIFICATION
& PERMIT
BUILDING - ELECTRICAL- PLUMBING - MECHANICAL
PERMIT NUMBER
r� O
f o
BUILDING OAPPLICATION
ADD s;i / O`
l C�/3 CCK
NAME (_ _
51`'�'�[[�'
QTY. ELECTRIC PERMIT FEE
PLAN CHECK VALIDATION
/"✓/�(� C y, � i I PHONE O�
CONTRACTORS
NAME
UTLETS-SWITCHES -RECEP 10.00/1.00
LIGHTING FIXTURES 10.00/1.00
,4 LIC. NO
DATE OF APPLICATION
CONTRACTORS
ADDRESS '
A [[
1.3 ,H PRONE�3O�-
APPLIANCES- RESIDENTIAL 4.00
PANELS 10.00
ARCHITECT `
OR S�7 iI ✓l (%Q ,
ENGINEER /
LIC , No.
PANELS (OVER 200 AMP) 20,00
PLAN CHECK FEE P,C. NO.
SIGNS TRANS. 3.00
ARCH. OR ENG. l
ADDRESS f/ �•
ZIP
SPECIAL CIRCUIT S,QQ
PERMIT VALIDATION
r (_
J
EMP. METER OR POLE INS. 20.00
APPLICANT'S
A DREss �"
. A/3.7
MOTORS SEE FEE SCH.
SERVICE CHANGE 00
LICENSEDC "IRACIORS LECi,RATION
_
MAY 0 1198 4
I hereby affirm that I am licensed under provisions of Chapter 9
(mmme Being with Section 7000) of Division 3 of the Business and
Professions Code, and Illy Iicmue in in full three and effect.
License Class Lie. Number
Date Contractor
ISSUANCE DATE
BLD ELECT. PLG. MECH.
❑ ❑
aq Of w
BUILDING PERMIT
+6 W 1!
OWNER -BUILDER DECLARATION
1 hereby atlirm that I am exempt from tile Contractor's License
Low for the followingreason.(Sec. 7031.5, Busincssand Professions
Code: Any city or co levy which requlresa permit tommt"FeLalteq
improve,demolish, or repair any Structure, prior to its issuance, also
or such permit to file o signed statement that
requires the alideanflm
lie is licensed pursuant to file provisions of the Coutramoi s License
Law (Chapter 9(commencing with Section 7000) of Division 3 ofthe
and Professions Code) or that he is exempt therefrom snit
S
the hasis for the ullopcJ exnnptiun. Any violation ul'Section 7031,5
INFORMATION
MISC. - REFER TO ORD
VALUATION
�O�✓�"
SIFT.
PERMIT ISSUANCE 10.00
ELEC. CONTR. LIC. NO.
FLEC.
TOTAL
PERMIT TO
• { I+Business
•� "'
OTV. PLUMBING PERMIT FEE
STORIES
TYPE CONSTR.
by any applicant for a permit subjects the applicant to acieil penally
of not more than five hundred dollars (55001.):
ALTER -DRAIN -WATER IEA.15.00
❑ 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 for sale (Sea. 7044. Business and Professions
BACKFLOW PROTECT. DEVICE 4.00
OCC. GROUP
RES. UNITS
DRAINS -FLOOR, ROOF, AREA, COND. 5.00
Code: The Contractor's License Law does not apply to art owner of
Property who builds or improves thereon, and who does such work
FIXTURES - PER TRAP 5.00
SD. FT. FLOOR AREA
TOTAL ACREAGE
himself or through his own employees, provided that such improve-
mclusare out imml,dedoroffered l'or sale. If, however, the building
GAS-EA.SVSTEM-l1NC.40UTLETS 6.00
or inipmermenf is sold within one year of completion, file owner-
builder will have the burden of proving Ilia[ he did not build or im-
prosel'et purpose of wle.).
❑ 1, as owner of the Property, am exclusively emllraciing with
licensed contractors to construct the project (See. 7044, Business
GAS - EA. SYSTEM - OVER 4 (EA.) 2.00
BUILDING USE
RES trvo CON PB One
❑ ❑ ❑ ❑ ❑
INDUSTRIAL WASTE INTER. 30.00
LAWN SPRINKLERS - 1 INC 5 V.B. 6.00
ASSESSORS PARCEL NO.
and Professions Code: The Contractor's License Low does not apply
to an owner of property who builds or improves thereon, and who
LAWN SPRINKLERS - OVER 5 (EA.) 1.00
contracts for such projects with a contracturts) licensed pursuant to
the Contractor's License Law.
gEWER-SANITAR V -STORM EA. 2001[/10.00
TRACT NO,
PARCEL NO.
WATER HEATER W/VENT 6.00
❑ l um exempt under See. ,I &P.C. for([Ifs
assn
Owner Uate
WATER SYSTEM 5.00
ACC.DATE
ACC, FILE NO.
WORK RRS'COMPIiNSA'IION DECLARATION
WATER TREATING EQUIP. 5.00
1 hereby effort, [hut I Have a certificate ofconsent to self -insure.
or u certificate of Workers' Compensation Insurance, or a certified
ZONING
ENG. SITE N0,
.
copy therepff ec. 800, Lab.y 2S, �C /n 6 ii
Policy Ndo l�i)�p ny Y14, l.►hffp_
CI cerlilied copy i�r ilylmpifbed, y
FIRESPRINK
ENERGY T-24
❑ Cerl,r cp isE d�.v Jl�tly yity. inspection 11UO'
Applicant 44 S[G CCEELL.t(
Y❑ N❑
Y❑ N❑
MISC.- REFER TO ORD.
PERMIT ISSUANCE 10.00
FLOOD ZONE
A.L.U.C.
CE RT I PICA" Oh EXEMPTION FROM WORKERS'
PLG.CONTR. LIC. NO.
PLG.
TOTAL
I PBNSATION INSURANCE
1'I'his sect'n ell mot be tonntlelted if file Permit IS I'or one
V❑ N❑
Y❑ N❑
DTY. MECHANICAL PERMIT FEE
FEE SUMMARY
hundred dollars (S 100) or less.)
1 certify that in the performance of the work for which this per-
Brit is issued, I shall not employ any person in any manner so as Di
become subject to the Workers Compensal ion Laws of California.
Date Applicant
BUILDING
y 7
(<Y�D
ALTER OR ADD TO MECH. 5.00
NOTICE TO APPLICANT. 11, alter making this Certificate of lix-
emption, you should become subject to the Workers'Congmnsafioi
provisions of the labor Code, you must forthwith comply with
such provisions or t11is permit s11all be deemed revoked.
CONS'TRUCIION LENDING AGENCY
APPLIANCE 5.00
PLAN CHECK
FEE
--�
AIR HANDLING UNIT (TO 10,00011F.M.) 4.00
AIR HANDLING UNIT (OVER 10DWC.F.M.) 6.00
SEISMIC FEE
r_
11;7s
EXHAUST HOOD (WITH DUCT) 5.00
MICROFILM
1 hereby affirm that there is a constriction lending agency for
the performance of the work for which this Permit is issued (Sec.
3097, Civ.C.).
HEATING UNIT (TO 100,000 B.T.U.) 8.00
HEATING UNIT (OVER 100,000 B.T.U.)9.50
ELECTRIC
Lender's Name__
Lemlet's Addresx
I certify that I have read this application and state that the above
infimnation is correct. I agree to comply with all city and county
ordinances and slate law, Riafing to buildinµ COnslrucfion, and
VENTILATION FAN (SINGLE) 4.00
PLUMBING
BOILER-COMP(3 H.P. or 100,000 B.T.U.) 6.00
BOILER-COMP(Over100,0008TU) SEE FEE SCH.
MECHANICAL
herehy aulorio, representatives of this city to enter upmi Ole
above-mentioned property for inspection purposes.
MISC. - REFER TO ORD.
CONST. TAX
(We) agree to save, indemnify and keep harmless the City of
Cupertino against liabilities, judgments, costs and expenses which
ma in any way a against said City in consequence of the
Tan ng'of([6sp mint
PERMIT ISSUANCE 10.00
MECH. CONT. LIC. NO. MECH.
TOTAL
TOTAL
72 17-
Signature of p ant/Con(mctor Umtc,
L/ OFFICE COPY