6886•
A
•
APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
BU LD1 NG PROJECT I DENT[ FICATI ON
APPLICATION & PERMIT
BUILDING - ELECTRICAL- PLUMBING -MECHANICAL
PERMIT NUMBER
6 V RR V 6
BUILDING
ADDRESS
O"N"'
PLAN CHECK VALIDATION
NAME 4 W��`r Jr`'-_" �G/rtVf
O 11>;.RL N PHONE
CITY. ELECTRIC PERMIT FEE
DATE OF APPLICATION
CONTRA ORS
NAME F�►coufrt' Pct" 0 0b
OUTLETS - SWITCHES -RECEP 5.00/1.00
LIGHTING FIXTURES 5.00/1.00
CONTRAAACCCTOR S •fix !' W O o
A� "-3BV(A.PHpryP'�0��•'QI
PPLIANCES- RESIDENTIAL 4.00
PANELS 5.00
ARCHi Ci I I9451•:(
OR
ENGINEER
LIC NO
SIGNS ELM
PLAN CHECK FEE P.C. NO,
SIGNS TRANS. 3.00 '
ADDRESS ENG'
SPECIAL CIRCUIT 5.00
PERMIT VALIDATION
EMP. METER OR POLE INS. 15.00
za,
0 '
APPLICANr's 24Ig0 PrIlKR.'VOn/ cT
ap
AOOR Ess OO r FI C _ 1
MOTORS SEE FEE SCH.
raftfIc dA
SERVICE CHANGE 10.00
LICENSED CONTRACTORS DECLARATION
I hereby alfrm that I am licensed under provisions of Chapter 9
(commencing with Section 7000) of Division 3 of the Business and
Professions Codc, and ley kunst is in frill force and effect
Class -G -J Lic. Numhcr
ISSUANCE DATE
BLDG. ELECT.
El ❑
PLG. I MECH.
11Liccnx
Uua _ Contractor
BUILDING PERMIT
' OWNER -BUILDER DIECLAI0N
I hereby uollo that I sat exempt from the Convactor'sfeicume
Law fortheity owl.greuon.(Sec.703so permit tocand Professions
Code: Any city or county which structure permit o its issuance, , also
improve, heUPPsh, or repair h p structure, prior to its issuance, also
that
requires the applicua for such permit It flu a signed Contractor's
heisapursuant ID the provisionsof the )cy Livisi s3ofthe
the
Lis (ChapterndProfessions
Professions Codc) or that he is exempt therefrom and
Cod with Section I, exempt the therefrom
INFORMATION
MISC.- REFER TO ORD
VALUATION
$/FT.
PERMIT ISSUANCE 6.00
ELEC. CONTR. LIC. NQ
TOTAL
TOTAL
PERMIT TO
CITY. PLUMBING PERMIT FEE
STORIES
TYPE CONSTR.
tare bass for Any violation of Section LS
the basis for the alleged exemption.
subjects en
hyjuany a,etita fora oodocrobjects th500).)cant toacivil penalty
of not more titan five hundmd dollen (5$00).):
ALTER-DRAIN-WATER(EA.)4.00
❑ I, as owner of the property, or my employees with wages as
their sole compensation, will do the work, and the structure is not
intended or offered for sale (Sec. 7044, Business and Professions
BACK FLOW PROTECT. DEVICE 2.00
OCC. GROUP
RES. UNITS
DRAINS-FLOORCRO� REA, M- ND. 4.00
Code The Contractor's License Law does not apply to an owner of
property will) builds Or Improves thereon, and who does such work
FIXTURES - PER TRAP 4.00t -w
sp. FT FLOOR AREA
TOTAL ACREAGE
himself or through his own employees. provided that such improve.
meals are not intended or offered for sale. If, however, the building
GAS - EA. SYSTEM -11 NC14b)TLETS 4.00 1 ig
or improvement is sold within one year of completion, the owner-
builder will have the burden of proving that he Aid not build or im-
prove for purpose of salcJ.
❑ I, as owner of the property, um exclusively contracting with
GAS - EA. SYSTEM - OVER 4 (EA.) 1.00
BUILDING USE
RES IND CON PB Omer
❑ ❑ ❑ ❑ ❑
INDUSTRIAL WASTE INTER. 20.00
LAWN SPRINKLERS- 1 INC 5 V.B. 5.00
LAWN SPRINKLERS - OVER 5 (EA.) 1.00
ASSESSORS PARCEL NO.
licensed contractors to construct the project (Sec. 7044, Business
and Professions Code: Pile Contractor's License Law docs not apply
to an owner of property who builds or improves thereon. and who
contracts for such projects with u contractor(s) liccroscdpursunnt to
the Contractor's License Law.
SEWER -SANITARY -STORM EA. 200ft/8.00 �
TRACT NO.
PARCEL NO.
O l amemanpt under Sec.-, B.&P.C. lin GIIS
rcason
�"-
WATER HEATER W/VENT 4.00
Owner Date
I WATER SYSTEM 4.00
ACCOATE
ACC, FILE NO.
WATER TREATING EQUIP. 4.00
WORKIERS'COMPIE NSA 'I]ON DECLARANI'[ON
1 hereby affrm that I have a certificate ofennum to self -i .... c.
Lir a certificate of Workers' Campensatiu. Insurance, or a certified
ZONING
ENG. SITE NO.
copy t�ircnf1'cc 3800, Iab.C�k-A tilO_
cPolicopyy `('E7 CoL"a"y .
❑ Cnliel )pyuse-1, Umished
y�ferlificd cc`is J 'N Ih oily inspcution Division.
)CpplCant ^"
T
FIRE SPRINK
Y ❑ N❑
ENERGY T 24
Y ❑ No
MISC.- REFER TO ORD.
CER TI PICA IT OF EXEMPTION FROM WORKERS'
PERMIT ISSUANCE 6.00 __
FLOOD ZONE
A.L.U.C.
PLG. CONTR. ❑C. O. p
b
N Q- 140s
PLG .
TOTAL I
COMPENSITION INSURANCE
I Ihis section need not be completed if the pervnit is for one
Y ❑ N❑
Y ❑ No
pp
O ECHANR`A'tPERM1T� FEE
FEE SUMMARY
hundred dol1ars($I00)or W,,f -
I certify that in the performance of the work for which this per-
issued, mit is I s1mll not employ any person in any aanner so its to
BUILDING
become olinen to the Workers' Compensation Laws of California.
Dmc Applicant
NOl'ICF TO APPLICANT: IC after making this Certificate of Es-
ALTER OR ADD TO MECH. 4.00
APPLIANCE 4.00
PLAN CHECK
enptito, you should became subject to the Workers' Compensation
provisions of the Labor Code, you must forthwith comply with
such provisions Lir this penuit shall be dcemed revoked:
FEE
AIR HANDLING UNIT (TO 10=C.F.M.) 3.00
AIR HANDLING UNIT(OVER 10pOQOEM.)5.00
SEISMIC FEE
CONSTRUCTION LENDING AGENCY
I hereby affrm that there is a construction lending agency for
EXHAUST HOOD (WITH DUCT) 2.00
the perfhrnnancec of 'thej _Work 1q,1r which this permit is issued (Sea
3097, Civ.C.).
MICROFILM
HEATING UNIT (TO 100,000 B.T.U.) 4.00
CW+'�{�TRIVILTIOt���l.�i�`•%IC
Lender's Name Va�
LcnAch Affdd,rers�,.y
HEATING UNIT MOVER 100,000 B.T.U.)7.50
ELECTRIC
I cer ti4t I B""aAtT!Fb;PIQUr1re-�f}e>�sfg hat the above
VENTILATION FAN (SINGLE) 3.00
infnrmabo rs corrcc . I aNryL to c�ugp�y wit�yit, n county
orAinuncrs sylCLLingWilS'uildingl asllht on, end
PLUMBING
BOILER-C)MP(3 H.P. or 100,000 B.T.U.) 4.00
BOILER -COMP 10ver 100,000 BTU) SEE FEE SCH.
MECHANICAL-'
hereby nuthnrwe sunatives of this city to enter upon the
above-mentioned property for inspection purposes.
MISC. - REFER TO ORD.
(we.) agree ,, tare, indemnify and keep Ilannless the City of
abilities, judgmame, costs and expenses which
Cupertino ug).y,
.nay in an e a against said City in consequence al the
CONST. TAX
PERMIT ISSUANCE 3.00grunting
of it
-':�
L
MECH. CONT. LIC. NO. MECH.
TOTAL
TOTAL
Sig at re of. pp ¢ant/Contractor Date
INSPECTOR COPY