12231APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
BU LDING PROJECT I DENT[ FICATION
APPLICATION &PERMIT
BUILDING -ELECTRICAL- PLUMBING -MECHANICAL
PERMIT NUMBER
12231
ADDRESS
ADDRESS 10191 Yoshino Place
OWNER'5
NAME
Eileen Crosno PHONE
QTY. ELECTRIC PERMIT FEE
PLAN CHECK VALIDATION
NAMER"croRs
OUTLETS -SWITCHES -RECEP 10.00/1.00
Atlas Heating LIC.No.46 266
LIGHTING FIXTURES 10.00/1.00
CONTRAS
ADDRESS
APPLIANCES-RESIDENTIAL - 4.00
PANELS 10.00
155 Commercial St. PHONE -y 16
DATE OF APPLICATION
ARCHITECT -
OR
ENGINEER
LAC. No.
PANELS (OVER 200 AMP) 2000
PLAN CHECK FEE P.C. NO.
'
SIGNS TRANS. 3.00
ARCH.
oo ESS LNG'
SPECIALCIRCUIT 5.00
PERMIT VALIDATION
rTEMP. METER OR POLE INS. 20.00
ZIP
APPLICANT s
ADDRESS
MOTORS SEE FEE SCH.
15 Commercial St.. Sunnymaip
SERVICE CHANGE 20.00
;y l
LICENSED CONTRACTORSMECLARATION
I hereby ul1'irm that I am licenwel*under provisions of Chapter 9
ISSUANCE DATE •.
(commencing with Section 7000) of Division 3 of the Business and
Professions Codssrr.� a y license is in full force ryryII �yy-��L[ O�t�-
LicenseC s L. Number,
BLDG. ELECT.
❑ ❑
I PLG. MECH.
Con A
Date Contractee.
OWNER -BUILDER DECLARATION
actor's License
1 hereby affirm ing Iso exempt from the Business Professions
Law fornycitthe (See. requires a permit to construct,
t Utonsuance, ter,
ep prior
coun repair
Code: e, dem y demolish,
improve, demolish, or repair any structure, prior n its issuance, that
structure,
requires the applicant for such permit to file a signed statement that
he is licensed pursuant en the with provisions of the Contractor's License
Law (Chapter 9 (commencing with Section 7s exe of Division l of the
Business and Professions Code) or that he is exempt therefrom and
BUILDING PERMIT
INFORMATION
MISC. - REFER TO ORD
VgLUATION
$/FT.
PERMIT ISSUANCE 10.00
ELEC. CONTR. LIC. NO.
ELEB.
TOTAL
PERMIT TO
M
QTY. PLUMBING PERMIT FEE
STORIES
TYPE CONSTR.
the basis for the alleged exemption. Any violation of Section
by any applicant lora permit subjects $500).hicamtotcivil penalty
malty
of not mom thml live hundred dollars ($500).1:
ALTER-DRAIN&VENT-WATER(EA.)5.00
❑ I, as owner of the property, or my employees 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
intended of offered for sale (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 does such work
himself or through his own employees, provided that such improve.
ments are not intended or offered for sale. If, however, the building
FIXTURES - PER TRAP 5.00
50. FT. FLOOR AREA
TOTAL ACREAGE
GAS-EA.SVSTEM-1 6.00
of improvement is sold within one year of completion, the nwner
builder will have the burden of proving that he did not build or im-
Prove for purposeofsale.).
❑ 1, 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
licensed Contractors to construct the project (See. 7044, Business
and Professions Code: The Cnnlraclor's License Law does not apply
to an owner M property who builds or improves thereon, and who
LAWN SPRINKLERS -I INC 5 V.B. 6.00
LAWN SPRINKLERS - OVER 5 (EA.) 1.00
ASSESSORS PARCEL NO.
ets Lwith xcontmetor/s)licensed pursuant to
the Cults for s License Law.
the Cilmor,lisuchLicense
SEWER -SANITARY -STORM EA. 200tt/10.00
TRACT N0.
PARCEL N0.
❑ I um exempt under Sec.., B.&P.C. for this
WATER HEATER W/VENT 6.00
reason
Owner Date
WATER SYSTEM 5.00
ACC. GATE
ACC. FILE NO,
WATER TREATING EQUIP. 5.00
WORK ERS'COMPENSATION DECLARATION
I hereby affirm that I have a certificate of mnsenl to self -insure,
or t certificate of Workers' Compensation Insurance, pr n curlified
ZONING
ENG. SITE NO.
copy Bref 0 Lab.C.L
Polity N&5- c many-Allied-2aQ..-
p Certified Copy is hereby furnished.
l� Certil'itW&h[lie11 the city inspection division.
Applicant Ll[1
FIRE SPRINK
Y❑ N❑
ENERGY T 24
Y❑ N
MISC.- REFER TO ORD.
CIE RTI FICATE OI: (EXEMPTION FROM WORKERS'
PERMIT ISSUANCE 10.00
FLOOD ZONE
A.L.U.C.
PLG. CONED, LIC. NO.
PLG.
TOTAL
COMPENSATION INSURANCE
(I his section aced not be completed if the permit is for one
Y F]N ❑
Y ❑ No
QTY. MECHANICAL "IJD FEE
FEE SUMMARY
hundred dollars IS 100) or less.)
I certify that in the performance of the work for which this per-
mit is issued, I site[[ not employ any person in any manner so as to
BUILDING
become subject to the Workers' Compensation Laws of California.
DateApplicant
ALTER OR ADD TO
NOTICE TO APPLICANT': If, after making this Certificate of Ex.
emption, you should become subject to the Workers' Compensation
APPLIANCE 5.00
PLAN CHECK
provisions of the Labor Code, you must forthwilhcomply with
such provisions or this permit shall be deemed revoker[.
FEE
AIR HANDLING UNIT (TO 10 0
SEISMIC FEE
- CONSTRUCTION LENDING AGENCY
AIR HANDLING UNIT (O 6.00
I hereby affirm that there is a Construction lending agency for
the performance of the work for which this permit is issued (Sec.
3097, CIv.C.).
EXHAUST HOOD (WITH DUCT) 5.00
MICROFILM
HEATING UNIT (TO 100,00 B.T.U.) 8.00
1 8.00
HEATING UNIT IDV
0 B.T.U.)9.50
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 to comply with all city and County
ordinances and state laws relating to building construction, and
hereby authorize representatives of this city to enter upon the
above-mentioned property for inspection purposes.
VENTILATION FAN SI
E) 4.00
PLUMBING
BOILER•CO H.P. ,000 B.T.U.) 6.00
BOL MP (Overt 0 OBTU) SEE FEE SCH.1
MECHANICAL
I kfsc.'- REFER TO ORD.'
(We) agree to save, indemnify and keep hmnslem the City of
Cupertino against liabilities, judgments, costs and expenses whichCONST.
may in any way accrue against send City in consequence of the
TAX
PERMIT ISSUANCE 10.00 10.0
granting of Ih' Full it.
��� /?)
, IC. NO, MECH.
MECHCONT. LTOT AL
Atlas Heating 465266 $18.00
TOTAL
Signature of Applicant/Cont actor Date aT
OFFICE COPY _ �,