18654 (2)APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
BUILDING PROJECT IDENTIFICATION
APPLICATION &PERMIT
UILDING -ELECTRICAL- PLUMBING -MECHANICAL
PERMIT NUMBER
., 18654
AVILmNG
An E55 � O
l �
OWNER'S
NhAANE ` y�, ,{ (p r�
(, ( ` 1 J lA Q• PHO IE1 3'015
O7V ELECTRIC PERMIT FEE
PLAN CHECK VALIDATION
Q_I brQ 1
l� 1.
DATE OF APPLICATION
CONTRACTORS I'''C/
orad 11 _hone I ,c. NO L1451
OUTLETS - SWITCHES -RECEP 10.00/1.00
LIGHTING FIXTURES 10.00/1.00
CONTRACTORS �l�1/n� PHI'
r 1�r f111. ONE aY
APPLIANCES - RESIDENTIAL 4.00
PANELS 10.00
ARCHITECT
OR
ENGINEER
LIC. NO,
PANELS (OVER 200 AMP) 20.00
PLAN C
P.C. NO.
._.-
SIGNS TRANS. 3.00
ADDRRESS ENG.SPECIAL
CIRCUIT S.QQ
HT Lam' E MI VJ[I�'(ION
rad ee
nv
EMP. METER OR POLE INS. 20.00
(E]q�
ADDRESSTS
MOTORS SEE FEE SCH.Qg
SERVICE
E 20.00
GIUap1!Lu
w
LICENSED CONTRACTORS DECLARATION
I hereby affirm tial l stn licensed under provisions of Chapter 9
(c'omnrs•ncing will, Section 7000) of Division 3 of fie Business and
PR`fcssions Code, and my license is in full Esrce and effect
License Class Lic. Number
Date Contractor
OWNER -BUILDER DECLARATION
ISSUANCE DATE
BLDG. ELECT. PLG. MECH.
❑ ❑
CJ
I
BUILDING PERMIT
I hem by collo that I exempt from the Contrsdor-a License
MISC.- REFER TO
INFORMATION
PERMIT ISSUANCE 10.00
VALUATION
g/FT.
sm
Code:Any cityl following which equine. permit tocodProfessions
Corte: Any city or county which structure permit tots nslrrmt, alter,
ELEC. CONTR. LIC. NO.
TOT
TOTAL
prior to its issuance, also
improve, demolish, or repair any permit
ne is tic Lie applicant for such permit Io file a signed actor's of that
to
he is licensed the provisions of Iht Contractor's License
PERMITTO
9 (comm n
Law(Chapterpter9(commenCodecing Section 7, twirls the
) Or
Business and Professions Code) or that he is exempt therefrom and
escra film,
filby basis for the alleged er mnpobje Any violation of Section eoulty
by any applicant fora permit subjects the applicant to a civil ptnulty
of not more than five hundred Dollars (SS001.1:
QTY. PLUMBING PERMIT FEE
ALTER -DRAIN & VENT -WATER (EA.) 5.00
STORIES
TYPE CONSTR.
❑ 1, as owner of the property, or my employees with wages as
their Side Compensation, will do the work, and the structure is not
intended or offered for sale (Sec. 7044. Business and Professions
Code: 'file Contractor's License Law does not apply to an owner of
. .
BACK FLOW PROTECTDEVICE 400
OCG GROUP
RES. UNITS
DRAINS- FLOOR, 'ROOF, AREA, COND. 5.00
FIXTURES -PER TRAP 5.00
GAS-EA.SYSTEM-11NC.40UTLETS 6.00
property who builds or Improves thereon, and who does such work
mhinrsell' or through his own employees, provided that such improve.
emsare not intended oroffered for sale. IL however, file building
50. FT. FLOOR AREA
TOTAL ACREAGE
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 of s:dc.l'
❑ 1, as owner of the property, am exclusively contracting with
and Professions Cods: Tho Contractors License (Sec.
and Pro coigns od to construct the priced (Sec. 7044, Baapply
docs not apply
to an owner of property who builds (ir improves thereon, and who
contracts for such projects with a conlracloos) licensed Portland to
the Contractor's Liccnsc [.as.
❑ 1 am exempt wider Sec. , Bf for this
reaso,r
GAS - EA. SYSTEM - OVER 4 (EA.) 200
.
BUILDING USE
RES IND CON PB Omar
INDUSTRIAL WASTE INTER. 30.00
LAWN SPRINKLERS - 1 INC 5 V.B. 6.00
ASSESSORS PARCEL NO.
LAWN SPRINKLERS - OVER 5 (EA.) 1.00
SEWER -SANITARY -STORM EA. 200ft/10.00
TRACT NO.
PARCEL NO.
WATER HEATER W/VENT 6.00
Owner Date
WATER SYSTEM 5.00
WORK I;RS'COMPFNSA LION DECLARATION
ACC. DATE
ACC. FILE NO.
WATER TREATING EQUIP. 5.00
1 hereby affirm (hilt I have a cer9fcafe of consent to self-iroure,
or a certificate of Workers' Compensation houranee, or a certified
Copy Ihereof (Sec. 3800, Lab.C.).
ZONING
ENG.SITEN0.
Policy No. Company
MISC. - REFER TO ORD.
❑ Certified copy is herchy furnished.
Cert ifi Py ,s file t ¢• city inspection division.
Applicant {)<
FIRE SPRINK
Y [] N 0
ENERGY T 24
Y [J N[D
Cli Tn FICA'1'Id OF 1:X1:. 'ION PROM WORKERS'
COMPFNSA7ION INSURANCE
(This section need nut be completed if the permit is for one
hwrdoed dollars IS 100) or less_)
PERMIT ISSUANCE '10.00
FLooD ZONE
Y ❑ N❑
A.L.u.c.
Y C] IN
PLG. CONTR. LIC. rv0.
PLG.
TOTAL
OTV MECHANICAL PERMIT FEE
FEE SUMMARY
I certify that in the Performance of the work for which this per-
mit is issued, I shall not employ any persti in any nmnner so as to
become subject to the Workers' Compensn(ion Laws of California.
Dale Applicant
NO'T'ICE TO APPLICAN P: If, afler making fills Certificate of Es-
BUILDING
ALTER OR ADD TO MECH. 5.00
empti.am you almond become subject to the Workers' Compensation
provisions of Ne Labor Code, you mus( 10RIWIdh comply Willi
such provisions or this permit shall be deemed revoked
APPLIANCE 5.00
AIR HANDLING UNIT (TO 10MC.F.fV0 4,00
PLAN CHECK
FEE
CONSTRUCTION LI'NDING AGENCY
AIR HANDLING UNI I(OVER IO,000CF.M.16.00
SEISMIC FEE
1 hereby uffirn that there is a construction lending agency for
the performance 01file work (or which this permit is issued IS".
3097, Civ.C.).
Lender's Name
Lender's Address
EXHAUST HOOD (WITH DUCT) 5.00
HEATING UNIT (TO 100,000 B.T.U.) 8.00 O
MICROFILM
HEATING UNIT (OVER 100,000 B.T.U.)9.50
ELECTRIC c�
VENTILATION FAN (SINGLE) 4.00
BOILER-COW(3 H.P. or 100,000 B.T.U.) 6.00
1 certify that I have read this application and state that the above
information r correct I agree to comply with all city and county and
ordinances and apace maws relating to building construction. upon and
hereby a.Ihoominned reRRy foriins of this city to enter upon the
shove-mcntioneJ propm(y for inspection Purposes,
PLUMBING
BOILER -COMP (Over 100,000 BTU) SEE FEE SCH. Q
ell
MECHANICAL
(We) agree to Nov. indemnify and keep harndess the City of
Cupertino against liabilities, judgments, costs and expenses which
nay in y way accrue against said City in conscruence of am
rant f t bill er it I
u rO�Cy�-
MISC. - REFER TO ORD.
PERMIT ISSUANCE 10.00
CONST. TAX
MECH. CONT. LIC. NO. MECH.
TOTAL
Sig store of Applicant/ nn for Uafe
� )
TOTAL�j l
OFFICE COPY