5210APPLICANT TO FILL IN INFORMATION WITHIN REDLINES - USE BALL POINT PEN ONLY
BUILDING PROJECT IDENTIFICATION
APPLICATION & PERMIT
BUILDING - ELECTRICAL- PLUMBING = MECHANICAL
PERMIT NUMBER
';,
BUILDING
Boo s n�
OWNER'S -
NAME
LPHONE
OTY. ELECTRIC PERMIT FEE
PLAN CHECK VALIDATION
PAID
p .(
MAR p 1 19H4.
CittAnORO,F
VION
'CONTRACTORS"-
- NA -
%�(¢ uc. ND.
-
OUTLETS - SWITCHES'-,RECEP 5.00/1.0A0
LIGHTING FIXTURES 5.00/1.00
CONTRACTDR's . •, i '
ADDRESS
,?7yy S 4IGNE2_T71((,
'APPLIANCES - RESIDENTIAL 4.00
PANELS 5.00
AgCHITECT
OR
ENGINEER
- uc. rvo. '•' -
SIGNS , 6.00
PLAN CHECKFEE. P.C. NO.
-
SIGNS TRANS. 3.00
AARCH OR DDRESS ENG.
SPECIAL CIRCUIT ,5.00
PERMIT VALIDATION
TEMP. METER OR POLE INS. 15.00
- ZIP
-
'G
APPLICA
ADDRESS •. -
MOTORS s SEE FEE SCH.
SERVICE CHANGE ,'/ry"I 10.00
"
I GG
LICENSED CONTRACTORS DECLARATION
t V- l� eC u•c'S
1 herehy affirm that 1'am licensed under provisions of Chapter 9
(commencing with Secliun'70001 of Division' 3 of the Business and'
Professions Coti;sld licenseisin I'uIl (u n p.
Lic�ns,SClas' 1. f Lic. Nu ofbI 60f; 1, y '
kccL
0 -�
NC ATE
,BLD ELECT. PLG. MECH,
❑ 1:1 ❑
- -
Date Contract.,-_ t74%��
r
s
-
OWNER -BUILDER DECLARATION.
I hereby affirm that I am exempt from the Contractor's License
Law for tire following reason. (Sec. 7031.5, Businessald Professions
Code:Any Cnypr county Which requires s pernifto eomstnmL site,,
BUILDING PERMIT
INFORMATION
MISC.-' 'R EFER TO ORD
s' PERMIT ISSUANCE '6.00
VALUATION
. $/FT;
ELEC. CONTR. LIC. NO.' ELEC.
- TOTAL
- -
OTY. PLUMBING PERMIT FEE
Improve, demolish, or repair any structure, pri.f to its issuance, also
requites the applicant for such permit to file a signet) statement that
he is licensed pursuant to the provisions of the Contractor's License
Law(Chapter9(commencingwit),Scclion7000).f Divisi.n3ofthe
Business and Professions Code) or that he is exempt therefrom and
d (Q
PERMIT TO
,p
i
/s -•Y/
/ STORIES TYPE CONSTR.
G..._
L,LLI�
the basis for the alleged exemption. Any violation of Section 7031.5
fora undresubjeds thespp]icanu.ucivil penalty
by any more
of not more taut five hundn•A dollars the ap.1:,
,
ALTER -DRAIN St VENT-WATER.(EA.) 4.00
'❑ 1: as owner of the "."coy, or my employee"With•wagesas
their sole compensation, will do the work, and the st nature is not
BACK FLOW PROTECT. DEVICE.. , 2.00
_ DRAINS -FLOOR, ROOF, AREA, COND.' 4.00
intended or offered for sale (Sec. -7044, Business and Professions
Code The Curnmelor's' License Law does not apply to an owner of
''�/�� "'`�•�1.
j/
FIXTURES - PER TRAP` 4.00
GAS -EA. SYSTEM -I INC.4 OUTLETS 4.00
sG. FT. FLOOR AREA TOTAL ACREAGE
'
Property who builds or improves thereon, and who docs such work
himself or through his own employees, provided that such improve-
mentsare not intended oroffered for sale, If, however, the building
or improvement is said within one year of completion, the owner-
builder will have the burden .f proving that he did not build or im-
prove for purpose ofsuleJ.
I, as owner of the.properly, mn•exclus,ely c.NmUting will
GAS - EA. SYSTEM -OVER 4 IEA.) 1.00
BUILDING USE
ES 'IND CON PB Oto,,'❑
❑ ❑ ❑ ❑
INDUSTRIAL WASTE INTER. 20.00
licensed contractors to construct the project (Sec. 7044, Business
and Professions Code: The Contractor's. License Law does not apply
to an owner of property who buildsorimproves thereon, and who
LAWN SPRINKLERS - 1 INC 5 V.8. 5.00
LAWN SPRINKLERS - OVER 5 (EA.). 1.00
ASSESSORS PARCEL NO.
contracts lin suchprojectswith t contractors) licensed pursuant to
theContractnrsLicenseLaw. -I
SEWER -SANITARY -STORM EA. 200ft/8.00
TRACT NO.
-
PARCEL NO.
❑ Ions exempt under Seca ,li:&I'.C, lorlhisWATER
reason "
HEATER W/VENT 4.00
Owocr Date
WATER SYSTEM 4,00
ACC. OATS
ACC, FILE NO.
WATER TREATING, EQUIP, 4.00
WORKI:RS' COMPENSATION DECLARATION
I hereby Ifirm that I have a certificate ofecnseat to self -insure.
.r a Certificate .f Workers' Compensation Insurance, or a certified
ZONING
ENG, SITE NO.
copy thereof (Sec. 3800, Lab.C.).
Policy No• Company
❑ Certified copy is hereby famished
❑ Certified copy is filed with. the city inspection division.
Applicant, _
I
FIRE SPRINK
Y ❑ ,N
ENERGY T-24.
Y ❑ :'N❑
MISC.'-" ". REFEWTO ORD.
C8R'I'IIq CATt;OF I XI7MP1'I ON FROM WORKERS'
PERMIT ISSUANCE - 6.00 ..
FLOOD ZONE
A.L.U.C.
PLG. CONTR. -LIC, NO.
PLG. ,
TOTAL.
COMPENSATION INSURANCE
(This section need not he completed if the permit is for one
Y ❑ N❑
Y ❑ IN
hundred dollars IS 100) or less.)
1 certify that in the performance of the work fix wliich t its per-
mit is issued, I shall not employ an Pers qq. can so
Decoy}qq s}J��nice he.Workeri p, !fo
Dat&., / ApplicanALTER
NOTIC17'I0 APPLICANT: G after making this Certificate of Ex-
OTV MECHANICAL PERMIT FEE
FEE SUMMARY
BUILDING '
�' •g,
. .
OR ADD TO MECH400
APPLIANCE 4.00
AIR HANDLING UNIT (TO 10=C.F.M.) 3.00
PLAN CHECK
FEE
emption, you should become subject t. the Workers'Compensation
Provisions of the Labor Code, you,must forthwith comply with
such provisions or this permit shall be deemed revoked,
AIR HANDLING UNIT(OVER 10=C.F.M.)'5.00
SEISMIC FEE
I
CONSTRUCTION LENDING AGENCY
1 hemby"ul'finn that there Is a construction lending agency for
- EXHAUST HOOD (WITH DUCT) 2.00
-
the perfarmance,of the work for which this permit is issue(] (Sec..,
3097, Civ.C.L
,MICROFILM
HEATING UNIT (TO 100,000 B.T.U.) '4.00
Lender's Name
HEATING UNIT 100,000 B.T.U.)7.50
ELECTRIC.
Lender's Address
I Certify that l lmve read this application and state that the above
VENTILATION FAN (SINGLE) 3.00
information is correct. I agree to comply with all city and county,PLUMBING
ordinances and state laws relating to building constrmtion,'and
BOILER- COMP (3 H.P. Or 100,000 B.T.U.) 4.00
BOILER -COMP (Over 100,000 BTU) SEE FEE SCH.
- MECHANICAL "
'
hereby authorise repm,ty falives of ,his city m.enter upon the
aboeby LithOril property Cotinspof thisIIIA
" (We) agree m save, indemnity and keep harmless the City of
Cupertino against liabilities, jl'JI m Is, sts and expenses which
may i ac cies• 7 st yin consequence of the
_
MISC. - " 'REFER TO ORD.
CONST. TAX
PERMIT ISSUANCE 3.00
e, `O /
MECH. CONT. '- LIC. NO. MECH.
TOTAL
"
TOTAL
� -
itin."Ge,.fAppli.rtContraclor Date
,� ^' OFFICE COPY