8283 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
BU LDI NG PROJECT 1 DENTI FICATI ON PERMIT NUMBER
BDnDINGL pT. a APPLICATION & PERMIT A
ADDRESS `{'
BUILDING-ELECTRICAL-PLUMBING -MECHANICAL
OWNER'
(45S 1 NAME. /� tZB.T,NO '� `�1„�2 PLAN CHECK VALIDATION` P QTY. ELECTRIC PERMIT FEE
ONE
CONTRACTORS
rvaME OUTLETS-SWITCHES-RECEP 10.00/1.00
I.C.NO, LIGHTING FIXTURES 10.00/1.00
A -
ADDRESS
DREss - APPLIANCES-RESIDENTIAL 4.00
PHONE PANELS 10.00 DAT E OF APPLICATION
ARCHITECT PLAN CHECK FEE P.C.NO.
OR PANELS (OVER 200 AMP( 20.00
ENGINEER
G LIC.No. SIGNS TRANS. 3.00
ARCH.DR ENG.,-'1a� PER TION
aDOREss A, S- SA241' c/S wNY rf SPECIAL CIRCUIT 5.00 8
C r R� EMP.METER OR POLE INS. 20.00 ^+L/
ADDRESS Ts 130 -:y- /yi ,(/ MOTORS SEE FEE SCH. 'JUL '1I(1e
SERVICE CHANGE 20.00 1 'J05
o 0 i
Foo LICENSED CON TRACTORS DECLARATION TEMP.POLE 30.00 .City of Cupertino
a v D I hereby affirm that I am licensed under provisions of Chapter 9
h a n (commencing with Section 7000)of Division 3 of the Business and ISSUANCE DATE
BE ELECT. PLG. MECH.
a i I'rofeoions Code,and my license is in full force and effect
o
i w o License Class- Lic.Number
m H Date Contractor
a r / BUILDING PERMIT
rt w ¢
OWNER-BUILDER DECLARATION
w ; ac y I hereby m ire that am exempt from the Contractor's License MISC.- REFER TO ORD INFORMATION
Law for the following reason.(Sr,7031.5.Busincssand Professions es PERMIT ISSUANCE vgLOATION $/FT.
Code:Any city or county which requiresa permit to construct,alter, 10.00
Qrt ¢ improve,demolish,or repair any structure,prior to its issuance,also ELEC.CONTR. LIC.NO. ELEC.
E m u requires the applicant for such penal(to file a signed statement that TOTAL
' he is licensed pursuant to the provisions of the Contractor's License VERMIT 0 y
e, Ps Law(Chapter 9(commencing with Section 7000)of Division 3 ofthc
x ao Business and Professions Code)or that he is exempt therefrom and CITY. PLUMBING PERMIT FEE I II
a H.m'^ the basis for the alleged exemptimt.Any violation of Section 703 L5 STORIES- T CON
a �_ by any applicant fora permit subjects the applicant toe civil penalty ALTER-DRAIN -WATER IEA.) 5.00 f�
of not more than five hundred dollars(55001.):
❑ 1,as owner of the property,or my employees with wages as BACK FLOW PROTECT. DEVICE 4.00
their sole compensation,will do the work,and the structure is not Occ.GROUP LR 5.UNITS
intended or offered for sale(Sec. 7044, Business and Professions DRAINS-FLOOR,ROOF,AREA,COND. 5.00
Code:The Contractor's License Law does nor apply to an owner of
property who builds or improves thereon,and who docs such work F IXTURES-PER TRAP 5.00 s0.IT.FL DR AREA TOTA@CREAGE
. himself or through his own employees,provided that such improve-
mentsarenotintendedorofferedforsale.If however,the building GAS-EA.SYSTEM-1 INC.4 OUTLETS 6.00
m
or auprovnunt is sold within one year of completion, the owner- GAS-EA.SYSTEM-OVER 4(EA.) 2,00
builder will have the burden of proving that he did not build or im- 0 DING USE
prove for purpose of tiled' INDUSTRIAL WASTE INTER. 30.00 RE5 I❑ ❑N o °o
I,as owner of the property,am exclusively cool reefing with
li sed contractors to construct the project(Sec. 7044,Business LAWN SPRINKLERS- 1 INC 5 V.B. 6.00 ASSESSORS PARCEL NO.
and ofessions Code:The Contractor's License Law does not apply
to an owner of property who huiWa or improves thereon.and who LAWN SPRINKLERS-OVER 5 (EA.) 1.00
contracts for such projects with a contmctor(s)licensed pursuant to
the Contractor's License Law. SEWER-SANITARY-STORM EA.200ft/10.00 TRACT NO. PARCEL NO.
❑ tato exempt under Sea ,B.&P.C.for this
reason WATER HEATER W/VENT 6.00
Owner / IDat_e ' WATER SYSTEM 5.00 A ACC.FILE No.
RKRts�^ �' -CLAI>-ATIo,� WATER TREATING EQUIP. 5.00
1 (tetchy offinn that I have a"Hificate of onsent to setI'-insure.
or a certificate of Workers'Compensation Insurance,or a certified ZONING ENG SITE NO.
copy thereof(Sec.3800,Lab.CJ.
Policy No. Company
O. ❑ Certified copy is hereby furnished. RE SPRINK ENERGYTY4
Z Z ❑ CerritaA copy is Bled with the cilY inspection division.
p Applicant misc.- REFER TO ORD. Y [] N[:] Y [D NE]
Cr TCIi RTI PICATIi OP EXEMPTION TION fh1 ROWORKERS' PERMIT ISSUANCE 10.00 AL. .0
FLOOD ZONE u .
W > COMPIiNSATIOTION INSURANCE PLG.CONTR, LIC.NO. PLG.
CL O (l his section need not be completed if the permit is for one TOTAL Y❑ NE] Y N1)
::lZ hundred dollars($100)or less)
U O 1 certify that in the performance of the work forlwhich this per- CITY. MECHANICAL PERMIT FEE FEE SUMMARY
LL U mit is issued,I shall not employ any person in any manner so as to
baonrn subject to the Workers Compensation Laws of California.
ED )etc Applicant BUILDING
} UD NOTICE TO APPLICANT'. If,alter making this Certificate of Ex- ALTER OR ADD TO MECH. 5.00
Z entprlon, u should become subject to the Workers'Com APPLIANCE 5.00 PLAN CHECK W s
F _ you poly with
provisions io the Labor Code, you must forthwith comply with
U such provisions or this permit shall be deemed revoked. AIR HANDLING UNIT(TO 10,000GF.M.) 4.00 FEE 3
CONSTRUCTION LENDING AGENCY AIR HANDLING UNIT(OVER 10=C.F.M.) 6.00 SEISMIC FEE IT
1 hereby affirm that there is a construction lending agency for EXHAUST HOOD (WITH DUCT) 5.00
the Performalice of thework!or which this permit is issue)(Sec.
Lender's Nen,c_R,4 - - MICROFILM
3097,Civ.C:). HEATING UNIT(TO 100,000 B.T.U.) 8.00
&n Q-, i G
Lender's Addrb�' HEATING UNIT(OVER 100,000 B.T.U.)9.50 f I•
I clHity that) , cl`Nf_ft this up`plicnn�� tucth✓'j"sett ihcubovn VENTILATION FAN (SINGLE) 4.00
information is correct 1 agree to comply with all city and countyPLUMB( G
• ordinances and state laws relating to building construction, and BOILER-COMP(3 H.P.or 100,000 B.T.U.) 6.00
hereby aurhorid ropresenfor insve, of this city es enter upon the BOILER=COMP (Ove 100,000BTU(SEEFEESCH. MECHANICAL
herebyn aulioned property for inspection purposes.
(We) agree to save, indemnify and keep harmless the City of / MISC.- REFER TO ORD.
Cupertino against liabilities,judgments, costs and expenses which
CONST.TAX '
may in any way accrue against said City in consequence of the PERMIT ISSUANCE 10.00
granting of thispcnnit. MECH.CONT. LIC.NO. MECH.
atTOTAL TOTAL n
" nure o . pp ea t/C ntrado Dale fd
INSPECTOR COPY '