4440APPLICANT TO FILL IN INFORMATION WITHIN REDLINES -USE, BALL POINT PEN ONLY
BUILDING PROJECT IDENTIFICATION
APPLICATION $L PERMIT
"AoDG-ELECTRICAL- PLUMBING - MECHANICAL
PERMIT NUMBER
.4440
CHECK VALIDATION
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7
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/ /7//J
DATE OF APPLICATION
BUILDING
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Gw ER'S IPLAN
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L PRo"E ) �a i !
QTY. ELECTRIC PERMIT FEE
coV ACTons
N M (,
.t%�t{�v
OUTLETS - SWITCHES -RECEP 5.00/1.00
`OU
Q` LIGHTING FIXTURES 5.00/1:00 V
CONTRACTORS (�[//'/' (q/
AI�REs •' llplrJ r dW
PHONE
APPLIANCES -RESIDENTIAL 4.00
PANELS 5.00
AnCIPPIELI -
OR
ENGINEER
uL. NO.
SIGNS 6.00
PLAN CHECK FEE P.C. NO.
SIGNS TRANS. 3.00
AARCI-I OR
DDRESS ENG.
SPECIAL CIRCUIT 5.00
PERMIT VALIDATION
TEMP.METER OR POLE INS.
zip
APPLICANTS ,
aooEss
MOTORS SEE FEE SCH.
SERVICE CHANGE PAIDO.00
LICENSED CONTRACTORS DECLARATION
`
herebyaffirm that 1 am licensed under rovisicd, of Chapter 9
p P
(commencing with Section 7000) of Division 3 of the Business and
Profevi.ns Codc. d y Erensc is in full Ibr- an cffe
License CP ss Li,Cu,=er
Date _ Conlndor
t.
-ISSUANCE DATE
BLDG. ELECT. PLG. MECH.
❑ ❑ - ❑' ❑
/�
City Of Cupertino
PERMIT,
OWNER -BUILDER DEC�AT N'
I hereby affirm that 1 am exempt from the Contractor' License
Law for the following reason, (Sec 7031.5, Business and Professions
'ode.Any city r county which requires a permit 1. e.ns;met alter
Improve, demolish or repair any structure, prior to its
niss n e, also
requires the applicant for such pernot to file a signed d st ;e nen; that
he Is licensed pursuant to the provisions of the Contractor's License
INFORMATION
MISC.- '- REFER TO ORD
PERMIT ISSUANCE 6.00 O`
4L OAT1[DNI (�/1,T
CeeU.JJ1,, h11, !I
gfFT.
ELEELEC.CONTR_ LIC. NO.
-
ELEC. (� p
TOTAL duIcy
01
py' ,
QTY. j qk4 PLUMBING PERMIT - FEE
f`^'
Law (Chapter 9(commencing with Section 7000) of Di ision 3 of
Business and Profession, Code) or that he is exempt th refrotn and
the basis for the alleged exemption. Any violationf5 ction 703 L5`
�/7_/0
STORIES
TYPE CONSTR.
by any applicant for a permit sabjectsthc applicant;. a civil penalty
offer more than five hundred dollars ($500).):
'
ALTER -DRAIN & VENT -WATER (EA.)'4.00
❑' L as owner of the property, or my employees with wages as
their sole compensation, will do the work, and the ,structure is not
BACK FLOW PROTECT. DEVICE 2.00
OCC GROUP
RES. UNITS
DRAINS-FLOOR,ROOF, AREA, COND. 4.00
intended or offered for sale (Sea 7044, Business and Professions
Code: The Contractor's License Law does not apply to an owner of
property who builds or improves,thereon, and who does gvFwork
himself or through his own employees, provided that such improve
ments are not intended or offered lot saleif, however, the building
FIXTURES - PER TRAP 4.00
s0. IT. FLOOR AREA
TOTAL ACREAGE
GAS - EA. SYSTEM -1 INC.4 OUTLETS 4.00
or improvement is sold within one yepr of completion,'tlte owner-
builder will have the burden of proving that he did not build or m-
prove for purpose of sale.).
❑ 1. as owner of the property, am esalusively contracting wit
GAS
GAS -EA. SYSTEM -OVER 4 IEA.) 1.00
BUILDING USE
.IND CON PB , .Oros.
❑ - ❑ ❑ ❑, ❑
INDUSTR IAL WASTEINTER: 20.00
licensed contractors to construct the Project (Sec. 7044, Business
end Professions Code: The Contractor's License Lav docs net apply
to amowner of property who builds or improves thereon, and who
LAWN SPRINKLERS- 1 INC 5 V.B. 5.00
ASSESSORS PARCEL NO.
LAWN SPR_ INKLERS_- OVER 5 (EA.) '1.00
contracts for such projects with contracteds) licensed pursuant to
the Contractors License Law.-
SEWER -SANITARY -STORM EA. 200ft/8.00
TRACT NO.
PARCEL NO.
❑ I am exempt under Sec • lBAP.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 E RS'COMPENSATioN DECLARATION -
1 hereby affirm that I have a certificate of consent m selfinone,
or a'certificate of Workers' Compensation Insurance, or a certified
ZONING
ENG. SITE NO.
ompb.C.1./E.��I �ll
copy [hereof [Sec_ Company.
Policy e,e C n Peny Y�1�/S� Y
.
-
FIRE SPRINK
Y ❑ . N❑_
ENERGY.T-2G
YE] N❑
g^Certified copy shembyfun tyY/d
L'i Certififd Copy -s,fil wt Ui/th city :peUion division.'
Appliemtt V
MISC. - REFER TO ORD.
CER IFICA.FE OF EXEMPTION FROM WORKERS'
PERMIT ISSUANCE 6.00
ELo00 ZONE
A:L.U. C.
PLG. COSTS. LIC. NO,
10iAL
COMPENSATION INSURANCE
not be ed if the pennh is for one
(This section need complet
Y❑ N❑
-Y E] N❑
QTY. MECHANICAL PERMIT FEE
_
FEE SUMMARY
hundred dollars (5100) or lessJ
I certify that in the performance of the work for which this per-
mit is issued, I shall not employ any person in any manner so as to
BUILDING
l
SK S
become subject 1. the Workers' Compensation Laws of California.
Date Applicant
NOTICE TO APPLICANT: If, after making this Certificate of F:x-
ALTER OR ADD TO A� 4.00 QB
APPLIANCE 4.00
PLAN CHECK
cmption, you should become subject to the Workers'Compensa;ion
provisions of the Labor Code, you must forthwith comply with
such provisions or this Permit shall be deemed revoked.'
FEE
AIR HANDLING
AIRHANDLING
IT(OVER 10,000C.F.M.) 5.00
SEISMIC FEE
%.rr
CONSTRUCTION LENDING AGENCY -
' 1 hereby affirm that there is a construction lending agency for
the performance of the work for which this permit is issued (Sec.
3097, Civ.C.). -
Lender's Adds Namress e
Lender'
EXHAUST HOO g4f 100 2.00
MICROFILM
UNIT (TO
HEATING 100,000 B.T.U.) 4-00
HEAT I NG UN IT (OV E R 100,000 B.T.U.)7.50
ELECTRIC
Af
VENTILATION FAN (SINGLE) 3.00
PLUMBING
'
-
Lernify that l have read this application and slam thin the shove
information is Correct. 1 agree to wmply with all city and county
ordin'tell and state laws relating to building construction, and
-
BOILER-COMPI3 H.R cr100,000B.T.U.) 4.00
BOILER -COMP (Over 100,000 BTU) SEE FEE SCH.
MECHANICAL
hereby authori/e representatives of this city to cn ter upon the
above-mentioned property for inspection purposes. .- .
MISC. - REFER TO ORD.
CONST. TAX
OV agree to save, indemnify and keep harmless the City of
Caped io agai s; Late tries, judgments, costs and expenses which
may i any y ac e against said -City in consequence of the
gr*ti g of ibi Pani .
PERMIT ISSUANCE 3.00
MECHICONT. LIC. NO.
MECH.
TOTAL 06
TOTAL
'
%9 a
Si urc 616Applicant/Contractor Date ,.
L. OFFICE COPY -
CITY OF CUPERTINO INSPECTION RECORD
(OFFICE COPY)
4440 10730 LaRoda
•PERMIT NO. ADDRESS
Addition La Pointe
PROJECr OWNER
Power Pole
ELECTRICAL DATE JINSP.'
DATE I INSP.
ELECTRICAL DATE (INSP.
Underfloor S.M.
/A"S0 4 TO 1 8 C
BUILDING
MISCELLANEOUS