7223APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL-POINT PEN ONLY
BU LDI NG PROJECT IDENTIFICATION
APPLICATION & PERMIT
BUILDING - ELECTRICAL- PLUMBING - MECHANICAL
PERMIT NUMBER
722'3
BUILDING
ADDRESs�99C 9 ,� /1
YL t�/2 T/?�� C,. �'
OWNER'S
NAME/ 106 Rt PHONE 3-//9
�
TV. ELECTRIC PERMIT FEE
PLAN CHECK VALIDATION ,
-
CONTRACTORS q
T` &i} /ate ,C. NO, JJQ4U9a
OUTLETS - SWITCHES -RECEP 5.00/1.00
LIGHTING FIXTURES 5-00/1.00
CONTRACTORS e�,U EsrilV� S! ••
ADOR Ess CJ
APPLIANCES - RESIDENTIAL 4.00
PANELS 5.00
/�I�
PHONE O/�//�S /u!r
DATE OF APPLICATION'•
ARCHITECTr
OR
SIGNS b-.QQ
PLAN CHECK FEE P.C'NO.
ENGINEER
uc. No,
SIGNS TRANS. 3.00
ARCH. OR
ESS END -
SPECIALCIRCUIT S.00
PERMIT VALIDATION
EMP. METER OR POLE INS. 15.00
ZIP
APPLICANT s.
ADDDRESSDRESSMOTORS
SEE FEE SCH`.
SERVICE CHANGE 10.00_
F_
LICENSED CONTRACTORS DECLARATION
4�:I�
- d T
~,
.ih. aL--..:+a:r,-T..r., ., ;, M Vis.--
I hereby affirm that I am licensed under provisions of Chapter, 9
(cammenemgrw flit Suction 7000) of Dhbl:mn 3 f the Business and
.professions th- Q.p •aicenscslifYtll Yorce,In f L •2RA:
License I i. - L Nuftt, .`
Dan Contractor _
OWNER -BUILDER DECLARATION
I hereby affirm Ihot I am exempt from the Contractor's License
Law for the fallowingneason.(Sec. 7031.5. BusinessanJ Professions
Code: Any city or County which requires a permit to construct, alter,
Improve, demolish, or repair any structure, prior ID Its Issuance. also
requires the applicant for melt permit t0 file a signed statement that
he is licensed pursuant to the provisions of the Contractor's License'
Law (Chapter 9 (commencing with Section 7000) of Division 3 of the
Business and Professions Code) or that he is exempt therefrom and
ISSUANCE DATE
BLDG ELECT. PLG. MECH.,
.•r-�' -.❑-
p ye p -
ty`
4
BUILDING PERMIT
INFORMATION
MISC.- REFER TO ORD
PERMIT ISSUANCE 6.00
vALUAT1oN
S/FT.
ELEC. CONTR. LIC. NO.
CLEC.
TOTAL
PERMIT TO
/�� "`---III ��,
QTY. PLUMBING PERMIT FEE
STORIES
TYPE CONSTR.
the basis for the alleged exemption. Any violation of Section 7031.5
by any applicant for a permit subjects the applicant to a civil penalty
of not more than five hundred dollars (8500).):
ALTER-DRAIN&VENT-WATER (EA.)4.00
❑ 1, as owner of the property, or my employees with wugcs as
their sole compensation, will do the work, and the structure is not
BACK FLOW PROTECT. DEVICE 2.00
OCG GROUP
RES. UNITS
DRAINS -FLOOR, ROOF, AR EA, COND. 4.00
intended or offered for sale (Sec. 7044, Business and Proessions
Code: The Contractor's License Law does not apply to an owner of
property who builds or improves thereon, and who does such work
himself or through his own employees, provided that such improve.
ments are not intended oro(fered for sale. If, however, the building
FIXTURES - PER TRAP 4.00
SD: FT: FLOOR AREA
TOTAL ACREAGE
,
GAS - EA. SYSTEM -1INC. 4 OUTLETS 4.00
or improvement is sold within one year of completion, the owner-
builder will have the burden of proving that 1e did not hi ild or im
prove for purpose of sale.).
❑ 1, as o her of the property, am excursively contracting with
GAS - EA. SYSTEM -OVER 4 IEA.1 1.00
BUILDING USE
RES IND CON PB Other
❑ ❑ ❑ 113 ❑
INDUSTRIAL WASTE INTER. 20.00
licensed contractors to construct the project (See'"7044, Business
and Professions Code: 1'he Cont rachor's License haw does not apply
to a.I owner of property who huilds or,inhproves Ilmrcon, and who
LAWN SPRINKLERS- 1 INC 5 V.B. 5.00
'LAWN SPRINKLERS- 'OVER 5 IEA.) 1.00
ASSESSORS PARCEL NO. -
cantracis 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.
❑ lam axempt under Sec. ,It.&I'.C. titer this
Ra\DIl
WATER HEATER W/VENTIt' ^.•N4.00
Owner Date
WATER SYSTEMt 4.RQQ
) • � ACC. DATE"
ACG FILE NO.,
_
WATER TREATING EQUIP. ,4.00
WORKERS'COMPENSA'I' ION DECLARATION
T hereby affirm lhm l have a c 'Idirtne of consent o"elf-insure•,
or a certificate of Workers' Con pensalion InSL ranee, or a cerldied
copy there�ISec ij{00 1 1 C.1.
rI.
ZONING
ENG. SITE NO:
}�
I'olicy.NwJ//L C man,' A1TEfi7iJ21St.
h mhy lmry Yh •d.
❑ Cert fie o Irl.".
L✓CerW d co�}�• filed (vit�h� ten�i�t,yAs m�pcchon division.
Applicant �l«1�l - aY�f_ic-1
,: - ..' ... ... _-
1.-' Lam/
l
's, - (
FIRE SPRINK
_ Y❑ N❑
ENERGY 4
Y❑ N❑
MISC.- REFER TO ORD
C17RI'IFICA'1'17 OF EXEMPTION FROM WORKERS'
PERMIT ISSUANCE 6.00
FLOOD ZONE
A.L.0 c.
PLG. CONTR. LIC. NO.
_
PLG.
TOTAL
COMPENSA'I ION INSURANCE
frhis wcomo need not be completed if the permit is for ane
Y ❑ N❑
Y ❑ N❑'
-n'
hundred dollars (S 100) or less.)
I certify that in the performance of the work for which this per-
mit is issued, I shall not cmpluy any person in any manner so as to
QTY. MECHANICAL PERMIT FEE
FEE SUMMARY
BUILDING
become) stibiect to the Workl•IY Compensation Laws of Calllornha.
Date Applicunt
NOTICE TO APPLICANTif. after making this Certificate of Ex.
ALTER OR ADD TO MECH. 4.00
APPLIANCE 4.00
PLAN CHECK
emption, you should became subject to the Workeri Compensation
provisions of the Labor Code, Yue mull forthwith Cum ply with
such provisions or this permit shall be deemed revoked.
FEE
AIR HANDLING UNIT (TO 10=CF.NL) 3.00
AIR HANDLING UNIT(OVER I0O00CEM.)5.00
SEISMIC FEE
CONST' RUCI' ION LENDING AGENCY
I 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, Civ.CJ,
MICROFILM
'
HEATING UNIT (TO 100,000 B.T.U.) 4.00
H EATI N G UN IT (OVER 100,000 B.T.U. )7.50
ELECTRIC
Lender's Name
Lenders Address
I certify that 1 have read this application and state that the above
VENTILATION FAN (SINGLE) 3.00
,
information is correct. 1 agree To comply with all city and county
ordinances and state laws relating m building construction, and
PLUMBING
BOILER-COMP(3 H.P. or 100,000 B.T.U.) 4.00
BOILER -COMP (Over 100,000 BTU) BEE FEE $DH.
MECHANICAL
hereby authorize representatives of this city to enter upon the
above-mentioned property for inspection purposes.
MISC. - REFER TO ORD.
(We) agree to save, indemnify and keep harmless the City of
Cupertino against liabilities, judgments, costs and expenses which
may in any way accrue ainsI said City in consequence of the
gra lh permit
CONST. TAX
'
PERMIT ISSUANCE 3.00," ,
MECH. CONT. •. LIC. N0. MECH.
16ogWf
\\r'f �l-�-gam
4*)V )c9rA4 0� 1 TOTAL
/,
TOTAL
7,00
Signature ofA licant Contractor Date
INSPECTOR COPY J