6202Il ;APPLICANT TO FILL IN INFORMATION WITHIN RED LINES —USE BALL POINT PEN ONLY
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BUILDING PROJECT IDENTIFICATION
APPLICATION & PERMIT
BUILDING — ELECTRICAL—PLUMBING —MECHANICAL
PERMIT NUMBER
/h�
V O Z'
BUILDING
arrRlss
OWNER'S
NAME
la&j PMNRK PHONE
QTY. ELECTRIC PERMIT FEE
PLAN CHECK VALIDATION
pa®
[�
JUN 7 1905
CONTRACTORS
NAME
I OUTLETS -SWITCHES 5.00/1.00
LIGHTING FIXTURES 5.00/1.00
m. NO. afold
I „ _
rt
CONTRACTORS
ADDRESS
PPLIANCES- RESIDENTIAL 4.00
PANELS 5.00
OLu v ILII ,1AUTION
�/ �N
ON I� 90001119ION
ARCHITECT
OR
ENGINEER
LIC, NO.
SIGNS 6•,DD
PLAN CHECK FEE
C
SIGNS TRANS. 3.00
ARCH. OR ENG,
ADDRESS
SPECIALCIRCUIT 5,00 V
PERMIT VALIDATION
EMP. METER OR POLE INS. 15.00
• ZIv
APPLICANTS
ADDREES
MOTORS SEE FEE SCH.
SERVICE CHANGE 10.00
LICENSED CON-1'RACfORS DECLARATION
I hereby af6nn that I len licensed under provisions of Chapter 9
ISSUANCE DATE
(co mmincing with Section 7000) of Division 3 of the BC,iocV, and
I'mfix,ro s Code, nd y license is in Cull force' oil cll'c A.
Licenu�Class Lic. Numbe
Ua¢ Contractor
Taclm
BLDG.
❑
ELECT.
PLG. MECH.
❑ ❑
BUILDING PERMIT
OWNER -BUILDER ECLARA'1'ION
I
I hereby affirm 1 am exempt from the Contractor's License
Law for tire following reason. (Sec. 7031.5. Business and ProfessionsVALUATION
Code: Any city or county which structure permit Totoi suance, also
improve, demolish, or repair any structure, prior to its issuance, also
routines the applicant for such permit to file a signed statement that
he is licenwd pursuant to the provisions of the Contractor's License
INFORMATION
MISC. — REFER TO ORD
§/FT.
PERMIT ISSUANCE 6.00 Ip, do
ELEC. CONTR. LIC. NO_y
IJ
ELEC. $$�.F-( to
TOTAL 7( W lr '
PERMIT TO
OTY. PLUMBING PERMIT FEE
Law (Chapter 9 (commencing with Section 7000) of Division 3 (it tile
Business and Professions Code) or that he is exempt therefrom and
STORIES
TYPE CONSTR.
the basis for the alleged exemption. Any violation of5ection 7031.5
by any applicantfor a permit subjects the applicant to acivil penalty
of not more than five hundred dollars(S500).):
ALTER-DRAIN & VENT -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
BACK FLOW PROTECT. DEVICE 2.00
OCC. GROUP
RES. UNITS
DRAINS -FLOOR, ROOF, AR EA, COND. 4.00
intended or offered for sale (Sec. 7044, Business and Professions
"
Code: "f he Contractor's Lecose Law docs not apply to un owner of
property who builds or improves thereon, and who docs such work
'
f FIXTURES - PER TRAP 4.00
SQ. FT. FLOOR AREA
TOTAL ACREAGE
himself or through his own employees. provided that such improve-
cents are not intended or offered l'or Sale. I L however, the building
7:
GAS - EA. SYSTEM -1 INC.4 OUTLETS 4.00
or improvement is sold within one year of completion, lire owner'
builder will have the burden of proving that he did not build mint-
prove for purpose of sale.).
❑ I, as owner of the property, am exclusively contracting with
. ..
GAS - EASYSTEM -OVER 4 IEA) 100
BUILDING USE
RES IND CON PB Other
❑ ❑ ❑ ❑ ❑
INDUSTRIAL WASTE INTER. 20.00
LAWN SPRINKLERS - 1 INC 5 V.B. 5.00
LAWN SPR IN KLERS - OVER 5(EA.) 1,00
ASSESSORS PARCEL NO.
,
licensed contractors to construct 0e project (Sec, 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
contracts for such projects with a contraclons) licensed pursuant to
the Contractor's License Lew,
SEWER -SANITARY -STORM EA. 200ft/8.00
TRACT NO,
PARCEL NO.
❑ l len exempt under Sec.—. BAP.C. ]or this
reason
WATER HEATER W/VENT 4.00
Owner Dam
WATER SYSTEM 4.00
ACC.OATE
ACC. FILE NO.
WATER TREATING EQUIP. 4.00
WORKERS'COMPENSA'I ION DECLARATION
I hereby off nn that I have a ceDificale of consent to self -insure.
a certificate of Workers Compensation Insurance, lir a certified
ZONING
ENG. SITE NO.
copy thereof (Sec. 3800, I,ah.C.I
Policy No CHIT .any
❑ CertlNedcopyisherebyfurnished. (,pt. Pesti
wL'l'rl lf' Yl y LS pled With Ille city aspect diViSif)Il.
Applicant �Qf..{
CER '1'IFICA'I'E OP EXEMPTION FROM W'ORAI:RS•
FIRE SPR INK
Y❑ N❑
ENERGY T 24
Y❑ N❑
MISC.- REFER TO ORD.
PERMIT ISSUANCE 6.00
FLOODZONE
A.L.UC.
PLG.CONTR. LIC. NO.
PLG,
TOTAL
COh1PIiNSAT10N INSURANCE
r of
(I his section need not be completed if the permit is foe
Y ❑ N❑
I Y F] NE],
OTV. MECHANICAL PERMIT FEE
FEE SUMMARY
handled della,, is 100) or less.)
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 sous to
BUILDING
hccome subject it, the Werkera' C to flat 1 I.aw • f G it in
Date 7�- 51Appliea '�� '�r' jy �
"f0
ALTER OR ADD TO MECH. 4.00
NOTICE APPLICANT: f; ma cg lis Curti I o I:x-
emption, you should become subject to the Workers'Compensation
APPLIANCE 4.00
PLAN CHECK
provisions of the Lahor Cede, Yoa must forthwith comply will,
such provisions or this permit shall be deemed revoked
AIR HANDLING UNIT (TO 10=11F.M.) 3.00
FEE
AIR HANDLING UNIT (OVER 10=C.F.M-)5.00
SEISMIC FEE
CONSTRUCT ION LENDING AG17NCY
I hereby Air ty thm there is u Construetlmt lending uscucy for
EXHAUST HOOD (WITH DUCT) 2.00
the periomance of the work for which this permit is issued (Sec
3097, Civ.C.l.
MICROFILM
HEATING UNIT IT 100,000 B.T.U.) 4.00
HEATING UNIT (OVER 100,000 B.T.U.)7.50
ELECTRIC
N
Lender's Name
Lender's AddrName
I certify that I have read this application and state that lite above
information is correct. I agree to comply with all city and county
ordinances and stale laws relating to building construction, amt
VENTILATION FAN (SINGLE) 3.00
PLUMBING
.
BOILER (3 H.P. o, 100,000 B.T.lI.) 4.00
BOILER -COMP (Over 100.000BTU)SEEFEESCH.
MECHANICAL
hereby mohoritc representatives of this city to enter upon the
hereby
above-mentioned property for inspection purposes.
MISC.- REFER TO ORD.
(We) agree to leve, indemnify and keep harmless the City of
Cupertino against liabilities, judgments costs and expanses which
may in tiny way accrue against said City in consequence of the
CONST. TAX
PERMIT ISSUANCE 3.00
MECH. CONT. LIC. NO. MECH.
grantirt off permit.
-
TOTAL
TOTAL
Ignaturc of Contractor Dae
INSPECTOR COPY