13127APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
BUILDING PROJECT- IDENTIFICATION
. - APPLICATION & PERMIT
BUILDING- ELECTRICAL- PLUMBING- MECHANICAL
PERMIT NUMBER ,
'
13127
IIUILDING
ADDRESS
Iq 07 £ [,p (Z p/C
'OwN R'S
NAME,,ee M /y
QTY.
ELECTRIC PERMIT
FEE
PLAN CHECK VALIDATION
CONTRACTORS
NAME
OUTLETS - SWITCHES - RECEP 10.00/1:00
LIGHTING FIXTURES 10,00/1.00
LIC.I
O z-
AD OR's
CODRESS ADDRESS
APPLIANCES - RESIDENTIAL 4.00
PANELS' 10,00
PHONE
DATE OF APPLICATION
ARCHITECT
OR
ENGINEER
LOU ND.
PANELS (OVER 200 AMP) 20.00
PLAN CHECK FEE P.C. NO.
SIGNS TRANS. 3.00
ARCH, OR ADDRESS ENG.
- ZIP
$PECIALCIRCUIT 5.00
PERMIT VALIDATION '
PAID
'y If
TEMP. METER OR POLE INS. 20.00
APPLICANTS
ADDRESS _
MOTORS .
6�P� SOH
'-SERVICE
CHANGE 2`0.00
'
I V
Tll y, ,,I
a 9`
LICENSED CONTRACTORS DECLARATION
191 O J 3
I hereby affirm that I am licensed under provisions of Chapter 9
si y` a
ISS '4' EroinTE^ne' "'nO
(commencing with Section 7000) of Division ,3 of the Business and
Professions Code, and my license is in full force and effect.
License Class Lic. Number
Dole-Contact.,
,.{ (s11g8 11
BLDG.
ELECT. PLG. MECH.
❑ 1:1 ❑
is en
BUILDING PERMIT
INFORMATION
OWNER - BUILDER DECLARATION
-
1 hereby affirm that I am exempt from the Contractor's License
Law for the following reason.( Sec. 7031.5, Businessman Professions
Code: Any city or county which requires a permit toconstruct ,alter,
.'MISC.
-. REFER TO ORD
--
pERMIT ISSUANCE 10.00
•�-'
VALUATION
$ /FT.
ELEC. CONTR. UC, NO.
ELEC.
improve, demolish, or repair any structure, prior W its issuance, also
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 Profession, or is ,oioft flisrefrom the
Business and Professions Code) or that he is exempt therefrom and
PERMIT TO
f ) ^ `T( O /
µ a I vEV/
CITY.
_
PLUMBING PERMIT
FEE
STORIES
TYPE CONSTR.
the basis for the alleged exemption. Any violation of Section
by any applicant fire permit subjects the applicuntmacivil penalty
of not more than five hundred dollars [SS00).) :
ALTER- DRAIN - WATER(EA.) -5.00
❑ 1, as owner of the property, or my employees with wages as
their sole compensation, wit] do the work, and the structure is not
BACK FLOW PROTECT. DEVICE ' 4.00
OCC. GROUP
RES. UNITS
-
DRAINS - FLOOR, ROOF„ AR EA,CON D. 5.00
intended or offered for,sole (Sec. 7044, Business and Professions
Code: ]'he Contractor's License Law dues not apply to an owner of
'
a
FIXTURES - PER TRAP 5.00
GAS - EA. SYSTEM - I INC.4 OUTLETS 6.00
property who builds or improves thereon, and who does such work
l himset5 or through his own employees, provided that such improve-
i meats are not intended or offered for sale. If, however, the building
SO. FT. FLOOR AREA
TOTALACREAGE
or improvement is sold within one year of completion, the owner-
builder will have the burden of proving that he dill not but](] or im.
prove for purpose of sale.):
❑, I, as owner of the properly, am exclusively con trading with
I
GAS - EA. SYSTEM - OVER 4 (EA.) 2.00
s
BUILDING USE
RES IND CON PEE Oman
❑ ❑ ❑ ❑ ❑
INDUSTRIAL WASTE INTER. 30.00
licensed contractors to construct the project (Sec. 7044, Business
and Professions Code: The Commoor's License Law does not apply
to an owner of property who builds or improves thereon, and who
LAWN SPRINKLERS - 1 INC 5 V.B. 6.00
LAWN SPRINKLER O_VaER 5 (EA.) 1.00
-
ASSESSORS PARCEL NO.
contracts for such projects will, a controctolis) licensed pursuont to
the Contractor's License Law, - -
SEWER- SANITAR V- TORMEA.200ft /10.00
TRACT NO,
PARCEL NO,
reD Ions ezempl under Sec. , BAP.C. I' or this
WATER HEATERIWpV�NT 1 - 6.00
Owner Date J -0 ye
7
WATER SYSTEM y" 5.00
ACC. DATE
ACC FILE NO.
o RK I?RS'COA I;NSAI'ION DEC (RATION
WATER TREATI G QUIPIIUf ?(1411 5.00
1 hereby affirm that I have a certificate of consent to self- insure,
or a eerlificate of Workers' Compensation Insurance, or a certified
�-
ZONING
ENG. SITE N0.
-
copy thereof(Sec. 3800, Lab.C.L _.
Policy No. Company
• Certified copy is hereby furnished.
• Certified copy is filed with the city inspection' division.
Applicant -
11 ,,
V�`I roof
FIRE SPRINK
Y ❑ N
ENERGY T-24
Y ❑ N❑
- MISC. REFER TO OED.
" .CERTIFICA'1' EOF GXP-M19'ION PROM WORKERS'
PERMIT ISSUP(f�✓rEO nil 10.00
FLOOD ZONE
A.L.U.C.
' COMPIIN$A7'ION INSURANCE
(This section need.not be completed if the permit is for one
-PEG . CONTR. - LIC. NO.
TOTAL
Y ❑ N ❑
Y C] N ❑
hundred dollars(SI00) or less.)
I certify that in the performance of the work for which this per-
unit is issued, I shall not employ any person in any manner so as to
QTY.
MECHANICAL PERMIT
FEE
FEE SUMMARY
BUILDING
become subject to the Workees' Compensation Laws of Calilornia.
Date Applicant -
-
,
ALTER OR ADD TO MECH.. 5.00
-
NOTICE TO APPLICANT: If, after making this Certificate of Ex.
_
APPLIANCE 5.00
PLAN CHECK
FEE
'
enl Ptim" you should beemcc subject do 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 (TO 10,000CF.M.) 4.00
AIR HANDLING UNIT (OVER 1OPWC.F.M.) 6.00
SEISMIC FEE
OG
CONSTRUCTION LENDING AGENCY
I hereby affirm that there is a construction lending agency for
EXHAUST HOOD (WITH DUCT) 5.00
`
the performance of the work for which this permit is issued (Sec.
3097, Civ.C.L
MICROFILM
HEATING UNIT (TO 100,000 B.T.U.) 8,00
Lender's Name
Lender's Address -
HEATING UNIT (OVER 100;000 B.T.U.)9.50
ELECTRIC
W
I certify that 1 have read this application and stale that the above
into ..nation is correct 1 agree to Comply with all city and county
ordinances and slate laws relating to building construction, and
VENTILATION F.(�NI(SIN LE) 4.00
PLUMBING
9r
BOILER- COMP13 .P. or 100,000B.T.U.) 6.00
BOILER- COMP tlOver 140,000BTl11jBEE FEE SOH.
MECHANICAL Ixp
hereby authorize representatives of this city t0 enter upon the
above - mentioned property for inspection purposes.
(We) agiec to save, indemnify and keep harmless the City of
Cupertino against ImbilinlM judgments, costs m'. ezpentts which
m0y In may Wa JCCN agalnSt said city m CDIISeQnence of the
mnling of [his Cnnit.
d L1__4 S
MISC. - J''I' rd REFER TO ORD.
CONST. TAX QI(�
_
PERMIT ISSUA E .j O 10.00
,C{ ( 1l(n
d
MECH. CONT. l,Ll O. MECH.
TOTAL i {
(moo
TOTAL
7�� Qb
nnhue of App ':art /Cmurac[or Da
UFFICE COPY _