15948 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY'
BUILDING PROJECT I'DENTI FICA -PERMIT NUMBER
BDLLDING ; APPLICATION & PE
7 AGpREOns VaN\Co 1.5 9 4 8
I DI Z-J AL
N• BUILDING -ELECTRICAL-PLUMBING-MECHANIC
z(R NWNEb 3PLAN CHECK VALIDATION
L T
11 5IZ-3-77- QTY. ELECTRIC PERMIT FEE
CONTRACTORS
NAME OUTLETS-SWITCHES�RECEP 10,00/1.00
--
LIC.NO. LIGHTING FIXTURES 10.00/1.00
ADDRESS TORS APPLIANCES-RESIDENTIAL 4.00
PHONE PANELS 10.00 DATE OF APPLICATION
ARCHITECT PLAN CHECK FEE P.C. O.
�[,
OR - PANELS (OVER 200 AMP) 20.00 .C. t
/ ENGINEER
IV f ' r0 LIC.N II'�"77 SIGNS TRANS. 3.00
AR CH.OR ENG. P MIT VALIDATION
Ap Hess. SPECIAL CIRCUIT -5.00
@ ZIP TEMP. METER OR POLE INS. 20.00
APPLICANT'S
MOTORS SEE FEE SCH.
ADDDRESSDRESS
'a Z-OI Ovrf ^t G X210 h�T1Mlo SERVICE CHANGE 20.00
FOD LICENSED CIRSDECLARAFIISN
DIiCLARA'
< i w I hereby affirm that I am licensed under provisions of Chapter 9 - - ISSUANCE DATE
(commencing with Section 7000)of Division 3 of the Business and
< n - 488 BLDG. ELECT. PLG. MECH.
F w i Professions Code,and my license is in full farce and effect. ❑ ❑ ❑ ❑
oZ m W License Class LIc.Number UL
�
Dale
N Contractor -
ers:E BUILDING PERMIT
¢ ¢ a OWNER-BUILDER DECLARATION
ED
a u INFORMATION
X 3: LL n I hereby affirm that I am exempt lata the Contractor's License MISC.-
u O a Law for the following reason.(Sec.7031.5,Businessand Professions Y LUATIPN�� $/FT.
_ PERMIT ISSUANCE 10.00 /1/ (CEJ
Code:Any city or county which structure permit to construct,,also
2 ¢G improve,Demolish,Or repair any structure,prior IU its issuance,also ELEC.CONTR. LIC.NO. ELEC.
u w m u requires etre applicant for such permit to file a signcA stutemenl that - TOTAL P MOTTO -
heris licensed pursuant to the provisions of the Contractor's License •
F z a Law(Chapter 9(commencing with Section 7000)o'Division 3 oflhe
4 O Business and Professions Code)or that he is exempt therefrom and OTY. PLUMBING PERMIT FEE
ICH the basis for the alleged exemption.Any violation of Section 7031.5 STORIES TYPE CONSTR.
d ; _ by any applicant for a permit subjects the applicant to a civil penalty ALTER-DRAIN -WATER (EA.) 5.00
of not more than five hundred dollars(85001.1:
❑ 1,as owner of the property,or my employees with wages as BACK FLOW PROTECT.DEVICE 4.00 OCC.GROUP RES.UNITS
their sole compensation,will Jo the work,and the structure is not
intended or offered for sale(Sec. 7044, Business and Profession, DRAINS-FLOOR,ROOF,AR EA,GOND. 5.00
I Code:The Contractor's License Law does not apply to an owner of
property who builds or improves thereon,and who does such work FIXTURES-PER TRAP 5.00 SQ FT.FLOOR AREA TOTAL ACREAGE
• himself or through his own employees,provided that such improve-
meats are not intended or offered for sale.If,however,the building GAS-EA.SYSTEM-11NC.40UTLETS 6.00 d L7l/
or improvement is sold within one year of completion,the owner- GAS-EA.SYSTEM-OVER 4(EA.) 2.00 BUILDING USE
builder will have the burden of proving that he did not build or im- RES IND CON PB�'_OtM1er
prove for purpose of sale.). INDUSTRIAL WASTE INTER. 30.00
❑ I,as owner of the property,am exclusively contracting with ❑ ❑i • ❑ ❑ ❑
licensed contractors to construct the project(Sec.7044,Business LAWN SPRINKLERS-1 INC 5 V.B. 6.00 ASSESSORS PARCEL NO.
and Professions Code:The Contractor's License Law 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 contractors)licensed pursuant to SEWER-SANITARY-STORM EA.200ft/10.00
the Contractors License Law. TRACT NO. PARCEL NO.
❑ l am exempt under Sec..,B&P.C.for this WATER HEATER W/VENT 6.00
reason
Owner Date WATER SYSTEM 5.00
ACC.GATE ALC.FILE NO.
WORK F-RS'COMPIINSATION DECLARATION WATER TREATING EQUIP. 5.00 '
1 hereby affirm that I have a certificate of consent to sell'-insure, ZONING ENG.SITE N0.
or a certificate of Workers'Compensation Insurance,or a certified
copy thereof(Sec.3800,Lab.CJ.
Policy No. Company
Q ❑ Certified copy is hereby furnished, FIRE SPRINK' • ENERGY T-24
I Z ZO ❑ Certified copy is filed with the city inspection Division.
Applicant MISC.- REFER TO ORD. V N Y❑ ❑ ❑ ❑
N
~ �+ PERMIT ISSUANCE 10.00
LU - CIiRTIFICI PEXEMPTION PROM WORKERS' FLOOD ZONE A.L.U.C.
W CCOOMPEF NSATION INSURANCE PLG.CONTR. LIC.NO. PLG. ❑ N❑ Y❑ N❑
0 Z (This action need not be completed if the permit is for one TOTAL V
hundred dollars IS 100)or less.)
U O 1 certify that in the performance of the work for which this per- QTY. MECHANICAL PERMIT FEE FEE SUMMARY
LL 1- mit is issued,I shall not employ any person in any manner so as Iu
O W become subject to the Workers'Compensation Laws of California.
IN. Date Applicant BUILDING /j C
} N NOTICE TO APPLICANT: If,after making this Certificate of Ex- ALTER OR ADD TO MECH. . 5.00 O�4 JQ
F ? eruption,you Should become subject to the Workers.'Compensation APPLIANCE 5.00 PLAN CHECK
F provisions of the Labor Code, you must forthwith comply with FEE
U . such provisions or this permit shall be deemed revoked. AIR HANDLING UNIT(TO 10,000C.F.M.) 4.00
CONSTRUCTION LENDING AGENCY AIR HANDLING UNIT(OVER IQOOOC.RM.) 6.00 SEISMIC FEE . ) 3sgo
I hereby affirm that there is a construction lending agency for EXHAUST HOOD (WITH DUCT) 5.00
the performance of the work for which this permit is issued(Sec. MICROFILM
3097,Cu.C.). HEATING UNIT(TO 100,000 B.T.U.) 8.00
Lender's Name JHEATING UNIT(OV ER 100,000 B.T.U.)9.50
Lender's Address ELECTRIC
e I certify that I have read this application and state that the above VENTILATION FAN (SINGLE) 4.00 '
information is correct. I agree to comply with all city and coumy PLUMBING
h� ordinances and state laws relating.to building construction, and BOILER-CCJIv1P(3 H.P.Or100,000B.T.U.) 6.00
hereby aurmrize representatives of this city to enter upon the BOILER-COMP (Over 100,000 BTU.)SEE FEESCH. MECHANICAL
above-mentioned property for inspection purposes.
(We) agree to save, indemnify and keep harmless the City of MISC.- REFER TO ORD.
upertino against liabilities,judgments, Costs and expenses which - PERMITISSUANCE - 10.00 CONST.,TAX
may in any way accrue against said City in consequence of the
ranting o f this permit MECH.CONT. LIC.NO. MECH.
TOTAL TOTAL
Signature of Applicant/Contractor Date
OFFICE COPY
ELECTRIC SERVICE NOTICE OFFICE COPY
BUILDING INSPECTORS NOTICE
CITY OF CUPERTINO
19
To
You are hereby authorized to Connect electrical service for
( /°A 6a !
'Owner or Tenant a
No.of Wires Size of Wires Size of Switch
Motor Load Voltage Phase
Hearing Load K.W. Voltage
No.of Meters Light 110New Service Reconnect
Heat 120 three Wire More Service I
No of Add. Meters Power Y� Three Phase Move Meter
O� ELECTRICAL INSPECTOR'"