6679APPLICANT TO FILL IN INFOffN WITHIN RED LINES -USE I POINT PEN ONLY
BU I LDING PROJECT I DENTIFIC A7 f
APPLICATION & PE T
BUILDING - ELECTRICAL- PLUMBING - MECHANICAL
PERMIT NUMBER
^ r�
b I
ADD
AOOR
.�F ��Dd.ei��L�•
GOP T{
NAME��/ �J
/ W t PHONE ' TJ3
pTY. ELECTRIC PERMIT '+FEE
PLAN CHECK VALIDATION
CONT
NAME c7oRs
NAME
UTLETS- SWITCHES -RECEP 5.00/1.00
LIGHTING FIXTURES 5.00/1.00
LIC. NO. QFJ
-
corvmACToe's
AOOREss
APPLIANCES -RESIDENTIAL 4.00
1PANELS 5.00
-Q O3
DATE OF APPLICATION
ARCHITECTBBO
OR
ENGINEER
' LIC. No.
SIGNS .
PLAN CHECK FEE P.C. NO,
SIGNS TRANS. 3.00
ARCH. ORENG.
ADDRESS
SPECIAL CIRCUIT 5.00
PERMIT VALIDATION
TEMP. METER OR POLE INS. 15.00
ZIP
r
J
APPLICANT s
ADDRESS
MOTORS SEE FEE SCH.
SERVICE CHANGE 10.00
"
A
LICI!NSED CONTRACTORS DECLARATION
I hereby effirn that I am licensed under provisions of Chapter 9
ISSUANCE DATE
Icommencing with Section 7000) of Division 3 of the Business and
Professions Ce, a999IIIImy license is in full forcg e f
License lass Lico, Number
Contract., Dale-�t
BLDG.
❑
ELECT.
❑
PLG. MECH,
❑
.BUILOF19A ERMIT<e" j
INFORMATION F x.
OWNER -BUILDER DECLARATION
I hereby affirm that f so exempt from the Contractors License
Law lot Professions
MISC.- REFER TO ORD
VALUATION
E/FT.
PERMIT ISSUANCE 6.00
citylowingreeson.(he requires perBusmitto
Code: Anycity or county which requires a permit to construct, alter.
Improve, demolish, or repair any structure, prior 10 Its Issuance, also
ELEC. CONTR. LIC. NO.
ELEC.
requires the applicem for such permit to file a sign.] statement Hurl
he is licensed pursuant to the provisions of the Contractor's License
Law (Chapter 9 (commencing with Section 7000) of Division 3 of the
Business and Professions Code) or that he is exempt therefrom and
the basis for the alleged exemption. Any violation of Section 7031.5
TOTAL
PERMIT TO
pTY. PLUMBING PERMIT FEE
1
STORIES
TYPE CONSTR.
ALTER -DRAIN & VENT -WATER (EA.) 4.00
by any applicant for a permit subjects the applicant toa civil penalty
of not more than five hundred dollars (5500).):
ggCK FLOW PROTECT. DEVICE 2.00
Oce. GROUP
RES. UNITS
❑ I, as owner of the property, or my en.ployees with wages as
their sole compensation, will do the work, and the Mmeture is not
int,aided or offered I'o! sale (Sec. 7044, 1lusines and Professions
DRAINS -FLOOR, ROOF, AREA, COND. 4.00
Code: The Contractor's License Law does not apply to an owner of
properly who builds or improves thereon, and who does such work
FIXTURES - PER TRAP 4.00
SO. FT. FLOOR AREA
TOTAL ACREAGE
himself or through his own mnployees, provided that such improve-
nlentsare not intended or offered for sale. If, however, the building
GAS - EA. SYSTEM -1 INC.4 OUTLETS 4.00
or improvement is sold within one year of completion, 11m owner-
builder will have lire burden of proving that he did not build or im-
prove for purpose•. of sale.).
❑ I, as owner of the property, am exclusively contracting with
licensed contractors to construct the project (Sec. 7044, Business
GAS - EA. SYSTEM - OV E 4 (EA.) 1.00
BUILDING USE
RES IND CON PB Omer
INDUSTRI ALWASTE IN E . 20.00
LAWNSPRINKLERS 1 .B. 5.00
ASSESSORS PARCEL NO.
un] Prufessinre Cndu: "I'he Qmlrac LLrr s License Law does not apply
to an owner of property who builds or improves thereon. and who
LAWN SPRINKLER - E E .00
contracts for such projects with a contraaods) licensed pursuant to
Hire Con lracnr's License L.M.
SEWER-SANITARY-;,TpR A. 200ft/8.00
TRACT NO.
PARCEL NO.
❑ taro exempt under Sec. .B.dIP.C. (or ads
rea5or
WATER HEATER W 04.00
Owner Date
WATER SYSTEM 4.00
ACC. DATE
ACC. FILE NO.
WORKF.RS'COMVI:NSA1]ON DECLARATION
WATER TREATING EQUIP. 4.00
I hereby "allirm that I have a cerlificateofcnnsent Hoself-insure,
or a certificate of Workers' Compensation Insurance. or a certified
Copy thereof(Sec. 3800, Lab.C.).
T
ZONING
ENG. SITE NO.
-35 ti
policy No. Company
FIRE SPRINK
ENERGY T-24
❑ CcHilied copy is hereby famished.
❑ CcrtifivQ�npy�wiHlWhe ypy/in-e�,1, division.
YE] NE]
Y� NC]
MISC.- - REFER TO ORD.;
PERMIT ISSUANCE B:OO
fLODD ZONE
A.L.U.C:
CER 'I']FICA '1'1: OF EXI'. MPTION FROM WORKERS'
PLG. CONTR. LIC. NO.
PLG.
TOTAL L,JG
COMPFNSA'fION INSURANCE
(This section need not be completed if the permit is for one
v N
Y C]N�
QTY. MECHANICAL PERMIT` -- FEE
FEE SUMMARY
hundred dollars(S 100) or les.)
I certify that In lire performance of the work lilt which this per-
mit is issued. I shall not employ any person in any manner So as to
become subject to the Workeri Compensation Laws of California.
Dan Applicant
NOTICE TO APPLICANT: If. after making this Certificate of [ix-
emption. you should become subject to the Workers' Compensation
provisions of the Labor Code, you must forthwith comply with
such provisions eu this permit shall be deemed revoked.
BUILDING
ALTER OR ADD TO MECH. 4.00
APPLIANCE 4.00
PLAN CHECK
FEE
AIR HANDLING UNIT (TO 10=11F.NL) 3.00
AIR HANDLING UNIT (OVER 10=C.F.M.)5.00
SEISMIC FEE
CONST RUCTION L17NDING AC17NCY
EXHAUST HOOD WITH DUCT) 2.00
MICROFILM
I hereby affirm that Deere is A construction lending agency for
the performance of the work for which (his permit is issued (Sec.
3097, Civ.C.).
HEATING UNIT (TO 100,000 B.T.U.) 4.00
HEATING UNIT (OVER 100,000 B.T.U.P.50
ELECTRIC
Lender's Name
Lenders Address
1 certify that I have read this applicallon and state that the above
information is correct. I agree In comply with all city and county
ordinances and state laws relating to building construction, and
VENTILATION FAN (SINGLE) 3.00
PLUMBING
BOILER-COMPI3 H.P. or 100,0006.T.U.) 4.00
BOILER -COMP (Over 100,000 BTU) SEE FEE SCH.
MECHANICAL
hereby authorize representatives ins ec this city to enter upon the
above-mentioned property for IflSpeellOm 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
may in any way accrue against Said City in consequence of the
PERMIT ISSUANCE 3.00
MECH.CONT. LIC. NO.
MOTAL
TOTAL
granting of this permit.
,& 6 -76-8
Signature of ApPicun(/Contra. or Date
OFFICECOPY