3443X'
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APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
BUILDING PROJECT IDENTIFICATION
APPLICATION &PERMIT_
BUILDING -ELECTRICAL -PLUMBING -MECHANICAL
v R BER
3443
ADILDING s E sr ru
ADDRESS
L AA -t4 ,T f %� `f
OWNER'S
NAME
12414 4WIAI41`141410 PHONE �J9_rf4
_
♦T - _ Y Lam'
PTV. r ELECTRICPERMIT -' .l x FEES'
-
PLAN CHECK VALIDATION
CONTRACTORS
NAME
UTLETS-SWITCH ES-RECEP 5.00/1.00
LIGHTING FIXTURES 5.00/1.00
,sr
M fe ttlag]sN4er0;J LIC. NO.
CONTRACTOR 'S
A
ADDRESS
PPLIANCES- RESIDENTIAL 4.00
PANELS 5.00
`�
.2/4(C AM<Irtan ri PHONE 7JJ-96S'
DATE OF APPLICATION
ARCHITECT
OR
ENGINEER
LIC. NO.
SIGNS G00
PLANCHECK FEE P.C. NO.
SIGNS TRANS. 3.00
ADDRESS ENO.
a,y
SPECIAL CIRCUIT 5.0Q
PERMIT VALIDATION
EMP. METER OR POLE INS. 15.00
APPLICANTS
ADDRESS/
MOTORS SEE FEE SCH.
SERVICE CHANGE 10.00
LICENSED CONTRACTORS DECLARATION
I hereby affirm that I am licensed under provisions of Chapter 9
ISSUANCE DATE
(commencing with Section 70001 of Division 3 of the Business and
Professions Code, 7y license is in full force a eff t
License C[as9�_ � Lie Number
BLDG. ELECT.
❑ ❑
PLG. MECH.
❑ ❑
Date 'f��.0 `YJ Contractor
OWNER -BUILDER DECLA RA ION
I hereby affirm that I am exempt from the Contractor's License
Law for the following reason. (Sec. 7031.5. Business and Professions
Code: Any city or county which requiresa permit toconstrucl. alter.
improve, demolish. Or repair any structure, prior to its issuance, also
DING PERMITT��..,,r"";h'
.P'.a+ -+
MISC.- REFER TO ORD
L
TF�OqRMATION'};'�r*11,
.'J
A IJ V J
$/FT:
PERMIT ISSUANCE 6.00
ELEC. CONTR. LIC. NO. EL C.
requires the applicant for such permit to file a signed statement that
he is licensed pursuant to the provisions of the Contractor's License
Law(Chapter 9(commencing with Section 7000) of Division 3 ofthe
Business and Professions Code) or that he is exempt therefrom and
the basis for the alleged exemption. Any violation of Section 7031.5'1
TOTAL
_ -,
+ - - A G -.
DTV. s' PLUMBING PERMIT "k v) FEE'
- .�. 's
p
J FwIu1T TO
1 �0 C Tfl1l�_
/.Q
_
STORIES
TYPE CONSTR.
ALTER-DRAIN-WATER(EA.)4.00
by any applicant for a permit subjects the applicant to a civil penalty
of not more than five hundred dollars (5500).):
❑ 1, as owner of the property, or my employees with wages as
their sole compensation, will do the work, and the structure is not
intended or offered for sale (Sec. 7044, Business and Professions
BACK FLOW PROTECT. DEVICE 2.00
OCC. GROUP
RES. UNITS
DRAINS -FLOOR, ROOF, AREA,COND. 4.00
Code: The Contractor's License Law does not apply to an owner of
property who builds Or improves thereon, and who does such work
FIXTURES - PER TRAP 4.00
50. FT. FLOOR AREA
TOTAL ACREAGE
himself or through his own employees, provided that such improve-
mentsarenotintendedoroffered for sale. I L however, the building
GAS - EA. SYSTEM - I INC.4 OUTLETS 4.00
or hnprovemem is sold within one year of completion, the Owner-
builder will have the burden of proving that he did not build or im.
prove for purpose Of sale.).
O I, as owner of the property, am exclusively contracting with
GAS - EA. SYSTEM - OVER 4 (EA.) 1.00
BUILDING USE
RES IND CON PB Other
❑ ❑ ❑ ❑ Cl
INDUSTRIAL WASTE INTER. 20.00
LAWN SPRINKLERS- 1 INC 5 V.B. 5.00
LAWN SPRINKLERS - OVER 5 (EA.) 1.00
ASSESSORS PARCEL NO.
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 builds or improves thereon, and who
contracts far such projects with a contractorls) licensed pursuant to
the Contractor's License Law.
SEWER -SANITARY -STORM EA. 200ft/8.00
TRACT NO.
PARCEL NO.
0 I am exempt under Sec.., B.&P.C. for this
reason
WATER HEATER W/VENT 4.00
Date Owner
WATER SYSTEM 4.00
ACG -DATE
ALL. FILE NO.
WATER TREATING EQUIP. 4.00
WORKERS'COMPENSATION DECLARATION
1 hereby affirm that I have a certificate ofconsent 10 SCINIISure'
or a certificate of Workers' Compensation Insurance, or a certified
ZONING
ENG. SITE No.
copy thereof c. 3800, Lah.C.�� T
Policy ere Company r- �.IYQe'+ieuf74
0 Certill, d c Py is her. by furnishejj
A�{%J Cetti Ded is fled I e ciN -action division.
icCet
FIRE SPRINK
Y ❑ N❑
ENERGY RI4
Y ❑ N❑
MISC. - REFER TO ORD.
CERT EXEMPTION FROM S RKERS'
PERMIT ISSUANCE 6.00FLOOD
ZONE
A.L.U.C.
PLG. CONTR. LIC. NO.
PLG.
TOTAL
OMPENSATION INSURANCE
(This section need not be completed if the permit is for one
Y❑ N[]
Y❑ N❑
'- i. :' i -- .'- 1. 1�r .f;.
- .. ', f
DTV. MECHANICAL PERMIT,' `n" I. ^FEE'C'
!-
,',r,,"iFEE SUMMARY
�<``',� .
-u`. 4T'S
hundred delta. IS 100) or less.)
I certify certify that in the performance of the work for which this per,
mit is issued. I shall not employ any person in any mannerto
become subject to the Workers' Com Compensation Laws California.-
P
Date Applicant
BUILDING
y(p
'VO•�
ALTER OR ADD TO MECH. 4.00
NOTICE TO APPLICANT: If. after making this Certificate of Ex-
emption, you should become subject to the Workers' Compensation
APPLIANCE 4.00
PLAN CHECK
q j
provisions of the Labor Code, you must forthwith comply with
such provisions or this permit shall be deemed revoked.
AIR HANDLING UNIT (TO 10,00DGF.M) 3.00
FEE
«�•^�
AIR HANDLING UNIT (OVER 10=C.F.M.) 5.00
SEISMIC FEE
.f0.
CONSTRUCTION LENDING AGENCY
I hereby affirm that there is a construction lending agency for
EXHAUST HOOD (WITH DUCT) 2.00
the performance of the work for which this permit is issued ISee.
3097, Civ.C.).
MICROFILM
HEATING UNIT (TO 100,000 B.T.U.) 4.00
HEATI NO UNIT(OV ER 100,000 B.T.U.)7.50
ELECTRIC
Lender's Name
Lender's Address
I certify that I have read this application and stale that the above
information is correct. I agree t0 comply with all city and county
ordinances and state laws relating to building construction. and
VENTILATION FAN (SINGLE) 3.00
PLUMBING
BOILER- COMP(3 H.P. or 100,000 B.T.U.) 4.00
BOILER -COMP (Over 100.000 BTU) BEE FEE SCH.
MECHANICAL
hereby authorize representatives this city to enter upon the
above-mentioned properlyerty for inspection purposes.
MISC. - REFER TO ORD.
CONST. TAX
(We) agree to Save, indemnify and keep harmless the City Ot
Cupertino against liabilities, judgments, costs and expenses which
may in any way accme agalast Said City in consequence of the
gmnrin Of this per _�J
y+�4/ h -l+ d'�
PERMIT ISSUANCE 3.00
MECH. CONT. LIQ NO.
TOTAL{"+''3'I-
"TOTAL+
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6 `J� -�
Signal 1p IicantlConlmctor Date
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OFFICE COPY