9197r
MRAATInnI NnTI41IdI RPn I IMPS - IISE RALL POINT PEN ONLY
Firr LIr.AM1V r ry r ,tea. n� .,.. �•••-••- _-_
PERMIT NUMBER
BUILDING PROJECT IDENTIFICATION
APPLICATION & PERMIT
BUILDING - ELECTRICAL- PLUMBING - MECHANICAL
9197
PLANCHECK VALIDATION
BmcowG
ADDRESS O /y �/
/ a2o �� ` A
9WN ER'E
NAME/ `
F6A2/ 7vJ PHONE
CONTRACTORS
q -VS 2aQ ZY LIc. No. %, 3( Z'�
OTY. ELECTRIC PERMIT FEE
UTLETS-SWITCHES-RECEP 4"0/1.00
DATE OF APPLICATION
PLAN CHECK FEE P.L. NO.
PERMIT VALIDATION
L 17�5�
ISSUANCE DATE
LIGHTING FIXTURES ��890/1.00
CONTRACTOR'S
SD 17JJvim; o„E 4" 9�
ARCHITECT
EONGINEER
LIC. 0.
OR
ARCH SS ENG.
ADDRESS
ZIP.
APPLIANCES -RESIDENTIAL 4.00
PANELS 1D.DD
PAN E LS (OVER 200 AM P) 20.00
SIGNS TRANS. 3.00
SPECIAL CIRCUIT 5.00
_ry
EMP. METER OR POLE INS. 20.00
APPLICANT'S
ADDRESS
MOTORS SEE FEE SCH.
SERVICE CHANG20.00
LICENSED CONTRACTORS DECLARATION
I hereby affirm that I am licensed under provisions oCChapter 9
(commencing with Section 7000) of Division 3 of the Business and
Professions Cod • and my license is in full force' el (Z
Licens9 Class ��m Lic. Number
Date /b7T/�j(� Contmclor ✓5s°
TEMP. POLE 30.00
BLDG. ELECT.
El El
PLG. MECH.
❑
Q
�a�ri �f C'up 1
BUILDING PERMIT
INFORMATION
/N
OWNER -BUILDER DECLARATION
1 hereby affirm that 1 am exempt from the Contractor's License
Law far the following reasoto. (Sec. 7031.5, Business and Professions
Code: Any city orcounly which requires a permit loconstruct,alter.
improve, demolish, or repair any structure, prior to its issuance, also
requires the applicant for such permit to file a signed statement that
he is licensed pursuant to the provisions of the Contractor's License
Law (Chapter 9 l commeHeingwith Section 7000)of Division 3 ofthe
Business and Professions Cade) or that he is exempt therefrom and
the basis for the alleged exemption. 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 (8500).):
❑ I, as owner of the properly, or my employees with wages as
their sole compensation, will do the work, and the structure is not
intended or offered for sale (Sec. 7044, Business and Professions
Code: 1'he 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 own employees, provided that such improve-
mems are not intended or offered for sale. If, however, the budding
or improvement is sold within one year of completion, the owner-
builder will have the burden of proving that he did not build or im-
prove for purpose afsale.).
❑ I, as owner Df 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 property who builds or improves thereon, and who
contracts for such projects with a contractors) licensed pursuant o
MISC. - REFER TO ORD
VALUATION E/FT.
PERMIT ISSUANCE r16 -.BB
ELEC.CONTR. LIC.NO.
ELEC.
TOTAL `-' X�,e-
PERMITTO
6�L/TIT
QTY, PLUMBING PERMIT FEE
STORIES
TYPE CONSTR.
ALTER -DRAIN & VENT -WATER (EA.) 5.00
BACK FLOW PROTECT. DEVICE 4.00
OCC. GROUP
RES. UNITS
DRAINS -FLOOR, ROOF, AREA,COND. 5.00
FIXTURES - PER TRAP 5.00
GAS-EA.SVSTEM-11NC.40UTLETS 6.00
SO. FT. FLOOR AREA
TOTAL ACREAGE
GAS- EA. SYSTEM - OVER 4 (EA.) 2.00
BUILDING USE
RES IND CON PB Other
❑ ❑ ❑ ❑
INDUSTRIAL WASTE INTER. 30.00
LAWN SPRINKLERS - 1 INC 5 V.B. 6.00
ASSESSORSPARCEL NO.
LAWN SPRINKLERS - OVER 5 (EA.) 1.00
SEWER -SANITARY -STORM EA. 200tt/10.00
TRACT NO.
PARCEL NO.
file Contractor's License Law.
❑ I am exempt under Sec. ,B.&P. C. for this
WATER HEATER W/VENT 6.00
reason
Owner Date
WATER SYSTEM 5.00
ACC.DATE
ACC. FILE NO.
WORKERS'- COMPENSATION DECLARATION
WATER TREATING EQUIP. 5.00
ZONING
ENG. SITE NO.
dI hereby affirm that I have a cerlifioh of consent to seFinsure,
Or a certificate of Workers' Compensation Insurance, or a certified
copy thereof (Sec. 3800, Lab.C.l. /�/✓ yr w0 ✓ T
Policy No. Company /Y�•�"r
❑ Certified cop rshereby fu fished.
❑ CertiNL•�/�Py'y i ede citJinspedion division.
FIRE SPRINK
y❑ N❑
ENERGY T -T4
v ❑ N❑
MISC.- REFER TO ORD.
APPlican ! �-
CER DFICA'fEOFEXEMPTION I7ROM WORKERS'
COMPENSATION INSURANCE
(1'hls section need not he completed if the permit Is for one
hundred dollars IS 100) or less I
I certify that in the performance of the work for which this per-
mit is issued I Shall not employ any person in ; ny anumer so as to
become subject to lire Workers' Compenmlion Laws of California.
Date Applicant
NOTICE TO APPLICANT: If, after making this Certificate of Ex
emption, you should become subject to the Workers' Cumpensalion
provisions of the Labor Code, you ..of forthwith comply with
Such provisions or this permit shall be deemed revoked.
CONSTRUCTION LENDING AGENCY
hereby affirm that there is a construction lending agency for
the performance of the work for which this permit is issued ISee.
3097, CN.C.).
Lender's Name
PERMIT ISSUANCE 10.00 .
FLOOD ZONE A. L.U.L.
Y❑ N❑ Y❑ N❑
FEE SUMMARY
PLG. CONTH. LIC. NO. PLG'
TOTAL
OTY. MECHANICAL PERMIT FEE
BUILDING
ALTER OR ADD TO MECH. 5.00
-
APPLIANCE 5.00
PLAN CHECK
FEE
AIR HANDLING UNIT (TO 10,00DQF.M.) 4.00
EE
SEISMIC FJ
AIR HANDLING UNIT(OVER IOAOOC.F.M.) 6.00
EXHAUST HOOD (WITH DUCT) 5.00
MICROFILM
HEATING UNIT (TO 100,000 B.T.U.) 6.00
ELECTRIC
&V
Sp-•..�-
HEATING UNIT (OVER 100,000 B.T.U.) 9.50
Lender's Address
1 certify that I have read this application and state that the above
Iinformation is correct. I agree to comply with all city and county
ordinances and slate laws relating to building construction, and
hereby authorize representatives of this city to enter upon the
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 SC H.
MECHANICAL
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
accrue against said City in consequence of the
is rmil.
z7 S
On
MISC. - REFER TO ORD.
CONST. TAX
PERMIT ISSUANCE 10.00
MECH. CONT. LIC. NO. MOTAL
TOTAL
Appicant/Contractor Date
..�--sa nnov