1751646
o ¢
w
Q V V
F a d
ryi
V
` ' w
L sem
Ca Ay
F u o
3Be<0
es CC
6 W es N
3 i o
¢f�
%
O
Z_2
P a
M -
Ui
ao
UO
LL U
O 6
} N
.a
I �•
APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
BU LDI NG PROJECT 1 DENTI FICATI ONI
APPLICATION & PERMIT
BUILDING - ELECTRICAL -PLUMBING -MECHANICAL
�^ IT NUMBER
/V'i .C.q 17516
BUILDING
ADDRES
O40 f D pr
G
DNHFR'S ,
NAME
A-PpLe PHONE
QTY. ELECTRIC PERMIT FEE
PLAN CHECK VALIDATION
/I
CONTRACTOR$
NAME
UTLETS,SWITCHES -RECEP 10.0011.00
//
r'YI F. No. � 2
UG g
�-
DAZE dF
LIGHTING FIXTURES 10.00/1.00
CONTRACTORS
ADDRESS
PRONE Zg88iOi
APPLIANCES - RESIDENTIAL 4.00
PANELS -10.00
ARCHITECTPANELS(OVER
on
ENGINEER
uc. NO.
200 AMP( 20.00
PLAN CHECK FEE C.NO.
71
SIGNS TRANS. 3.00
ARCH. OR ENG.
ADDRESS.
nP
SPECIAL CIRCUIT 5,00
PERMIT VALIDATION
EMP. METER OR POLE INS. 20.00
Ars
ADDDRESSDRESS
MOTORS SEE FEE SCH.
SERVIC
G 20.00
14-- 'n' -e
'.
LICENSED CONTRACTORS DECLARATION
I hereby affirm that 1 am licensed under provisions of Chapter 9
ISSUANCE DATE
(commencing with Section 7000) of Division 3 of the Business and
Profession Cod- anGy� d Ip41icgnse is in full forg�nL girtZ
DateClass q
ConLic. radarNo a YIr S-
Dale •'g a Contractor hA�-1.[�
SAG ELECT. PLG. GH.
❑ ❑
�� 111
DINGPERMIT
BUILORMATION
/
OWNER -BUILDER DECLARATION
1 hereby aolrm that 1 am exempt pl Gom the Conlradoisfc,ime
r.7ossapeusit tocnlomecssions
Law forAnycity or iounty which loconsuanc , fte"also
Code. proe, d city or county whiny structure prior
improve, demolish, m repair any structure prior ler its issuance, also
INFORMATION
MISC. - REFER TO ORD -
VALUATION
//_� � I, �ya-(��
{J`l V%"'��E
S/FT.
PERMIT ISSUANCE 10.00
ELEC. CONTR. LIC. NO.
ELEC.
requires the applicant for such permit to Ek a signed statement that
he is licensed pursuant to the provisions of (lie Contractor's Linenss�
TOTAL
PERMIT TO
CITY. PLUMBING PERMIT FEE
Law (Chapter 9(commencingwith Section 7000) of Division 3 ofthe
Bu ine, and Professions Cush) or that he isexumpt thcmfroan and
'
'
STORIES
TYPE CONSTR.
the basis for the alleged exemption. Any violation of Section 7031.5
ALTER -DRAIN -WATER IEA.) 5.00
by any applicant for a permit subjects the applicant to a civil penalty
of not more than five hundred dollars (S5000:
❑ I, as uwncr of the property, m any Cmplo,ces, 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
imcnded or offered for sale (Sec. 7144. Business and Professions
Cade: The Contractors License Law does not apply to an owner of
primerty who builds or improves thereon, and who docs such work
FIXTURES - PER TRAP 5.00
SO. FT, FLOOR AREA
TOTAL ACREAGE
himself or through his own employes. provided that such improve-
mems are not intended or offered for sale. If, however, the building
GAS-EA.SVSTEM-1 6.00
oLimpmerment is sold within one year of completion, the owner.
builder wdl have the burden of proving that he did not build or am-
prove for purpose of sale.).
' :1I, as owner of the property, am exclusively contracting with
GAS- EA. SYSTEM - OVER 4 (EA.) 2.00
BUILDING USE
RES IND CON PB Omer
❑ ❑ ❑ ❑ ❑
INDUSTRIAL WASTE INTER. 30.00
LAWN SPRINKLERS- 1 INC 5 V.B. 6.00
ASSESSORS PARCEL NO.
licensed contractors to construct the project ISec 7144, lit itass
and Professions Code: The Contractor's License L.C. does not apply
to an owner of property who builds or improves thereon, and whir
LAWN SPRINKLERS - OVER.5 (EA.) 1.00
cataracts fur suchcenects Lwithucontructorls)liccnad pursuant to
the lrec tar's License
SEWER -SANITARY -STORM EA. 200ft/10.00
TRACT NO.
PARCEL NO.
Ium exempt under Sea .B,ffiP.C. for this
ec.
Sec.-,
reason
rcasnn
� WATER HEATER W/VENT 6.00
Owner [)-is Date
WATER SYSTEM 5.00
ACC. DATE
ACG FILE NO.
WOR`KER6S'COMPENSA'IION DECLARAT ION
WATER TREATING EQUIP. 5.00
I hereby of firm that I hmo a certificate of consent to self -insure.
or mrlifi�ca/Le�o IR'rW�op, ,Col�'ns�aym Ins�nce, or a certificA
ZONING
ENG. SITE NO.
l
copy No f Cj!'Qj LJ'[.
Policy No. Company
❑ Certified copy is hereby lurnished.
u tiled wuh Iry inspection division.
Aaphcam � ^ a
,FIRE SPRINK
v [:]N ❑
ENERGY T-24Certifled
v ❑ N[]
MISC. - REFER TO ORD.
CER'riFiCATE OPEXEAIPHON FROM WORKERS'
PERMIT ISSUANCE 10.00
FLOOD ZONE
A.L.U.C.
PLG. CONTR. LIC. NO.
PLG.
TOTAL
COMI'HNSATION INSURANCE
This section reed not be completed if the permit a for arta
Y ❑ N ❑
Y 1:1 N❑
-
OTY. MECHANICAL PERMIT FEE
-
FEE SUMMARY
hundred dollars IS 100) FT les)
I I certify that in the perl'onnaulce of the work for which the per.
mit is issued. 1 shall not employ any person in any nmnncrso as to
Become subject to the Workers' Compensation Laws of C.lifomia.
Date Applicant
NOTICE TO APPLICANT: If, .fit, making this Certificate .I' Ex-
BUILDING J
ALTER OR ADD TO MECH. 5.00
APPLIANCE 5.00
PLAN C C
Cmplion, you should become subject to the Workery Compensation
provisions of the Labor Code, you most forthwith comply with
such provisions err Lhis permit shall be dccmcd mvokcd.
AIR HANDLING UNIT (TO 10=C.F.M.) 4.00
AIR HANDLING UNIT (OVER 10= C.F.M.) 6.00
SEISMIC FEE
CONSTRUCTION LENDING AGENCY
I hereby affirm that there is a construction lending"agency for
tire performance of the work for which this permit is issued (Sec.
. ,
3097, CivC.).
EXHAUST HOOD (WITH DUCT) 5.00
MICROFILM
HEATING UNIT (TO 100,000 B.T.U.) 8.00
HEATING UNIT (OVER 100,000 B.T.U.) 0.50
ELECTRIC
Lender's Name
Lender's Address
I certify that I have read this application and nate that the.hove
information is correct. I agree to comply with all city and county
ordinances and state laws relating to building construction, and
hereby authorizerepresentutiVeof ihu City to enter upon the
above-mentioned properly for inspection purposes.
VENTILATION FAN (SINGLE) 4.00 -
PLUMBING
BOILER- ODMP(3 H.P. or 100,000 B.T.U.) 6.00
BOILER-COMPIOser 100,000 BTU(SEE FEE SCH.
MECHANICAL
MISC. REFER TO R.r
CONST. TAX
.UUV
(We) agree to save, indemnify and keep harmless -the City of
Cupertino against liabilities, judgments, costs and expenses which
may in any way accrue against said City in consequence of the
PERMIT ISSUANCE -3AvB0
MECH. CONT. LIC. NO. MECH.
TOTAL
s
TOTAL. 5/
grantpg ofthis permit's /2
Kam---/^tyv.� �8�
igsfature of Applitent Contract r D to
OFFICE COPY .