C8446(;APPLICANT TO FILL IN INFORMATION WITHI
LINES - USE BALL POINT PEN ONLY
' BUILDING PROJECT IDENTIFICATION
11.1
APPLICATION & PERMIT
PERMIT NUMBER
BUILDING
ADDRESS
Torre Avenue. Cuperti
BUILDING - ELECTRICAL- PLUMBING -MECHANICAL10701
'
"..//8446
OWNER '$ ,/
fY� Ld9n/E' " (415)--....
,14
QTY. ELECTRIC PERMIT FEE
PLAN CHECK VALIDATION
_-_
ENAME
oMrRacroR's
UTLE TS =SWITCHES -RECEP 10.00/1.00
TTrTLIc. No��
LIGHTING FIXTURES 10.00/1.00
DATE OF APPLICATION
LONTRAcroR's
ADDRESS 1011 x~'(415)
Hamilton CUMONE
- PPLIANCES-RESIDENTIAL: 4.00
PANELS 10.00
ORRCHITEL Q 81 q4 V
ENGINEER
uC. No:"..v4
pgNELS (OVER 200 AMP(• 20.00
PLAN CHECK FEE P,C, N0.
SIGNS TRANS. 3.00
ARCH.
oo Ees ENG. ` • - -
- SPECIAL CIRCUIT 5,00
PERMIT VALIDATION
Ape AIMra�` 'ZIP
^--
EMP. METER OR POLE INS. 20.00
M
C
APPLI DDRESNrS - - -
ADDRESS [rjIiCi '
- • MOTORS SEE FEE SCH. ".
SERVICECHANGE 20.00
J
%
Q�7 4
LICENSED CONTRACTORS DECLARATION' -
TEMP. POLE 30.00 :i
I hereby affirm that I am licensed under provisions of Chapter 9'
(comnteac ng with Section 7000) of Division 3 of the Business and
Professions Code, and my license is in full force and effect. N
License Class B Li,. umber aWg
Date Contractor
ISSUANCE DATE
BLDG.
El
ELECT.
O
PLG. MECH.
❑ ❑
�R-BUILDER DECLARATION-- -, ....
License
I hereby affirm that I am exempt from the Contractor's and
Law for the following reason. (Sec 7031.5, Busiilessand Professions
ns
Code: Any city orcounty which requires a permijtoconsuanc idler,
improve, demolish, or repair any structure, prior to its issuance, also
requires the applicant for such permit to file a signed statement that
he is licensed pursuant to the provisions of the Contractors License
Law (Chapter 9(commencing with Section 7000] of Division 3 of the'
Business and Professions Code) or that he is exempt therefrom and
`
BUILDING PERMIT
INFORMATION
MISC.- REFER TO ORD
PERMIT ISSUANCE 10.00
VALUATION
ey OOr„
QC V
$/FT.
ELEC. CONED. LIC. NO. ELEC.
TOTALPERMIT
QTY. PLUMBING PERMIT FEE
TO
A/%,YCC /�C% LAG e__
the basis for the alleged exemption. Any violation of$ection 7031.5
by any applicant for a permit subjects the applicant to a civil penalty
of not more than five hundred dollars ($500).):
STORIES
TYPE CONSTR.
ALTER -DRAIN -WATER IEA.) 5.00
❑ I, as owner of the property, or my employees with wages as
their sole compensation, will do the work, and the structure is not
BACK FLOW PROTECT. DEVICE 4.00
OCC. GROUP
RES. UNITS
DRAINS -FLOOR, ROOF, AREA, COND. 5.00
intended or offered for sale (Sea 7044, Business and Professions
Code: The Contractor's License Law docs not apply to an owner of
'
FIXTURES - PER TRAP 5.00
GAS - EA. SYSTEM -11 NC.4 OUTLETS 6.00
SO. FT. FLOOR AREA
TOTALACREAGE
properly who builds or improves thereon, and who does such work
himself or through his own employees, provided that such improve.
mems are not intended or offered for sale If, however, the building
or improvement is sold within one year of completion, the owner-
builder will have the burden of proving that he did not build or int-
GAS - EA. SYSTEM - OVER 4 IEA.) 2.00
BUILDING USE
prove for purpose of sale.).
:(3, 1, as owner of the property, am exclusively' contracting with
RES IND CON PB other
INDUSTRIAL WASTE INTER. 30.00
licensed contractors to construct the project (Sec. 7044, BusinessLAWN
and Professions Code: The Contractor's License Law does not apply
to an owner of property who builds orimproves thereon, and who
SPRINKLER$ - 1 INC 5 V.B. 6.00
LAWN SPRINKLERS - OVER 5 (EA.) 1.00
ASSESSORS PARCEL NO.
contracts forsuch projectswitli acontraclons) licensed pursuant to
the Contractor's License Law.
SEWER -SANITARY -STORM EA. 200ft/10.00
TRACT NO. r
PARCEL NO.
O. I am exempt under Sea ,B.&PC. for this
reason
WATER HEATER W/VENT 6.00
Owner Date
WATER SYSTEM - 5.00
Ace. DATE
ACC FILE NO.
WORKERS'COAIPEHSATION DECLARATION
WATER TREATING EQUIP. 5.00
'
1 hereby affirm that I have a certificate of consent to self -insure.
or a certificate of Workers' Compensation Insurance, or a certified
ZONING
ENG. SITE N0.
copy thereof (Sea. 3800, Lab.C.). Republic lndemni
Policy No.$�7@�fq�fq mpany
❑ Cert IH•9i fopyi bmreb'fm any, p�D
❑ Certified ropy is filed with the cul ...Oclionweis=ioi:
Applicant-%It'•I�
'
,
FIRE BPRINK�
Y N O
ENERGY T -Z4
V N
❑
MISC.- - •-- - REFER TO ORD.
CERTIFICA :01' EXESIPTION FROM WORKERS'
PERMIT ISSUANCE 10.00
PL000 ZONE
A.L. u.c.
COMPENSATION INSURANCE
(This section need not be completed if the permit is for one
I NE]
PLG.CONTR. LIC. NO.
PLG,
TOTAL
Iwndred dollars IS 100) or less.)
I certhy 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
QTY. MECHANICAL PERMIT FEE
FEE SUMMARY
BUILDING
17o Sv
become subject to the Workeri Compensation Laws of California.
Date Applicant
NOTICE TO APPLICANT: If, after making this Certificate of 1!x-
ALTER OR ADD TO MECH. 5.00
APPLIANCE 5.00
AIR HANDLING UNIT (TO 10;MCF.M.) 4.00
PLAN CHECK
FEE
i
emption, you should become subject to the Workers' Compensation
provisions of the Labor Code, you most forthwith comply with
such prove -cions or this permit shall be deemed revoked.
AIR HANDLING UNIT IOVER10,000CEM.) 6.00
SEISMIC FEE
74'
I 1 CONSTRUCTION LENDING AGENCY
1 hereby, affirm that there is a construction lending agency for
EXHAUST HOOD (WITH DUCT) 5.00
the performance of the work for which this permit is issued (Sec.
3097, Civ.0). �S. MQit
MICROFILM
'
HEATING UNIT (TO 100,000 B.T.U.) 8.00
Lender's Name gag@
Lender's Address "-'� -`- - -
HEATING UNIT (OVER 100,000 B.T.U.)9.50
ELECTRIC
I certify that lhaa'yypp��cad this apppcaNun an I,Atc I� �u�o
VENTILATION FAN (SINGLE) 4.00
information isjcarrlUU.rMie�to ply with all city and county
ordinances and�'state laws relating to building construction, and
PLUMBING
BOILER-COMP(3 H.P. or 100,0008.T.U.) 6.00
hereby authorise representatives of this city to enter upon the
above-mentioned property for inspection purposes.
BOILER -COMP (Over 100,000BTUISEE FEESCH.
MECHANICAL
(We) agree to save, indemnify and keep harmless the City of
MISC. - REFER TO ORD.
Cupertino against liabilities, judgments, costs and expenses which
may in any way accrue against said City in consequence of the
granting Of lhslpe`mit.
Si r p t/Co sac r
PERMIT ISSUANCE 10.00
CONST. TAX
MECH. CONT. LIC. NO.
TOTAL
TOTAL
;
INSPECTOR COPY