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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
PERMIT NUMBER
6827
ao'o,°Ess S4 1 T r 200
20 .3 ST EE LrO
OwNEH'S
NAME
tp;1YM 1 A dC3s i4 '��,nfapL '� /+..;
ELECTNICtPENMITI E
nTV' �ft
PLAN CHECK VALIDATION
U 4 PHONE
+, 4 ,W.a .'O >L
5., f
DATE OF APPLICATION
NT.ACTORs
hNAME 11
am 103 II AU.i' 1 ua Na 5I
UTLETS-SWITCHES-RECEP 5.00/1.00
LIGHTING FIXTURES 5.00/1.00
cONTRACTORPS t L05)
0 AooREss
L ioo, en . Sid . PHONE i-
PPLIANCES- RESIDENTIAL 4.00
PANELS 5.00
Aq HITECTSIGNS
Go
ENGINEER
-LIC.NO,
6.00
PLAN CHECK FEE P,C. NO.
SIGNS TRANS. 3.00
aoo Boss ENG
ZIP
SPECIALCIRCUIT 5.00
PERMIT VALIDATION
�IEMP. METER OR POLE INS. 15.00
APPLICANTS
oonEss
MOTORS SEE FEE SCH.
SERVICE CHANGE 10.00
-'
A / y
LICENSED CONTRACTORS DECLARATION
I hereby affirm that I :un licensed under provisions of Chapter 9
I tummennng .,it, Section 7000) 01' Division 3 of the Business and
Pot sgoits C.6. al rpy nse o in full fore .IruLeftec .
Licenxe ❑.a1ss_' fey Lie. Number _ `IS /
ISSUANCE DATE
BLDG.
❑
ELECT. PLG. MECH.
❑ ❑
�-may Contractor 1rJ__.._
l M C/
OWNER-BIIILDER DGCLA ATIC N `J
I hereby affirm that I am exempt from lire Contractor's License
Law tor lire following reason. (Sec. 7031.5, Business and Professions
Code: Any city .r county which requires a permit to construct, 41ter,
Improve, demolish. or repair any structure, prior to Its Issuance, also
r y its the eppl c' 1 fors Such permit to file J signed statement that
lea Is lensed purvuant to the provisions of the Contractor's License
Law (Chapter I(commencing with Section 7000) of Division 3 oflh
Business and P f sslons Code) r that he is exempt therefrom end
the basis for the alleged exemption. Any violation of8ecl un 7031 S
MISC. - REFER TO ORD
PERMIT ISSUANCE 6.00
VALUATION
5/FT.
ELEC. GONER. LIC. NO.
ELEC.
TOTAL
PERMIT TO
/
Wv-,1y}
�'TY' P' xVLt1MBINQ PE RMITi RY.VjlF Fe 1
'j?E�-+ i�� r. -T. v/ 3•`fi
STORIES
TYPE CONSTR.
by any applicant for a permit subjects the applicant too civil penalty
of not more than live hundred dollars (55001.1:
ALTER -DRAIN& VENT -WATER (EA.) 4.DD e.4 OV
❑ more
owner of the property, or my employees with wages as
then sale compensation, will do the work, and tire structure is not
BACK FLOW PROTECT. DEVICE 2,00
OCC. GROUP
RES, UNITS
DRAINS -FLOOR, ROOF, AREA, COND. 4.00
intended or offered for sale (Sec. 7044, Business and Professions
Code: Tile Contractor's License Law does not apply to an owner of
property who builds Or improves thereon, and who does such work
himselfor through his own employees, provided that such improve.
mems arc not intended or offered for sale. If, however, the building
FIXTURES - PER TRAP 4.00 QO
SO. FT. FLOOR AREA
TOTAL ACREAGE
GAS - EA. SYSTEM - I INC.4 OUTLETS 4.00
or improvement is sold within one year of completion, the owner-
builder Will have the burden of proving that lie did not build or Int-
for purpose of sale.).
I, as owner of the property, am exclusively contracting with
GAS - EA. SYSTEM -OVER 4 IEA.) 1.00
BUILDING USE
RES IND CON PB Other
E] ❑ ❑ El1:1❑
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:m owner ul property who builds or improves thereon. and who
LAWN SPRINKLERS - 1 INC 5 V.B. 5.00
LAWN SPRINKLERS - OVER 5 (EA.) 1.00
ASSESSORS PARCEL NO.
contracts for Mich projects with a contractorls) licensed pursuant to
the Contractor's License Law.
SEWER -SANITARY -STORM EA. 200ft/8.00
TRACT NO.
PARCEL NO.
O lam exempt under Sec.-, B.&P.C. for this
re'Jsotl
WATER HEATER W/VENT 4.00
Owner- Date
WATER SYSTEM 4.00
ACC. DATE
ACC. FILE NO.
WATER TREATING EQUIP. 4.00
WORK ERS'COMPENSATION DECLARATION
1 hereby affirm that I have a ttrtilicate W'consent to self -insure,
or a certificate Of Workers' Compensation Insurance, or a certified
ZONING
ENG. SITE NO.
Copy Iherxot )Sec. 3800, Lab.G).
Policy No. Company
FIRE SPRINK
Y ❑ N ❑
ENERGY T-24
Y ❑ N❑
❑ Certified copy is hereby furnished.
❑ Certified copy is filed with the City inspection division.
Applicant
MISC.- REFER TO ORD.
CERTIFICATE OF EXEMPTION FROM WORKERS'
PERMIT ISSUANCE 6.00
FLOOD ZONE
A.L.u.c.
PLG. GONER. LIC. NO,
PLG. O'
TOTAL
COMPENSATION INSURANCE
1'I'[,is section need not be completed if the permit is for one
V❑ N❑
V❑ N❑
• nm - MECHANICAL,PERM
+Fl+ aq FEES;
n ,`F ?}.VR` x `SaF ,• X -•4 - „^ ✓^ esu,
2
yTe4-rt: ;RnBE• ': ^1�1�• _
'-'
BUILDING
hndrd dollars(S 100) or less.)as�s,�
certify that in the performance of the work for which this per.CITr.
ouITCEcfiNI,�
mil Is sd I shall not employ any person in any manner so es to
h 1y �sohau•1 1y,lye Workers' Co nsation ws of Cali la
D' I ICE TO
\O 1'ICIi TO APPLICANT: If, term ng this C ¢ate of Lx.
I
ALTER OR ADD TO MECH. 4.00
APPLIANCE 4.00
PLAN CHECK
elnption, you should become subject m the Work ' Compensation
pookions of the Labor Code, you most forthwith comply with
such provisionsOr this permit shall be deemed revoked.
FEE
AIR HANDLING UNIT (TO 10=12-F.M.) 3.00
AIR HANDLING UNIf(OVER 10p00C.flM) 5.00
SEISMIC FEE
CONSTRUCTION LENDING AGENCY
I hereby affirm that lbere Is a construction lending agency for
EXHAUST HOOD (WITH DUCT) 2.00
the performance of the work for which this permit is issued (Sec.
3097. Cis,C.),
MICROFILM
HEATING UNIT (TO 100,000 B.T.U.) 4.00
HEATING UNIT (OVER 100,000 B.T.U.17.50
ELECTRIC
Lender's Name
Lender's Address
I certify that I have read this application and stale that the above
..formation is orect. I agree to comply with all city and county
ordinances and slate laws relating to building construction, and
VENTILATION FAN (SINGLE) 3.00
PLUMBING
p�
/ ✓.
BOILER-COW113 H.P.Oe 100,000 B.T.U.) 4.00
BOILER -COMP IOver 100,000 BTU) SEE FEE SIGN.
MECHANICAL
hereby authorve representatives of this city to enter upon the
above-mentioned property for inspection purposes.
MISC. - REFER TO ORD.
CONST. TAX
IWe) 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 3-00
gmnling of this permit.
MECH. CONT. LIC. NO.
MECH.
TOTAL
s -
_
Signature of Applicant/Contractor Date
OFFICE COPY