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APPLICANT TO FILL IN INFORMATION WITHIN,RED,LINES -'USE BALL POINT PEN ONLY
PER
BUILDING PROJECT IDENTIFICATION
' OFFICE COPY
APPLICATION & PERMIT
BUILDING- ELECTRICAL- PLUMBING - MECHANICAL
MITNUMBER'
' 6 6 9 8-
6698
IILDING
(� A/ F� 'O
OW�NfEPp'S /l --• - py0Q
NAME 8
PHONE
s tI e.,
M
Qdo
TYi 6,E"LEyq'rtnh r nus ^,
PLANCHECKVALIDATION
-
DATE PLAN CHECKFFEE APPLICATION
N0.
'
PERMIT VALIDATION
/r
J
crOns
NAME
NAME
I. no.
UTLETS-SWITCHES-RECEP 5.00/1,00
LIGHTING FIXTURES 5.00/1.00
AVDRESsT fry�f- 'omi•+u lC(iw( yds
PHONE 969 ef7o/
ARCHITECT -
OR
ENGINEER
/! - .t' A/.R sec. No. .?�Ossli
ARCH, OR ENG.
ADDRESS z�$il/L `/I M(! fCr•{z,
PPLIANCES-RESIDENTIAL_ 4.00
PANELS ' 5.00
SIGNS 6.00
SIGNS TRANS. 3.00
SPECIAL CIRCUIT ., _ 5.00
EMP. METER OR POLE INS. - 15.00
APPLICANT'S
ADDRESS
07A a c -
MOTORS - ^ SEE FEE SCH.
SERVICE CHANGE ' h 10.00
LICENSED CONTRACTORS DECLARATION
I hereby at that I am licensed under provisions ol'Chapter 9
(Commencing with Section 7000) of Division 3 of the Business and
Professions Code, and my lice So is in full force a d e NI /
License C -Cvf6 Lic. Number O
Date Contactor - fd'oc_
ISSUANCE DATE
-
BLDG.
. ❑
ELECT, PLG.
❑ ❑
MECH.
❑
A
A
BUILDING PERMIT
- OWNER-BUILUIIR DECLARATION
'I hereby affair that I am exempt from the Contractor's License
Law for the followingreason.(Sec. 7031.5, Busimantnd Professions
Code: Any city or County which requires a petmit to Construct, alter,
improve, demolish, or repair any shouclnm, pro, ID its Issuance, also
requites the applicant for such permit to file a signed statement that
he is licensed pursuant to the provisions of the Contractor's License
Law (Chapter 9(cammencing with Section 7000)of Division 3 of the
Business and Professions Code) or that he is exempt therefrom anJ
the basis for thenllegcd exemption. Any violation ofSectic 7031.$
by any applicant for a permit subjects the' applicant to a civil penalty
of not mom than five hundred dollars (5500).):
INFORMATION
MISC.- 'REFER TO OR
UATION $/FT.
�'�
PERMIT TO
S'
. PERMIT ISSUANCE 6.00
ELEC. CONTR. LIC. NO.
ELEC. (� yp ( f1
TOTAL City oI Y
-
��'
QTY. PLUMBING PERMIT FEE
,Pi'..
ALTER -DRAIN & VENT -WATER (EA.)4.00
STORIES
TYPE CONSTR.
'
❑ I, as o ener,of the property, or my employees witlh 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
properly 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 4.00
SO, FT. FLOOR AREA
TOTAL ACREAGE
-
GAS=EA.SYSTEM-11NC.40UTLETS 4.00
or improvement is sold within one year of completion,. the owner-
builder will have the burden of proving dull he did not build or ire-
prove l'or purpose of sale.). ` '.. I '-
❑ Las owner of the property, am exclusively contracting with
licensed contractors In, construct the project (Sec. 7044, Business
GAS - EA. SYSTEM - OVER 4 (EA.) 1.00
BUILDING USE
RES IND CON PB Omer
❑ ❑ ❑ ❑ ❑
INDUSTRIAL WASTE INTER. 20.00
-
LAWN SPRINKLERS - 1 INC 5 V.B. 5.00
ASSESSORS PARCELING. -
and Professions Code: The Contractor's License Law does not apply
to an owner or property who buildsor improves thereon, and who
LAWN SPRINKLERS - OVER 5 (EAI) 1.00
contracts for such projects with a contractors) licensed pursuant to
the Contractors License Law.
SEWER -SANITARY -STORM EA. 200ft/8.00
TRACT NO.
PARCEL NO.
WATER HEATER W/VENT 4.00 '
❑ I an, ew:ninMlnde, Sec., 114P.C. ]or this
reason /' 7
_
Owner= . - <"'= .-o+e
WATER SYSTEM 4.00
ACC. DATE
ACC. FILE NO.
WURKERS'COMPENSATION DECLARATION
WATER TREATING EQUIP. 4.00
I hereby drrm.tlmlI have a certiEcnte of consent to self insure,
or a certificate of Workers' Compensation Insuran^e, or.a:ccrtififscd
ZONING
ENG. SITE NO.
_
'copy lhereof(SA. 3900, Lab.C. h.!y
Policy Isr Company /,4^,.oA
❑- Certified copy is hereby furnished,
❑ CertifjFeT�jQj)j--i�filed�,+wiMi the city inspection Division.
APPlic(7vir -+r
-
FIRE SPRINK
Y❑ 'N❑
ENERGY T$4
I Y❑ N❑
MISC.- REFER TO ORD.
PERMIT ISSUANCE 6.00
FLOOD ZONE
A.L.U.C.
CF-RTIFICA'I'1:OP EXEMPTION 1°110 NI WORKERS'
PLG. CONTR. LIC. NO.
PLG.
TOTAL
COMPENSATION INSURANCE
d^•'
(I his section need not tic completed if the permit is I'or one
V❑ N❑
V❑ N❑
�.,� 11 -. -„'b
OTV P w'!'"s*" v MECHANICAL%PE RM IT'•p 'a„'N,�s,�Ty° 'Y`FEER�y
*n ., • s„yrs ;!r± su{`+1xy
i °'r'""s"'A'®P
yy,„"+.*r t,'�FEE SUMMARY
BUILDING
r
hundred dollars($ 100) irc less.)
I certify that in the performance of the work for which this per.
out Is issued, I shall not employ any person in any manner so as to9N�'.
- become subject tolhe Workers'Compensation Laws of California.
Date - Applicant
NOTICE TO APPLICANT: If, after making this Certificate of Ex-
enlplinn,'you.should become subject to the Workers' Compensation
provisions of the Labor Code, you misp'forthwllh comply with
such provisions or this permit shall be deemed revoked.
''CON SI' RUCTION I.1?NDING AGENCY'
ALTER OR ADD TO MECH. 4.00
APPLIANCE 4.00
PLAN CHECK
FEE
AIR HANDLING UNIT (TO l0=C,F.M.I 3.00
AIR HANDLING UNIT (OVER I0,000GF.M.) 5.00
SEISMICFEE
EXHAUST HOOD (WITH DUCT) 2.00
MICROFILM
' 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.).
HEATING UNIT (TO 100,000 B.T.U.) 4.00
HEATING UNIT (OVER 100,000 B.T.U.P.50
ELECTRIC
Lendir's Name
Lender's Addr,ss'
. I certify that I have read this application and state that the above
inl'onnation is correct. I agree to comply with all city and countyPLUMBING
ordinances and state laws relating to building construction, and
VENTILATION FAN (SINGLE) 3.00
-
^
..
BOILER -COW (3 H.R. Or 100,000 B.T.U.) 4.00'
BOILER -COMP (Over 100,000 BTU) SEE FEE SCH.
MECHANICAL
hereby anthorre repiescntalives of this city to enter upon the
above-mentuRcd properly for inspection purposes.
MISC. - REFER TO ORD.
(We) 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 sequence of the
granting of tispr h. / /
6 � { 0 2/
CONST. TAX
-
- PERMIT ISSUANCE - . 3.00
MECH, CONT. - LIC. NO.
MECH.
TOTAL
,,TOTAL'
3J
Signature of Applicant/Contractor Date
' OFFICE COPY