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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
6233
aUILDING �s nq,q� l gtiI
ADss DRE
N
OWrveR'S
NAME �w �Cuh,/) ml: ._
OTY. ELECTRIC PERMIT FEE
PLAN CHECK VALIDATION
PHONE
'
DATE OF APPLICATION
PLAN CHECK FEE P.C. NO.
CONTRACTOR N
OME /
.Gf•Q-� �7ee-4 LIC. No. f2
UTLETS-'SWITCHES 2 RECEP 5.00/1.00
LIGHTING FIXTURES 5.00/1.00
CONTRACTORS /E}7, Y/,'ewy/S
AOOR ESSS.yam Q
115's,05/ef bA /.Ja 0.PROrvE (Ij7 y OZ
ARC HDECT
OR
ENGINEER
LIC. NO.
PPLIANCES- RESIDENTIAL 4.00
PANELS 5.00
SIGNS 6.00
SIGNS TRANS. 3.00
ARCH. OR ENG.
ADDRESS
Lar
SPECIAL CIRCUIT 6.00
PERMIT VALIDATION
/X, /��
EMP. METER OR POLE INS. 15.00
APPLICANTS
ADDRESS
MOTORS SEE FEE SCH.
SERVICE CHANGE 10.00
LICENSED CONT' RAC'TORS DECLARATION
1 herchy affirm that 1 am licensed under provisions of Chapter 9
(commencing with Section 7000) of Division 3 of the Business and
Professions Coje, and my license is in full forcylatl_cffc t --�
'Licalsc CL sC ' Lie. Nwnber •J �` %
ISSUANCE DATE
BLDG. ELECT.
❑ ❑
PLG. I MECH.
❑
DatcL/_//�Contmctorc�_J.y4,�i•-
OWNIiR-BUILUIiR DECLARATION
1 hereby collo Ilett I am exempt from the Contractor's License
c. rets iresa Permit tocand Professions
Law for nyctileit following co my which
tr uimsa permit to construct,, alter,
Cada: Any city or county which structure,
or repair any permit 101Lie prior Sneits tatemen, also
requires the applicant for such permit In fate a Signed statement that
requires the applicant
he is licensed pursuant to the provisions of the Contractor's License
he is
BUILDING' PERMIT
•TI_
f7ATION ATION „ W.
MISC. - REFER TO ORD
DATION E/FT.
PERMIT ISSUANCE '6.00
ELEG CONTR. LIG NO.
ELEC. ((��
TOTAL OlJ
ER
PERMIT TO
PLUMBING PERMIT FE
svl
Law (Chapter 9 (commencing with Section 7000) of Division 3 of the
Business and Professions Code) or that he is exempt therefrom and
the basis for the alleged exemption Any violation of Section 7031.5
by any applicant for a permit subjects the applicant lou civil penalty
than
of not Lamle than live hundred dollars ($500).1:
IES TYPE CONSTR.
ALTER -DRAIN & VENT -WATER (EA.)4.00 C10
BACK FLOW PROTECT. DEVICE 2.00
OCC. GROUP
RES. UNITS
❑ 1, as of the property, Or my employees with wages as
their sole Compensation, will do the work, and the Structure is not
intended or offered for Sale (Sec. 7044, Business and Professions
DRAINS -FLOOR, ROOF, AREA, COND. 4.00
Code: The Contractors License Law docs not apply to an owner of
property who builds or improves (harcon, and who does such work
himself or through his own employees. Provided lie.( sach I..prove-
Laienlx arc not intended or offered for sale. If, however, the building
FIXTURES - PER TRAP 4.00 d 0
SO. FT. FLOOR AREA
TOTAL ACREAGE
GAS - EA. SYSTEM - I INC. 4 OUTLETS 4.00
or imprnvemcnt is sold within one year of completion, the owner.
milder will have the harden of proving that he did not build or int-
prove for purpose of sale.).
1, as owner of the properly, am exclusively contracting with
licensed contractors to construct the project (Sec. 7044, Business
GAS - EA. SYSTEM -OVER 4 IEA.) 1.00
BUILDING USE
RES IND CON PB Orhe,
-❑ El C1 ❑ 1:1O
INDUSTRIALWASTE INTER. 20.00
LAWN SPRINKLERS- 1 INC 5 V.B. 5.00
r ASSESSORS PARCEL NO.
and Professions Code:I lie Cuntmetur s License Law docs not apply
I. uo owner of Properly who builds or improves thcrcun, and who
LAWN SPRINKLERS - OVER 5 (EA.) 1.00
conuaots for such projects with a contractor(s) licensed pursuant to
the Comrac(or's License Law,
SEWER-SANITARYV-STORM EA. 200fI/8.00
TRACT NO.
PARCEL NO.
WATER HEATER W/VENT 4.00
O I emcxcmpt under Sea ,B.&P.C. for this
.."a
Owacr Date
WATER SYSTEM 4.00
ACC. DATE
ACF FILE NO.
'
WORKERS'COMPENSATI ON DECLARATION
WATER TREATING EQUIP. 4.00
1 hereby affirm That I have a curl it [tate ofcmxCGI to wIf-insure,
or a certificate of Workers' Compensation Insdrunce�, or La cerci Dcd
copy thereof(SeC. 3800. UILC.). ;
Policy No. Company h
ZONING
ENG. SITE NO.
.
❑ Certified copy is horeh urnlsbtRl�
u Cc Py h the t inspection division.
Apprab, "'� --
- CERTIFICA'1'1: OF FXEMP1'ION FROM WORKERS'
FIRE SPRINK
v ❑ N ❑
ENERGY T24
v ❑ N
MISC. - REFER TO ORD.
PERMIT ISSUANCE 6.00 QV
FLOODZONE
A.L.0 c.
PLG.CONTR. LIC. NO.
PLG. /�
TOTAL
COMPENSATION INSURANCE
1'I'his CCHCe need not he complutcd it the Permit is for oI s
hlmdrCddo1lursl$1001orlc11.)
I ceflity thal in the performance of the work for which this PCr-
mi( is issued, I shall not employ any person in any manner so as to
become subject to the Workers Compensation Laws of California.
Dale Applicant
V❑ NO
Y❑ N❑
DTV. MECHANICAL PERMIT FEE
FEE SUMMARY
BUILDING
I OR ADD TO MECH. 4.00
NOTICE 'ID APPLICANT. If, after nmking (his Certificate Of Ex-
cnGuion, you should become subject to the Workers CompensationNCE
provisions of the Labor Code, you must forthwith comply with
such provisions or this permit shall be deemed revoked.
4.00
PLAN CHECK
FEE
DLING UNIT (TO 10MCF.M.) 3.00
DLING UNIT(OVER 10=1C.FM.15.00
SEISMIC FEE
coNs'fRUCr1ON LENDING AGENCY
HOOD (WITH DUCT) 2.00
MICROFILM
I hereby affirm that there is a construction lending agency loxST
the performance of the work Ox which this permit is issued (Sec.NG
3097, Ce,.C.).
UNIT ITO 100,000 B.T.U.) 4.00
R
NG UN IT(OV ER 100,000 B.T.U.)7.50
ELECTRIC
Lender's Name
Lender's Address
I certify that l have read this application and state that the aboveLATION
information is correct. I agree In comply with all city and county
Ordinances andsnitc laws relating to buibIVag construction, and-CONP.(3
FAN(SINGLE) 3.00
PLUMBING
H. P. or 100,000 B.T.U.) 4.00hereby
(Over too,000 BTU) SEE FEE SCH.
MECHANICAL
authodee representatives of this city to enter upon thR-COMP
above-mentioned properly for inspection purposes.
(We) agree to Save, indemnify and keep harmless the City of
Cupertino against liabilitiescosts and expenses which
only is any way- -' iJ 1 in consequence of the
grunt the r 1.
/o //"/S-
MISC. - REFER TO ORD.
CONST. TAX
PERMIT ISSUANCE 3.00
MECH. CONT. LIC. NO.
MECH.
TOTAL
TOTAL; .
Ignature ant/Contac or Dale
OFFICE COPY