12402 (3) 10. APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BAL. OINT PEN ONLY.
I3UI LDING PROJECT I DENTI FICA PERMIT NUMBER
ADORE.
AO,XC5,r«J�/ 'S&^J APPLICATION & PE 1� 12402
ADDRESS
/02GOSta• Z>E .VZO4 4C.%/D. BUILDING-ELECTRICAL-PLUMBING-MECHANICAL
OWNER'S 1,3/91 A 4� �,.^QT _D�a K C+/0 PLAN CHECK VALIDATION.
"AME ~I T CITY. ELECTRIC PERMIT FEE
WA 9A4AI
CONTRACTOR
NAME UTLETS-SWITCHES-RECEP 10.00/1.00
NAME
601-s'.... G~-Iic.Ivo.rje54�3-Z- LIGHTING FIXTURES 10.00/1.00
CONTRACTORS
aRs
ADDRESS //`` / APPLIANCES-RESIDENTIAL 4.00
A �j• V•
1LIZN PANELS 10.00 DATE OF APPLICATION
ARCHITECT AKGSd�,f6C/ PANELS IDV ER 200 AMP) 20.00 PLAN CHECK FEE P.C.NO.
OR yp 9
ENGINEER ��/ '
LIC.. -ire"rvl '-ire SIGNS TRANS. 3.00
ARCH.OR ENG./)O4 v 5.00 P IDATION
AD ES
�iR4 /�0+� �.S7Z pA SPECIAL CIRCUIT
ZAJL90-1V G^49A _9 SbI EMP.METER OR POLE INS. 20.00 r��p 1 J
ADDRESrvrs p� �� 2V 72 MOTORS SEE FEE SCH. APR !. O
ADDRESS a
ez-161 4946-01 SERVICE CHANGE 20.00 City.Of.Cupertino
woo LICENSED CONTRACTORS DECLARATION ,
az
U u I hereby affirm that I am licensed under provisions of Chapter 9 ISSUANCE DATE
Z w (commencing with Section 7000)of Division 3 of the Businessand ELECT. PLG. MECH.
hZ ProCessions Co dc, nd my license is in full forceandV f12 ❑ ❑ O
t o w License lass Lic.Number 2
Dr D Datc .11T Contractor-OI,.Sf -isAJ
a y UILDING PERMIT
¢ ¢ w OWNER-BUILDER DECLARATION INFORMATION
X g' U I hereby affirm that I am exempt from the Contractor's License MISC.- REFER TO ORD
u 0¢ Law for the following reason.(Sec.7031.5,Business and Professions PERMIT ISSUANCE 10.00 VALUATION g/FT.
� - 0 Code:Anycityurcounly which requires a permit to construct,alter, �^1
a ¢¢o improve,demolish,or repair any structure,prior to its issuance,also ELEC.CONTR.
O u requires the applicant for such permit to file a signed statement that TOTAL PERMIT TO
a w m he is licensed pursuant to the provisions of the Contractor's License AOh/ft dAJ 44.
r Law(Chapter 9(commencing with Section 7000)of Division 3 of t he
fez o Business and Professions Code)or that he is exempt therefrom and CITY. PLUMBING PERMIT FEE 4•r�M
¢ H the basis for the alleged exemption.Any violation of Section 7031.5 STORIES TYPE CONSTR.
d3: by any applicant for a permit subjects the applicant to a civil penalty 00) 5.
of not more than five hundred dollars($500).): ALTER-DRAIN&VENT-WATER (EA. 00 ,
❑ 1,as owner of the property,or my employees with wages as BACK FLOW PROTECT.DEVICE 4.00
their sole compensation,will do the work,and the structure is not OCC.GROUP RES.UNITS
intended or offered for sale(Sec. 7044, Business and Professions DRAINS-FLOOR,ROOF,AR ENCOND. 5.00 -3-2 A.)A-
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 5.110 SO.FT,//FLLOOOR AREA TOTAL ACREAGE
himself re through de own employees.provided that such improvo- S`f-fir QQ4'
hients mself a throuot gh
or employees,ffered for prove. ided
thathowevs,the building GAS-EA.SYSTEM-1INC.4OUTLETS 6.00 04J
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 No CO PB Other
prove for purpose of sale.). INDUSTRIAL WASTE INTER. 30.00 ❑ ❑ ❑ C3
❑ 1,as owner of the property,am exclusively contracting with - -
licensed contractors to construct the project(Sec.7044,Business LAWN SPRINKLERS-1 INC 5 V.B. 6.00 ASSESSORS EL 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 contractor(s)licensed pursuant to -
the Contractor's License Law, SEWER-SANITARY-STORM EA.200ft/10.00 TRACT NO. PARCEL NO.
C1 am exempt under Sec. ,BAP.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
I hereby affirm that I have a certificate of consent to self-insure, ZONING
or a certificate of Workers'Compensation Insurance,or a certified ENG.SITE N0.
copy thereof(Sec.3800,Lab.C.).
Policy No. Company BIJC.'R o l-lao"
O ❑ Certified copy la hereby furnished. FIRESPRINK ENERGY T 24
Z Z ertifi it co y is ❑led with the city inspection division. MISC.- REFER TO ORD.
O Applin rt Wc-oi AM/Sd=1 Y ❑ N❑ Y ❑ N❑
Fw PERMIT ISSUANCE 10.00 fLOOD ZONE A.L.u.c.
2 CERTIFICATE OF EXEMPTION FROM WORKERS'
LU _ COMPENSATION INSURANCE PLO,CONTR. LIC.NO. PLG. Y❑ NE] Y C] N
CL ❑ (This section need not be completed if the permit is for one TOTAL
:3 Z hundred dollars IS 100)or less.)
U O 1 certify that in the performance ol'tile work for which this per. OTY. MECHANICAL PERMIT FEE FEE SUMMARY
LL F• mit is issued,1 shall not employ any person in any manner so as to
O W became subject to Ole Workers'Compensation Laws of California.
Date ApplicantBUILDING
} in NOTICE TO APPLICANT: If,after making this Certificate of Ex-
ALTER OR ADD TO MECH. 5.00 !�
Z emption,you should become subject to the Workers'Compensation APPLIANCE 5.00 PLAN CHECK
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 10MC.F.M.) 6.00 SEISMIC FEE S�
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,CY.C.). HEATING UNIT(TO 100,000 B.T.U.) 6.00
Lender's Name HEATI NG UN IT(OV ER 100,000 B.T.U.)9.50 ELECTRIC
Lender's Address
1 certify that 1 have read this application and state that the above VENTILATION FAN (SINGLE) 4,00 d
information is correct.1 agree to comply with all city and county PLUMBING
ordinances and state laws relating to building construction, and BOILER-COMP(3 H.P.or 100,000 B.T.U.) 6.00
hereby authorize representatives of this city to enter upon the BOILER-COMP Over 100,000 BTU)SEE FEE SCH. MECHANICAL
above-mentioned property for inspection purposes.
(We) agree to save, indemnify and keep harmless the City of MISC.- REFER TO ORD.
Cupertino against liabilities,judgments, casts and expenses which CONST.TAX
may in any way accrue against said City in consequence of the PERMIT ISSUANCE 10.00
gran g of this permy'y MECH.CONT. LIC.NO. MECITTOTAL TOTAL �2J11
\ N Signature of Applicant/ tractorAA D
\\l V\ OFFICE COPY