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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
PERMI t NUMBER
12265
BUILDING n
ADDRESS / `
Z Z % 7-/,t_0 J
OWNER'S
NAME / 'y 1
MA �EzI/W PHONEL ��i
':, ,p, r,Ty, ., - , ,.
UTV: ,'"�.. r_��."ELECT RIC PERMIT'", -FEE
PLAN CHECK VALIDATION
DATE OF APPLICATION
PLAN CHECK FEE P.C. NU.
CONTRACTORS
NAME
r/!/O[F 4 SFWFf2 LOC.N.�?f 3
UTLETS- SWITCHES -RECEP 10.00/1.00
LIGHTING FIXTURES 10.00/1.00
CONTRACTORS
.ADDRESS Q�J L/ `//��
`'! PHONEZ - f6
ARCHITECT
OR
ENGINEER
LOC. Na.
PPLIANCES-RESIDENTIAL 4.00
PANELS 10.00
PANELS (OVER 200 AMP) 20.0D
SIGNS TRANS. 3.00
ARCH. OR ENG.5.00
ADDRESS
ZIP
SPECIAL CIRCUIT
PERMIT VALIDATION
e�J
� Y
TEMP. METER OR POLE INS. 20.00
APPLICANTS
AOOflsss
MOTORS SEE FEE SCH.
SERVICE CHANGE 20.00
LICENSED CONTRACTORS DECLARATION
I hereby affirm that I am licensed under provisions of Chapter 9
(commencing with Section 7000) of Division 3 of the Business and
Professions Code n mg license Is in full force n f t
License lass- // Lic. Number
ISSUANCE DATE
BLDG. ELECT. PLG. MECH.
❑ ❑ ❑ 0
-Ar 009
Dale CoNmc[or
BUILDING PERMIT
OWNER -BUILDER DECLARATION
I hereby s((inn that I am exempt from the Conlracloi s License
Law far the following reason. (Sec. 7031.5, Business and Professions
Code: Any city or county which requires a permit to construct, alter,
improve, demolish, or repair any structure, ptiot la its issuance, also
requires the applicant for such permit to file a signed statement [list
INFORMATION
MISC. - REFER TO OR
VALUATION $/FT.
PERMIT ISSUANCE 10.00
LIC. NO.
FLEC.
TOTAL
PERMIT TO
he is licensed pursuant to lite provisions of the Conlmetor's License
Law (Chapter 9(commencingwith Section 7000) of Division 3 oflhe
Business and Professions Code) or that he is exempt therefrom andMBING
bails for Ilse alleged exempt tan. Any viola) ion of Sect ion 7031.5STORIES
by any applicant for a permit subjects the applicant ton civil penalty
of not more than five hundred dollars (5500).):
PERMIT.the
9iai;
TYPE CONBTR.
III VENT -WATER IEA.)
DEVICE 4.00
OCC. GROUP
RES. UNITS
❑ 1, as owner of the properly or my employees with wages asROTECT.
their sole compensation, will do the work, and the structure is not
intended or offered for sale (Sec. 7044, Business and ProfessionsR,
ROOF, AREA, CONO. 5.00
Code: The Contractor's License Law does not apply to an owner of
property who builds Or Improves thereon, and wlln does sHch work
himself or through his own employees, provided Ilat such ingmove-
mentsarenotintendedorofferedforsale. If, however, lite hufiling
FIXTURES, PER TRAP 5.00
SO. FT. FLOOR AREA
TOTAL ACREAGE
GAS-GAS-11NC.40UTLETS 6.00
or Improvement is sold within one year of completion, the owner-
builder will have the burden of proving that he did not build or im-
prove for purpose of sale.).
❑ I, as owner of the property, an exclusively contracting with
licensed contractors to construct the project (Sec. 7044, Business
GAS - EA. SYSTEM -OVER 4 IEA.1 2.00
BUILmNG USE
RES IND CON Pit Other
INDUSTRIAL WASTE INTER. 30.00
LAWN SPRINKLERS - 1 INC 5 V.B. 6.00
ASSESSORS PARCEL NO.
and Professions Code: The Contractor's License Law docs not apply
to an owner of properly who builds or improves thereon, and who
LAWN SPRINKLERS - OVER 5 (EA.) 1.00
contracts for such projects with a contractor(s) licensed pursuant toSEWER-SANITARY-STORMEA.
the Contractor's License Law.
20011/10.00 Of'
TRACT NO.
PARCELNO.
WATER HEATER W/VENT 6.00
❑ lam exempt under Sec. ,B.&P.C. fnr this
reason
Owner Date
WATER SYSTEM 5.00
ACC. DATE
ACCFILE NO.
WORKERS'COMPENSATION DECLARATION
WATER TREATING EQUIP. 5.00
I hereby air,,. [hal I have a cer[ifielt a of consent to self -insure
( or a'certificate of Workers' Compensation Laurance, or a certified
copy Iherecf(Sec. 3800. Lab.C.)t7.UrI+O.
Policy NrT Company
ZONING
ENG. SITE NO.
❑ Certified copy is hereby furnished.
Celdil' d co Y is '1 the mly ins a lion division.
I %i a: A I c
Applicmh Le-
FIRE SPRINK
V [] N❑
ENERGY T-14
Y o NL]
MISC. - REFER TO ORD.
-
PERMIT ISSUANCE 10.00 %
FLOOD ZONE
Y ❑ NE]
A.L. u.c.
Y N
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(This section need not be completed If the permit Is for one
PLG. CONTR. LIC. NO.
PLG. Gs U
TOTAL
QTY. MECHANICAL PERMIT FEE
FEE SUMMARY
hundred dollars (S 100) or less.[
I certify that in the performance of the work for which this per
all is issued, I shall not employ any person in any manner so as to
.
become subject to the Workers' Compensation Laws of California.
Date Applicant
BUILDING
ALTER OR ADD TO MECH. 5.00
NOTICE TO APPLICANT: IL after making this Certificate of Ex-
emption, you should become subject to the Workers' Compensation
provisions of the Labor Code, you must forthwith comply with
such provisions or this permit shall be deemed revoked.
APPLIANCE 5.00
PLAN CHECK
FEE
AIR HANDLING UNIT ITO 1OPMr-F.M.) 4.00
AIR HANDLING UNIT (OVER IQOOOC.EM.16.00
SEISMIC FEE
CONSTRUCTION LENDING AGENCY
EXHAUST HOOD (WITH DUCT) 5.00
MICROFILM
I hereby affirm that [here is a construction lending agency for
the performance of the work for which this permit is issued (Sec.
3097, CN.C.).
HEATING UNIT (TO 100,000 B.T.U.) 6.00
HEATING UNIT (OVER 100,000 B.T.U.) 9.50
ELECTRIC
Lender's Name
Lenders Address
I certify that l have read this application and state that the above
information is correct. I agree to comply with all city and County
ordinances and stale laws relating to building construction, and
VENTILATION FAN (SINGLE) 4.00
PLUMBING
j4 r./D
J
BOILER-COMPI3 H.P. ar 100,000 B.T.U.) 6.00
BOILER -COMP IOver t00,0008TUI SEE FEE SCH.
MECHANICAL
hereby authorise representatives of this city to enter upon the
above-mentioned property for inspection purposes.
(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 consequence of the
MISC. - REFER TO ORD.
_ _
CONST. TAX
PERMIT ISSUANCE 10.00
MECH. CONT. LIC. NO. MECH.
TOTAL
TOTAL
El
gran g of this permit,
%Z�Z' L,`�
1-/ aiv iGi r'r/O"c
5 ¢cure o pphicant/Contractor Date
OFFICE COPY