5944APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
BUILDING PROJECT IDENTIFICATION
APPLICATION &PERMIT
BUILDING - ELECTRICAL- PLUMBING - MECHANICAL
PERMIT NUMBER
5944
a°ILoINo 87 A -r*? Woob
ADDRESS
OWNER'S
NAME YOM'fV tiOZF IL
OTV. ELECTRIC PERMIT
cPLAN CHECK NVALIDATION
Af-��PHONE
6CONTRACTOR'S vNAMI)ijr
OUTLETS-SWITCHES-RECEP 5.00/1.00
ca uc. NO.
y
DATE OF APPLICATION
LIGHTING FIXTURES 5.00/1.00
ADDRUE caoR'
ADDRESS
PHONE
APPLIANCES 4.00 v
PANELS 5.00
ARCHITECT / C..n I.1•:k fY}�%1
OR f/ T
ENGINEER
r,>" IronfGR uc. No.
SIGNS 6.00
PLAN CHECK FEE P.C. NO.
PLAN
SIGNS TRANS. 3.00
ARO,. OR ENG.
ADDRESS �P6 11_ Sr
g7 �LEBL1�f�' 2tP (y
SPECIALCIRCUIT v 5.00
• PERMIT VALIDATION
��
EMP. METER OR POLE INS. 15.00
APPLICANTS
ADDRESS
MOTORS SEE FEE SCH.
SERVICE CHANGE 10.00
/Y/,J '
LICENSED CONTRACTORS DECLARATION
I hereby affirm that I am licensed under provisions of Chapter 9
(cnnunencing with Section 7000) of Division 3 of the Business and
Professions Codc antl my license is in full force and effect.
License Class Lic. Nun, ber
ISSUANCE DATE
BLDG. ELECT.
PLG. MECH.
UamContractar
rBUILDING PERMIT
OWNER -BUILDER DECLARATION /<
I hereby Ellin that I un, osempt from the Contmmors License
Law for to following reason.(Sec. 703 1.5, flushessand Professions
Code: Any city or county which requiresa permil loconstruct,aller.
improve, demolish. ar repair any struelure, prior to its issuance, also
requires the applicant fur such permit 10 Nle a signed statement that
Ile is licensed pursuant to the provisions of the Contrmtor's License
Law (Chapter 9(cnmmencingwith Sectino 70000of Division 3of the
Business and Professions Code) or that he is exempt therefrom and
the basis for the alleged exemption. Any violation of Sect ion 7031.5
!I INFORMATION
MISC. - REFER TO ORD
PERMIT ISSUANCE 6.00
VALUATION
$/FT.
ELEC. CONTR. LIC. NO.
ELEC.
TOTAL 3' �
PERMIT TO
/
q d
CITY. PLUMBING PERMIT FEE
I_
STORIES
TYPE CONSTR.
by any applicant for a permit subjects the applicant to acivil penalty
of not more than five hundred dollars 155001.1:
ALTER -DRAIN & VENT -WATER (EA.) 4.00
❑ I, as owner of the property, or my employees with wages us
their sole compensation, will do the work, and the st rocture is not
BACK FLOW PROTECT. DEVICE 2.00
OCC. GROUP
RES. UNITS
DRAINS -FLOOR, ROOF, AREA, COND.4.0 0
intended or offered for sale (Sec 7044, Business and Professions
Code: The Contractor's License Law dos not apply to an owner of
ro
property who builds or improves thereon, and who does such work
I I in,sellor through his own employees, provided that such improve.
k'h�Rrnents are not intended or offered for sale. If, however, the building
$0. FT. FLOOR AREA
TOTAL ACREAGE
FIXTURES - PER TRAP 4.0 -
f GAS - EA. SYSTEM -1INC. 4 OUTLETS 4.00 Ile I,
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 sale.).
❑ I, as owner of the property, am exclusively contracting with
I GAS' EA. SYSTEM - OV ER 4 (EA.) .1.00
BUILDING USE
RES IND CON PB Omer
❑ ❑ ❑ ❑ ❑
INDUSTRIAL WASTE INTER. 20.00
licensed contractors to emstruct the project (Sec. 7044, Business
and profession, Code: *1 he Can tractors License Law does not apply
In an owner of property who builds or improves thereon. and who
LAWN SPRINKLERS - 1 INC 5 V.B. 5.00
ASSESSORS PARCEL NO.
LAWN SPRINKLERS - OVER 5 (EA.) 1.00
contracts for such projects with a contractors) licensed pursuant to
the Contractor's License Law.
SEWER -SANITARY -STORM EA. 200ft/8.00
TRACT NO.
PARCEL NO.
❑ I am exeRmt under Sec. , [I &P C. tin this
reason
WATER HEATER W/VENT 4.00
Owner Date
WATER SYSTEM 4.00
ACC.DATE
ACC. FILE NO,
WORK ERS'COMPENSATION DECLARATION
WATER TREATING EQUIP. 4.00
I hereby ;dorm that 1 hove a certificate of cumwill to ,H insure,
or a certificate of Workers' Compensation Insurance, Or a certified
ZONING
ENG. SITE NO.
copy Ther- fISee 3 00, Lah.C.).
Policy N -on,Pany /
ElCertified copy is hereby famished.
❑ Certit� y�d� p s ,Ided Th II • city inspection division.
Applicant-ll//��-�51CG1W�� �(�.
FIRE SPRINK
YE] N❑
ENERGY T 24
Y❑ NEIN
MISC.- REFER TO ORD.
CE;R'I'I FICAT17 OF EXEMPTION FROM WORK ERS'
PERMIT ISSUANCE 6.00 �"
rp
FLOODZONE
A.L.U.C.
PLG. CONTR. LIC. NO.
PLG
TOTAL �`
COMPENSATION INSURANCE:
('Phis section need not he completed if file Punnit is for one
Y ❑ N❑
v ❑ N❑
CITY. `MECHANICAL PERMIT FEE
--
FEE SUMMARY
hundred dollars (S 100) or Icss.l
I certify that in the performance of the work for which this per.
mit is issued, 1 shall not employ any person in any manner so as to
become subject to the Workers' Compensation Laws of California.
Dale Applies,,(
BUILDING
e2 5 G
O
ALTER OR ADD TO MECH. 4.00
N(1'] WE'f0 AI'I'LICAN'1': It, after making this Certificate of Bx-
APPLIANCE 4.00
PLAN CHECK
eruption, 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.
FEE
AIR HANDLING UNIT (TO 10SMC.F.M.) 3.00
AIR HANDLING UNIT (OVER 10=C.F.M.) 5.00
SEISMIC FEE
77
J ��
CONSTRUCTION LENDING AGENCY
I hereby affirm that there is a construction lending agency Or
EXHAUST HOOD (WITH DUCT) 2.00
the performance of the work for which this permit is issued (Sec.
3097, Civ.C.).
MICROFILM
HEATING UNITITO 100,000 B.T.U.) 4.00
Lender's Name
HEATING UNIT (OV ER 100,000 B.T.U.17.50
ELECTRIC
/
Lenders Address
I certify Ilia t I have read this application and state that the above
information is correct. I agree to comply with all city and county
Mances and state laws relating to building construction, and
.elsy authorise representatives of this city to enter upon the
above-Inenh... ell property for inspection Im,poscs,
VENTILATION FAN (SINGLE) 3.00 -
PLUMBING
pY
BOILER -DOW (3 H.P. or 100,000 B.T.U.) 4.00
BOILER -COMP lover tDO,00D BTU) SEE FEE SCH.
MECHANICAL
/ (P
MISC. - `\ REFER TO ORD -
(we) agree to save, indemnify and keep harmless the City of
Cupertino against liabilities;judgments, costsand expenses which
.may in any way accrue against said City in consequence of the
CONST. TAX
PERMIT ISSUANCE 3.00 --
grantingofthispemft.
GtllrA/S egkr �j F.f //a hoET
MECH. CONT. LIC. NO, MECH.
TorAL o =0
TOTAL
3/r� FS
SignaW"�pplicant Detractor Dui
INSPECTOR COPY