2094 (2)APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
BUILDING PROJECT IDENTIFICATION
-
APPLICATION & PERMIT
BUILDING -ELECTRICAL -PLUMBING -MECHANICAL
PERMIT NUMBER
O 9 /�
X1'7
BUILDING
. aooREss L�w
OWNER'S
PLAN CHECK VALIDATION
NAME ' y �s('DTY
L NE e- ?_ t0;
ELECTRIC PERMIT FEE
.
DATE OF APPLICATION
e NpMTRAcroRs -
E
y f L A LNo. 32-1-70
UTLETS- SWITCHES - PIECED 5.00/1.00
LIGHTING FIXTURES 5.00/1.00
CONTRACTOR
R's
M C (f HOL�PHONE &6'J ID
APPLIANCES -RESIDENTIAL 4.00
PANELS 5.00
ARCHITECT
OR
ENGINEER
LIc. No.
SIGNS 6.00
PLAN CHECK FEE P.C. NO.
SIGNS TRANS. 3.00
Doo ESS Ervc'
SPECIAL CIRCUIT 5.00
'PERMIT VALIDATION
CrEMP. METER OR POLE INS. 15.00
ZIP
S
APPLICANTS
ADDRESS
MOTORS SEE FEE SCH.
SERVICE CHANGE 10.00
r
LICENSED CONTRACTORS DECLARATION
p U e
�O
•� 2 ��... SIF
I hereby affirm that I am licensed under provisions of Chapter 9
(commencing with Section 7000) of Division 3 of the Businin, and
'rofesslons Code,' d r y license is in full fur��-}}•in_d of-c}�
License Class l.ic. Nu=trd'4}"j�_J7
ISSUANCE DATE
BLDG. ELECT.
❑ ❑
PLG. - MECH.
❑ ❑
Uale Contractor
OWNER -BUILDER UECLARIA'FIOOtN• - J
hereby affirm that I um exmnpt from the Contrualor'A License
Law for the following reason. ch(Sec. 703 Professions
Code: Any city or county which requirese permit to construct, alter,
reuireta,ermit to
any structure, prior n its issuance, also
improve, demolish, or for such
requires else dp u applicant f0! the permit is flit' a aimed Contractor's Li nsI
he is licensed pursuant t to the provisions of the Contractor's 3 License
Law(ChapterProfessions Codewith Section 7000)of Otherefoof lite
Business and
exempt or that he is exempt therefrom and
BUILDING PERMIT
INFORMATION
MISC.REFER TO ORD -
PERMIT ISSUANCE 6.00
VALUATION
1qz9"
/
$/FT.
ELEC. CONTR. LIC: N0. ELEC.
TOTAL
11 IMF%
DTV. PLUMBING PERMIT FEE
w / "` A PERMIT TO
F n
p G} -
he alleged of Section
the basis for the alleged exemption: Any
STORIES
TYPE CONSTR.
malty
applicant toacivil penalty
by any more
of not more liveor permit dollars ($500):):
live hundred
(iny
•g
KE
ALTER -DRAIN -WATER (EA.)4.00 '
❑ I, as owner at the property, or my employees rocs wages as
owner property, o employees
their sole compensation, will do the work, and the structure Is not
intended or offered for sale (See 7044, Business and Prol'essiona
BACK FLOW PROTECT. DEV ICE 2.00
CC. G U
%� ,Py
/ '9�� %'Q`r
RES. UNITS
�I I�sT/L
DRAINS -FLOOR, ROOF, AREA, CON.. N.
Code: The Com actor's License Law docs not apply to an owner of
FIXTURES - PER TRAP 4.00
SO, FT, FLOOR AREA
TOTAL ACREAGE
property who builds or improves thereon, and who docs such work
himself or through his own employees, provided that such improve-
mal
es are not Intended or ofored for sale. If, however, the building
GAS - EA. SYSTEM -11NC. 4OUTLETS 4.00
or improvement is sold within one year of completion, the owner-
builder will have the burden of proving that he did not build ori
❑ I, as owner of the property, am exclusively contracting with
GAS - EA. SYSTEM - OVER 4 (EA.)' 1.00
BUILDING USE
RES IND CON PB Omar
INDUSTRIAL WASTE INTER. 2000
.
licensed contractors to construct the project (Sec. 7044, BusinessLAWN
and Professions Code: The Contractor's License Law does not apply
to an owner of property who builds or improves thereon, and who
SPRINKLERS- 1 INC 5 V.B. 5.00
ASSESSORS PARCEL NO.
LAWN SPRINKLERS - OVER 5(EA.) 1.00
contacts for such projects with it contractons) licensed pursuant to
the Contractor's License Law.
SEWER -SANITARY -STORM EA. 200ft/8.00
TRACT NO.
PARCEL NO.
❑ I am exempt under Sec,-, BAP.C. for this
WATER HEATER W/VENT 4.00
reason
Dale Owner
WATER SYSTEM 4.00
ACC. DATE
ACC FILE NO.
WATER TREATING EQUIP. 4.00
WORK FRS'COMPENSATION DECLARATION
-I hereby affirm that I have a cereifmate ofconsem to sd if infame.
or a certificate of Workers' Compensation Insurance, it a crti(red
copy thereyyf((��.. 3/j{,0�.($] L`c"�'dy}d�.�C(.1.
Policy No.{/.1(k(�-(RpDIyryY-
ZONING
ENG. SITE NO.
'
ElCertified copy is IIc y famished.
❑ Certified copy is filed with the oily inspection division.
Applicant_ f, -y, i �hob.s"
FIRE 6PRINK
Y ❑ N[3
ENERGY T-24
Y ❑ NEI
MISC. - REFER TO ORD.
CERTIFICAI'li OF EXEMI'110N PROM WORKERS'
PERMIT ISSUANCE 6.00
FLOOOZONE
A. L.U.C..
COMPENSATION INSURANCE
(Phis section need not be completed if the perruit is for one
PLG.CDNTR.LIC.NO.
PLG.
TOTAL
Y ❑ 'IN
Y No
hundred dollars ($100) or less.)
-
I certify that in the performance of the work for which this per.
mil is issued, 1 shall not employ, any person in any mannerso as to
DTV. MECHANICAL PERMIT - FEE
FEE SUMMARY
BUILDING
a�(f
become Subject m the Workers' Conepens,oinn Laws of Culilorniu.
Dale ApplicantALTER
NOT !CF TO APPLICANT: If, after making this Certificate of Ex-
OR ADD TO MECH. q,pQ '
APPLIANCE 4.00
AIR HANDLING UNIT (TO 10=C.F.M.) 3.00
PLAN CHECK
FEE
emption. you should become subject to the Workers'Compensation
provisions of the Labor Code, you must forthwith comply with
such provisions or this permit shall be deemed revoked.
AIR HANDLING UNIT(OVER 10,000C.F.M.) 5.00
SEISMIC FEE
pfd
CONSTRUCTION LENDING AGENCY
1 hereby affirm that there is a construction lending agency for
EXHAUST HOOD (WITH DUCT) 2.00
the performance of the work for which this permit is issued (Sec.
3097, Cw,C.).
MICROFILM
HEATING UNIT (TO 100,000 B.T.U.) 4.00
Lender's Name
Lender's Names
HEATING UNIT (OVER 100,000 B.T.U.)7.50
ELECTRIC
'
VENTILATION FAN ISINGLE) 3.00
I certify that I have read this application and state that the above
information is correct. 1 agree to comply with all city and county
ordinances and state laws relating to building construction, and
PLUMBING
'
BOILER-OOMP(3 H.P. or 100,000 B.T.U.) 4.00
BOILER -COMP (Over, 100,000 BTU) SEE FEE SCH.
MECHANICAL
hereby authorirc representatives of this city to enter upon the
above-mentioned property for inspection purposes.
(We) agree to Save, indenoify 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
MISC. - REFER TO ORD.
CONST. TAX
PERMIT ISSUANCE 3.00
L
gan' o is trout.
MECH.CONT. - LIC. NO.
MECH.
TOTAL'
TOTAL'S/�
Signmure o pplicant/Contractor Date
OFFICE COPY