C8447ICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT P, N ONLY
t BUI LDI NG PROJECT 1 DENTI FICATION
F -
APPLICATION &PERMIT
PERMIT NUMBER
ADDRESG
ADDRESS
BUILDING -ELECTRICAL-PLUMBING -MECHANICAL
Wce R s
"AME .S1e,,t,_+-(415) 571-2200
_
-
QTY. ELECTRIC PERMIT FEE
PLAN CHECK VALIDATION
AE croR$ '
OUTLETS-SWITCHES-RECEP 10.00/1.00
LIGHTING FIXTURES 10.00/1.00
LIC.NO.
CONTRACTORS
ADDRESS (415) 328-0851
APPLIANCES -RESIDENTIAL 4.00
PANELS 10.00
CA
DATE OF APPLICATION
ARCHITECT
OR
ENGINEER
LIC.NO.
PANELS (OVER 200 AMP) 20.00
PLAN CHECK FEE P.C. NO.
SIGNS TRANS. 3.00
ARC" OREND '
94025
SPECIAL CIRCUIT - 5.00
PERMIT VALIDATION
EMP. METER OR POLE INS. 20.00
1011 HAvirilton Clio, Mill pimt� CA
APPLICANT 'S
ADDDRESSDRESS
MOTORS SEE FEE SCH.
SERVICE CHANGE 20.00
1011 EIM01111i rt,iii Menlo Park, CA
4-
?Ycn�s
LICENSED CONTRACTORS DECLARATION
ITEMP. POLE 30.00
I hereby affirm that 1 am licensed under provisions of Chapter 9
(commencing with Section 7000) of Division 3 of the Business and
Professions Code, and my license is in full force and effect.
License Class B Lic. Number -377-579❑
DateContractor j�jT-
-•-
BLDG.
ELECT.
PLG. MECH.
❑
.... .. _
s BUILDING PERMIT
OWNER -BUILDER DECLA RA'RTvi - -
1 hereby affirm that I am exempt from the Contract ods License
Law for the following reason. ch(Sec. aitocnd Professions
requires
Code: Any mu ley whiny structure permit riot o is i smart'", also
improve, demolish,applicant
Or reran any permit
requires tireedpplleant tt SUCK permit 10 IIIc J signed actor's Li lyse
toa sign Its latement that
he
he is licensed pursuant en the with provisions of the Contractor's License
7000)of Division3 and
Busi(Chapter9(commencingwi with that therefrom end
BusinessandProfessionsxempton that veil tion
INFORMATION.
MISC.- REFER TO ORD
VALUATION
UV's
5/FT.
PERMIT ISSUANCE 10.00
ELEC CONTR. LIC NO.
ELEC.
TOTAL
PERMIT TO
�N7' �cMOD@L
DTV. PLUMBING PERMIT FEE
STORIES
TYPE CONSTR.
the of
the basis for the alleged exemption. Any
oto
action malty
by of payP the fora permit subjects the 0).). ant toe civil penalty
applicant
of not more than rive hundred dnllrrs (55001.1:
ALTER -DRAIN VENT -WATER IEA.) 5.00
❑ 1, as owner of the property, or my employees with wages as
their role'compensulion, 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 (Sec. 7044, Business and Professions
Code: The Contractor's License Law coconut apply to an owner of
property who builds or improves thereon, and who docs such work
himself or through his own employees, provided that such improve
ments are not intended or offered lot sale. If, however, the building
FIXTURES - PER TRAP 5.00
$o. FT. FLOOR AREA
TOTAL ACREAGE
GAS - EA. SYSTEM -1 INC.4 OUTLETS 6.00
or improvement is sold within one year of completion, the owner-
builder will have the burden of proving that h e did not build or he.
prove for purpose ofsale.).
❑ 1, as owner of the property, am exclusively contracting with
- . -..
GAS EASYSTEM OVER 4 (EA) 200
BUILDING USE
RES IND CDN PB Other
❑ ❑ ❑ ❑ ❑
INDUSTRIAL WASTE INTER. 30.00
licensed contractors to construct the project (Sec. 7044, Business
and Professions Code:'I'hc Contractor's License Law Jots not apply
to un owner of property who builds or improves thereon, and who
-pursuant
LAWN SPRINKLERS - 1 INC 5 V.B. 6.00
ASSESSORS PARCEL NO- -
LAWN SPRINKLERS - OVER 5 (EA.) •1.00
contracts for such projects with a contractor(s) licensed In
the Contractor's License haw.
SEWER -SANITARY -STORM EA. 200ft/10.00
TRACT NO.
PARCEL NO.
I um exempt tinder Sec.A_, It.&RC. for this
arson
WATER HEATER W/VENT _6.00
Owner Date
WATER SYSTEM 5.00
ACC.DATE
ACC FILE NO.
- WATER TREATING EQUIP. 5.00
WORKBRS'COMP¢NSA'r1ON DECLARATwN
hemby affirm Thal I have a cerlificaw ofconsent to nc1f-inmra'
or a Certificate of Workers' Co{p{��nsut l'} [Ilsurance, ,, a ,rt II "I
copy thereof (Sec. 3800, Lab.CLCCpuD l�Q hidemnit
ZONING
ENG. SITE NO.
Policy No unit Gt , m,y}r� _�E_
O Cert p R l,c] with th Vf LYYei' C$
O Certified ropy is Illcd with the only inspect on Jivision:
Applicant �1j�._'.Y_J,�_(,t __
FIRE SPRINK
v❑ N❑
ENERGY L}4
) Y❑ N❑
MISC.- REFER TO ORD.
CftRT'ICA'I ' P :XEh1 PT ONF 1 I'It(lM WORKERS'
PERMIT ISSUANCE 10.00
FLOOD ZONE
A.L.U.C.
PLG.CONTR. LIC. NO.
PLG.
TOTAL
COMPENSATION INSURANCE
(This section need not be completed if the permit is list line
YE] N❑
v❑ N❑
Hundred dollars IS 100) or le,,)
I certify that in the performance of the work for which this per-
mit is issued, I shall not employ any person in nny manner so as to
OTY. MECHANICAL PERMIT FEE
FEE SUMMARY
BUILDING
a
become subject to the Workers' Campensat ion Laws of California.
Date Applicant
ALTER OR ADD TO MECH. 5.00
NOTICE TO APPLCAN 1': If, after making this Certificate of Ex-
anlotion, you should become subject to the Workers'Conepen,Wiop
APPLIANCE 5.00
PLAN CHECK
provisions of the Labor Code, you must forthwith comply with
such provisions or this permit shall be deemed revoked.
FEE
'
AIR HANDLING UNIT (TO 10,000C.F.NL) 4.00
AIR HANDLING UNIT(OVER IQOOOC.F.M.)6.00
SEISMIC FEE
�fO
CONSTRUCT ION LENDING AGENCY
I hereby affirm that there is a construction lending agency for
EXHAUST HOOD (WITH DUCT) 5.00
performance of the work for which this permit is issued (SCC.
1310 7, Ci.0
FBS Mortg$ge
MICROFILM
HEATING UNIT (TO 100,000 B.T.U.) 8.00
Lender's Name
Lender's Add7pn
ress LJU L9
HEATING UNIT (OVER 100,000 B.T.U.)9.50
ELECTRIC
Vital OU
Icertify that lyyp�yyerreadthis applIiyy-auonapp��jgg(Fele r e live
-
VENTILATION FAN (SINGLE) 4.00
information is co$& �JDw wIIH'blI ci or,
ordinances and slate law ting to building construction, and
hereby authorize representatives of this City to enter upon the
above mentioned property for inspection purpous.
PLUMBING
BOILER-COMP(3 H. Ror100,000B.T.U.) 6.00
g01LER-COMP (Over 100,000 BTU( BEE FEE SCH.
MECHANICAL
MISC. - REFER TO ORD.
(We) agree m save, indemnify and keep tropics, the City of
Cupertino against liabilities, judgments, costs and expenses which
may in, any way accrue against said City in conseycence of the
CONST. TAX
PERMIT ISSUANCE 10.00
granting of this permit
MECH. CONT. LIC. NO. MECH.
Si re oXz
p lir one a or a
TOTAL
,�
TOTAL
� �`�
INSPECTOR COPY