6284 ' • APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
PERMIT NUMBER
BUILDING PROJECT I DENTIFICATI ON APPLICATION & PERMIT
euILOIrvG
—!' AD R vo �; Q BUILDING —ELECTRICAL—PLUMBING—MECHANICAL 6284
WNER'a-- 1` I - PLAN CHECK VALIDATION
NAE SSf9fb° � FE•I:PECTRICERMIT` �°�'.�-" " FEE -+ r
PHON � , T k
CONTRACTOR'S
NAME OUTLETS-SWITCHES-RECEP 5.00/1.00 s—
LIC.No, LIGHTING FIXTURES 5.00/1.00 J—
NTRACroR's
ADDRESS
PPLIANCES-RESIDENTIAL 4.00
C
PRONE PANELS 5.00 DATE OF APPLICATION
ARCHITECT PLAN CHECK FEE P.C.NO.
OR SIGNS 6.00
ENGINEER
uc.NO SIGNS TRANS. 3,00
ARCH EOR
ENG' SPECIAL CIRCUIT 5.00 PERMIT VALIDATION
zlv EMP.METER OR POLE INS. 15.00 /c/j/CJS
V '
APPLICANTS MOTORS SEE FEE SCH.
' ADDRESS /
SERVICE CHANGE P41D 10.00
w o a LICENSED CONTRACTORS DECLARATION -T
a u I hereby all'irm that 13M licensed under provisions of Clwpter 9 ISSUANCE DATE
w< w (comntenCing with Seeliun 7000)of Division 3 of the Business and
m PBLDG. ELECT. PLG. MECH.
o License Class Li
F z rofessions Code,and my her,,.Bin full force and effect. ❑ EL El Elz m — a Number City of Cupertino .
9 — D Ditc Contractor
H w
Ix w 4. OWNER-BUILDER DECLARATION 7,:1 BUILDING PERMIT
w ;LL H I hereby affirm that I am exempt from the Contractor's License MISC.— - REFER TO ORD t_
,J_N,FDRMATIDN
u o j Law for the following reason.(Sec.7031.5,Business and['ro(essions VALUATION $/FT,
PERMIT ISSUANCE 60014" "—
Cod¢Any city or county which requires a permit to construct,alter, ./ft
QO improve,demolish,or repair any structure,prior to its issuance,also ELEC.CONTR. LIC.NO. ELECO—
. /
n wD 2 requires the applicant for such permit to file a signed statement that TOTAL PERMIT TO
$ he Is licensed pursuant to the provisions of the Contractors License �a,
Law(Chapter 9(commcncing with Section 7000)of Dinson3ofthe s. .Ms °`2 .,-"x'+` atx4 1.` nat4
x c Business and Professions Code)or(hat he is exempt therefrom and OTV1 7�-'PLUMBINGVP.ERMIT a `•`- FEE
W F- the basis for the alleged exemption.Any violation of Seclion7031 5 "OY' sAb >�"-'. ° 5*+' ,s P e R STORIES TYPE CONSTR.
by any applicant fora permit subjects the applicant toacivil penalty ALTER-DRAIN -WATER (EA.) 4,00
of not more than five hundred dollars(my em: -
❑ I,as owner of the property,or my employees with wages as BACK FLOW PROTECT. DEVICE -2.00 OCC.GROUP RES.UNITS
their sole compensation,will do the work,and structure is not
intended or offered for sale (Sec. 7044, Businessess and Professions DRAINS-FLOOR,ROOF,AR EA,COND. 4.00
Code:The Contractor's License Law docs not apply to an owner of
property who builds is improves thereon,and who does such work FIXTURES-PER TRAP 4.00 a0.FT.FLOOR AREA TOTAL ACREAGE
himself re through his own employees,provided that such improve-
ments.....re neatiended or within
on yearsale.o if,however,thebuildingower- GAS-EA.SYSTEM-1INC.4OUTLETS 4,00
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- IGAS-EA.SYSTEM-OVER 4 (EA.) 7,00 BUILDING USE
prove for purpose of sale.). RES IND CON PB OtherINDUSTRIAL WASTE INTER. , 20.00 ❑ ❑ � ❑ ❑
❑ d as owner rs the property,he exclusively contractBusine h
andPro contractors In construct the project(Sec.7044,Business LAWN SPRINKLERS-1 INC 5 V.B. 5.00 ASSESSORS PARCEL NO.
and Professions Code:The Conbuilds a License Law does not apply
to tr owner of property who builds t r improvesrasedthereon.and who LAWN SPRINKLERS-OVER 5(EA.) 1,00
contracts for such cenjecta with a conlmcfor(s)licensed pursuant to
the Contractor's License Law. - SEWER-SANITARY-STORM EA.200ft/8.00 TRACT NO, PARCEL NO.
❑ lam exempt under Sec.—,B.&P,C.for this WATER HEATER W/VENT 4.00 '
(Ca]an
Owner- Date f'j,— WATER SYSTEM 4.00 ACC.DATE ACC.FILE NO.
WORKERS'COMPENSAI'ION DECLARATION WATER TREATING EQUIP. 4.00
I hereby Id7irm Dmf I have a certificate of elnlsent to sel&insum,
or a certificate of Workers'Compensation Insurance,ar a certified ZONING ENG.SITE NO.
copy thereof(Sec.3800,Lah.C..).
Iblicy No, Company
O 0 Certified copy ishereby furnished. FIRESPRINK ENERGY T-14
Z Z ❑ Certified copy is filed with the city inspection division. MISC- REFER TO ORD.
O Applicant Y❑ N❑ Y ❑ N❑
~ va PERMIT ISSUANCE 6.00
LuCIiR'I'FICA] OF I AX I PTINS FROM WORKERS' FLOOD ZONE A.Lu.C.
W COMPIiNSATION INSURANCE PLG.CONTR. LIC.NO. PLG, V❑ N❑ Y❑ N❑
CL Z f I ins section need not be completed if the permit is for one _ + • TOTAL
hunArcA dollars(8100)or luxs.) a .0 „ 4 bA r a,w NUN,H a; �sv
U O - I certify that In the performance of the work for which this per A -q s - x e .+ �p ka W:fij FEE SUMMARY
LL H mit Is Issued,I shall not employ any person in any manner so as to QIF 4- _. :MECHANICACP•ERMIT •, ry p FEE ;I`4 e ,. t.s,.a„o.�
O W becomesubject to the Workers'Compensation Lawsof California, v
Q_ Dat. - Applicant - ALTER OR ADD TO MECH. 4.00 BUILDING
} So NOTICE 'TO APPLICANT: 11,after making this Certificate of Ex'
♦— ? crop,ion,you should become subject to the Workers'Compensation APPLIANCE 4.00 . PLAN CHECK
provisions of the Labor Code, you must forthwith comply with FEE
U such provisions or this permit shall be deemed revoked AIR HANDLING UNIT(TO 10MC.F.M.) 3.00
CONSTRUCTION LENDING AGENCY AIR HANDLING UNIT(OVER I0.00DC.F.M.) 5.00 SEISMIC FEE
I hereby aIirn that there is a construction lending agency for EXHAUST HOOD (WITH DUCT) 2.00
the performance of the work for which this permit is issued(Sec. MICROFILM
3097,Civ.C.). HEATING UNIT(TO 100,000 B.T.U.) 4.00
Lender's Name H EATING UNIT(OVER 100,000 B.T.U.)7.50 ✓
Lender's Address ELECTRIC
I certify that I have read this application and slate that the above VENTILATION FAN (SINGLE) 3.00
information is correct. 1 agree to comply with all city and county BOILER-COMP(3 H.P,fit 100,0008.T.U.) 4.00 PLUMBING
mminanecs and stale laws relating to building construction, and
hereby authorize representatives of this city to enter upon the BOILER-COMP Over 100,000 BTU)SEE FEE SCH. MECHANICAL
above-mentioned property for inspection purposes.
(We) agree to save, indemnify and keep harmless the City of MISC.- REFER TO ORD.
' pertino against liabilities,judgments, Costs and expenses which PERMIT ISSUANCE - - 3.00 - CONST.TAX
s, in any y accrue a last s 'd in onsequence of the '
Icing of 11
I is er lI ECH.CONT. LIC.NO. MECH.
TOTAL ".TOTAL .
Si eft Applicant/Contracln Date
OFFICE COPY