3881 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
BU I LDING PROJECT IDENTIFICATION PERMITNu BER
BUILDING APPLICATION & PERMIT Q O
ADDRESS (� 1 ' f� U Q
� DaZO P6l�asslj C/,Y BUILDING - ELECTRICAL-PLUMBING-MECHANICAL
OWNER'S PLAN CHECK VALIDATION
NAAMaE�� C4
- ` p 1 CITY. ELECTRIC PERMIT FEE
\_V4 G,I C4,CW PHONE
NAMTnacT s UTLETS-SWITCHES-RECEP 5.00/1.00
//N��A�M��E��
CA4 o 'E_ uc No. LIQ1,16LIGHTING FIXTURES 5.00/1.00
oN eACTORS `,`ve e.f� APPLIANCES-RESIDENTIAL 4.00
Z U'I"k lotccat PHONE '19•L-4�E PANELS 5.00 DATE OF APPLICATION
ARCHITECT SIGNS B-OD PLAN CHECK FEE P.C.NO.
OR
ENGINEER
-' LIC.NO. SIGNS TRANS. 3.00
ARCH.OR ENG. SPECIAL CIRCUIT 5,00 PERMIT VAU DATION
ADDRESS
ZIP TEMP.METER OR POLE INS. 15.00
APPLICANTS MOTORS SEE FEE SCH. OFT
ADDRESS �t t^ '�
2,14:6 ♦uL•� l�r•(Hv�pvvE SERVICE CHANGE PAID
10,00
wo o LICENSED&N'PRACTORS DECLARATION 1
a U U I hereby aflirnh that I am licensed under provisions of Chupler 9 ISSUANCE DATE
z d (Eonnneneing with Section 7000)of Division 3 UI the B uiness and JUL 19 BLDG. ELECT. PLG. MECH.
yi Professions Code,and my license in'h full force upJjl I. - ❑
z O m Liccnsc Class Lic.Numhc ``ll -
❑ ❑
° ° Dale- C.ntracl°r F`^ City of Cupertino
Q Y f J
m w ¢ OWNER-BUILDER DECLARATION BUILDING PERMIT
INFORMATION
w3 REFERTOORD
LL I- 1 hereby affirm that I am exempt from the Contractor's License MISC.-
LOa Law forthe following reason.(Sec.703 I.S.Business and Professions PERMIT ISSUANCE 6.00 VALUATION 5/FT.
� - 0 Code:Any city or county which requiresa permit to construct.alter.
Se R< 0 improve,demolish,ar repair any structure,prior to its issuance,also ELEC.ACONTR. LIC.NO. o ELEC. Fpy
ca
- °IS requires the applicant for such permit to file a signed statement that Lv sYTOv� E�-ec. L•`LO1360 TOTAL PERMIT TO
n w m he is licensed pursuant to the provisions of the Contractor's License
H z a Law(Chapter 9(commencing with Section 7000)of Division 3 ofthe <<'L7
Business and Professions Code)or that he is exempt therefrom and DTV. PLUMBING PERMIT FEE
¢ c the basis for tat alleged e.emptim,Any viol,inn of Section 703 LS
STORIES TYPE CONSTR.
i ; m by any applicant for a permit subjects the applicant to a civil penalty ALTER-DRAIN& VENT-WATER (EA.) 4.00
of nut more than five hundred dollars 1$5001.1:
0 I,as owner of the property,or city Employes with wages as BACK FLOW PROTECT.DEVICE 2.00 DCC.GROUP RES.UNITS
their sole compensation,will do the work,and the structure is not
intended or offered for sale (Sec. 7044, Business and Professions DRAINS-FLOOR,ROOF,AR EA,COND. 4.00
Code:The Contractor's License Low does not apply to an owner of
'property who builds or improves thereon,and who does such work FIXTURES-PER TRAP 4.00 SO.FT.FLOOR AREA TOTAL ACREAGE
himself ents re of rote his own emnd for s le.lldhJ that such improve-
mmsellonotintended onenriedforsprovihowever,tic.(
budding GAS-EA.SYSTEM-1INC.4OUTLETS 4.00
or improvement is sold within one year of completion.the owner- GAS-EA.SYSTEM-OVER 4 (EA.) 1.00 BUILDING USE
builder will have the burden of proving that lie did not build or im-
proveforpurposeofsale.). INDUSTRIAL WASTE INTER. 20.00 RES IND CON PB Omer
❑ 1,as owner of the property,am exclusivaly contracting with ❑ ❑ ❑ ❑ ❑
licensed contractors to construct the project ISec. 7044,Business LAWN SPRINKLERS- 1 INC 5 V.B. 5.00 ASSESSORS PARCEL NO.
and Professions Code:The Contractor's License Law docs not apply
to an owner of property who builds or improves tmreon.and who LAWN SPRINKLERS-OVER 5 (EA.) 1.00
contracts for such projects with u contractor(t)licensed pursuant to SEWER-SANITARY-STORM EA. 200ft/8,00 TRACT NO. PARCEL NO.
the CnNmetor's License Law.
❑ I ant Exempt under Sec.-,B.&P.0 for III is WATER HEATER W/VENT 4.00
rctson
Dam owner WATER SYSTEM 4.00 ACC.DATE ACC.FILE No.
WORK Ii RS'COMPFNSA'I ION DECLARATION WATER TREATING EQUIP, 4.00
I hereby affirm that I have o ecrlllcote tit consent to self-insure,
or a certificate of Workers'Compensation Insurance,or a certified ZONING ENG.SITE NO.
copy thereof(Sec.3800,La b.C.).
Policy IN -Company
-
0 ❑ Certified copy is hereby furnished. FIRE SPRINK ENERGY T 24
Z Z ❑ Certified copy is filed with the city inspection division. MISC.- REFER TO ORD.
Y E] No , v ❑ NE]F" O Applicant
- PERMIT ISSUANCE 6.00 FLOOD ZONE A.L.0 c.
i2
CC CERTIFICATE 0I7 FAFNIPfION PROM WORKERS'
UJ _ COMPENSATION INSURANCE PLG.CONTR. LIC.NO. PLO. Y❑ N❑ v❑ N❑
CL O 1rhis section need not be completed it the permit is for of TOTAL
0 Z Immdred do11.,,15100)or In,,.)
U O 1 certify that in the perforn ace of Ohe work tor whlch this per- QTV MECHANICAL PERMIT FEE FEE SUMMARY
LL H mil S issued, 1 shall not employ any person in any Inunncr so as it,
U w be"!,acs 6E- the Worker bautinn Ef Calitorni:L BUILDING
a,
Umc Avvlicant "z- ALTER OR ADD TO MECH. 4.00
} N NOl'ICIi O APPLICANT: IL after making this Certificate.1 Bx-
F-. ? en,dion,you should become subject to the Workers'Crlmpensaiion APPLIANCE 4.00 PLAN CHECK
provisions of the Labor Code, you most forthwith comply with FEE
U such provisions or this permit shall be deemed revoked. AIR HANDLING UNIT(TO 10=C.F.M0 3.00
CONSTRUCTION LENDING AGENCY AIR HANDLING UNIT(OVER 10=C.F.M.) 5.00 SEISMIC FEE
I hereby affirm that there is a construction lending agency for EXHAUST HOOD (WITH DUCT) 2.00
the performance of the work for which Ibis permit is issued(Set. MICROFILM
3097,Civ.C.1. HEATING UNIT (TO 100,000 B.T.U.) 4.00
Lender's Name HEATI NG UN IT(OVER 100,000 B.T.U.)7.50 ELECTRIC ,Pn�
Lender,Address e Li
( certify that l haveread this applicati.... Is tate that the above VENTILATION FAN (SINGLE) 3.00
Information is correct-1 agree to minply I'll it,and county BOILER-COMP(3 H.P.or 100,000 B.T.U.) 4.00 PLUMBING
mlinanees and state laws relating to building construction, and
hereby aullhoriee representatives of this city to enter upon the BOILER-COMP (Over 100,000BTU)SEE FEESCH. MECHANICAL
above-mmntioned property for inspection purposes.
(We) agree to save, indemnify and keep humbles,the City of MISC.- REFER TO ORD.
Cupertino against liabilities,judgments, costs and expenses which CONST.TAX
may in any way accrue against said City in consequence of the PERMIT ISSUANCE 3.00
granlingofthispefmfL MECH.CONT. LIC.NO. MECH.
TOTAL TOTAL
1 k
Signa tpplicant(Contraclor Wand
OFFICE COPY
it