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APPLICANT TO FILL IN INFORMATION WITHIN RED LINES- USE BALL POINT PEN ONLY
' 4
'BUILDING
PERMITNUMBER
PROJECT I DENTI FICATION
BUILDING APPLICATION &PERMIT
3 456
ADORESSV
/O -/ / C'D. QE A�/Z� BLUj�, BUILDING -ELECTRICAL -PLUMBING -MECHANICAL
[�(� J
PLAN CHECK VALIDATION
DATE OF APPLICATION
OWNER'S
N/AANM�Q �/I //�� L QTY. ELECTRIC PERMIT FEE
V/ l,rl P" �prRr r PHONE
CONTRACTOR'S
NAME C�0/v rl2*C V,(4
$13 .C,{NDSGRpE LID.ND.351b33
- SWITCHES -RECEP 5.00/1.00
OUTLETS
LIGHTING FIXTURES 5.00/1.00
'S �?'SMT W� L54 //LiGAte- �D//3.
CONTRACTOR
AOORE55
QA l3EuA �E- go-.-, 7,f 7
APPLIANCES -RESIDENTIAL 4.00
PANELS 5.00
ARCHITECT Cru LT7 A/o .1 1
on �' a.l C s >43
ENGINEER
'v uc. No.
SIGNS 8.00
PLAN CHECK FEE P.C. NO.
ISIGNS TRANS. 3.00
ARCH,OR ENG,
AOORESSZIP
SPECIAL CIRCUIT 5,00
PERMIT VALIDATION
EMP. METER OR POLE INS. 15.00
i(O/
/
7 'W
A
ADORESS S
ADORE
MOTORS SEE FEE SCH.
SERVICE CHANGE 10.00
N
LICENSTU CONTRACT RS DECLARATION
I hereby affirm that I am licensed under provisions of Chapter 9
ISSUANCE DATE
(emllmeneing with Section 7000) of Division 3 of the Business and
Professions Code, and n, Ikea. is in full Juice and Alyce . �
License Cl'rss hi c.NunHe1
BLpG.
❑
ELECT. I
❑
PLG. MECH.
❑ ❑
Uute� Contracto
'
BUILDING PERMIT
OWNBR-RUILDER D17CLARATION
vollo that I um cxne.7R,o 31.5 IhtCossand is feisions
I herebyothe
Law forthtity or countywhihec.703sa Befsin town Professions
Code: Any city or county which structure Permit locos suanc alnc
t0 its issuance that
Of ftpatf any smit tore,ea signed
retleires e applicant
thedp pursuant t to th h permit m fill n signed smtemtm that
hu is licensed pursuant to the provisions of the ConlNctor's License
lie is licensed
INFORMATION
MISC.- - REFER TO ORD
VALUATION
$/FT.
PERMIT ISSUANCE 6.00
ELEC. CONTR. LIC. NO.
�"
n
ELEC.
TOTAL
PERgqMIT TO
QTY. PLUMBING PERMIT FEE
Law(Chaptur 9(commencing with Section 7000) of Division 3 of the
Business and Professions Code) or that he is exempt therefrom and
�L•4C
STORIES
TYPE CONSTR.
the basis for the allegtd exemption. Any violation of Section 7031.5
by any applicant for 'apermit subjects the applicant toa civil penalty
of not more than five hundred dollars (5500).):
ALTER -DRAIN -WATER (EA.) 4.00
❑ I. asowner of the property, or my employees with wages as
their sole cwill do the work, ..it the structure is not
BACK F LOW PROTECT. DEVICE 2.00
OCC. GROUP
RES. UNITS
DRAINS -FLOOR, ROOF, AREA, COND. 4.00
rompensation,
intended o0ffered for sale (See. 7044, 13u.mr,.. and [',ofessior,
Code: The Can tractor's License Law docs not apply to:in owner of
property who builds or improves thereon, and who docs such work
Himself or through his own employees, provided that such improve-
n,ems are not intended or offered for sale. If, however, the building
FIXTURES - PER TRAP 4.00
SO. FT FLOOR AREA
-�T, TALACREAGE
GAS-EA.SYSTEM-11NC.40UTLETS 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 orint-
proveforpurpouofsulu.L
❑ I, as owner of the property, am exclusively contracting wi dt
GAS - EA. SYSTEM - OVER 4 (EA.) 1.00
BUILDING USE
RES Irvp CON PB omen
❑ ❑ ❑ ❑ ❑
INDUSTRIAL WASTE INTER. 2000
.
LAWN SPRINKLERS - 1 INC 5 V.B. 5.00
ASSESSORS PARCEL NO.
licensed contractors to construct the proiccl (Sec. 7044, Business
and Professions Code', 'I'hc Contnmtor's License Law Jnes not apply
to an owner of property who builds or ar,roves thereon. and who
LAWN SPRINKLERS - OVER 5 (EA.) 1.00
contracts for such projects with a contractorls) licensed pursuant to
the Contractor's License Law.
SEWER -SANITARY -STORM EA. 200ft/8.00
TRACT NO.
PARCEL NO.
❑ Il on exempt under Sec .B.&P.C. for this
reason
WATER HEATER W/VENT 4.00
Date Owner
WATER SYSTEM 4.00
ACC. DATE
ACC. FILE NO.
WATER TREATING EQUIP. 4.00
WORK ERS'COMPERSA"TION DECLARATION
I hereby affirm that I have a certificate of certificateconsent to elf-inau re,
or a certificate of Workers' Compensation Insurance, or a certified
ZONING
ENG. SITE N0.
copy thereof (Sec. 800, Lab. C. I.
Policy No - 'ompeny
❑ Certified copyis hemby furushed
cCrrar tificd ' is filed witl k city inspection division.
A*
FIRE SPRINK
Y❑ N❑
ENERGYT-24
v❑ NEIpfj
MISC.- REF ER TO ORD.
CliR1'I1'lolni OP lixEM1l rIlON FROM WORKERS'
PERMIT ISSUANCE 6.00r 0j, J919FIf
LOODZONE
A. L.U.C.
PLG. CONTR. LIC. NO.
PLG.
TOTAL ia(/
COb11'IiNSA'I'ION INSURANCE
(This section need not be Completed if the permit is for one
Y ❑ N❑
I Y ❑ N
hundred dollars IS 100) or less.)
I certify that in the performance of "I' work for which ih is per
Pit is issued, I shall not employ any person',, any in unner S0 us to
QTY MECHANICAL PERMIT FEE
FEE SUMMARY
BUILDING
become subject to the Workers' Compensation Laws of California.
Data Applicant
NOTICE l'O APPLICANT: If, He, making this Cerlifiaate of I".
ALTER OR ADD TO MECH. 4.00
APPLIANCE 4.00
PLAN CHECK
cntption, you should become subject to the Workers Compensation
provisions of the Labor Code, you must forthwith comply with
such provisions or this permit strait be deemed revoked.
FEE
AIR HANDLING UNIT (TO 10SM C.F.M.) 3.00
AIR HANDLING UNIT(OVER 10=C.F.M.) 5.00
SEISMIC FEE
CONSTRUCTION LENDING AGENCY
I hereby uflirm thus 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, CieC.). '
MICROFILM
HEATING UNIT (TO 100,000 B.T.U.) 4.00
HEATI NG UN IT (OV ER 100,000 B.T.U.)7.50
ELECTRIC
Lender's Name
Addre
Lndtf's ss
I certify that I have read this application and state that the above
information is correct. I agree to comply with all city and county
ordinances and state laws relating to building const R¢tion, mrd
VENTILATION FAN (SINGLE) 3.00
PLUMBING
zz Q
BOILER -COMP (3 H.P. or 100,000 B.T.U.) 4.00
BOILER -COMP (Over 100,000 BTUISEE FEE SCH.
MECHANICAL
Hereby authorize representatives of this city toenmr upon the
above-mentioned properly for inspection PLIR)OWs.
MISC. - REFER TO ORD.
(Wu) agree to Saveindemnify and keep harmless the City of
Cupertino against liabilities, judgments, costs and expenses which
may in any way accrue against said City in conserurece of the
CONST. TAX
PERMIT ISSUANCEpi , 3.00
`n
RI
gral�if per
MECH. CONT. LIC. NO.
MECH.
x '/
T /9 �5
TOTAL
TOTAL
Signaluor of A,,lr nt/Commctat D.tc
INSPECTOR COPY