8144APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
- -BUILDING PROJECT IDENTIFICIMN.
APPLICATION & P IT
BUILDING - ELECTRICAL - PLUMBING - MECHANICAL
PERMIT NUMBER
8144 "
BILGING
AGgRE
` 4F
awNER "T -
NAME
7. •L, ebc/ C , PRONE 5s -
QTY.
ELECTRIC PERMIT
FEE
PLAN CHECK VALIDATION
,
DATE OF APPLICATION
NAME
W C.NTRACTORS ••��.. p
P bet VL'C In LC.N0.3p 24i8qC10
1E
UTLETS - SWITCHES - RECEP 10,00/1.00
M
LIGHTING FIXTURES 10.00/1.00
CONTRACTORS ADDRESS R's Sn-•� se CY/9
RES S/f
/ P alI PHD.E Z -
PPLIANCES - RESIDENTIAL - 4.00
PANELS - 10.00
oRcHRECr -
ENGINEER ."
' uc. rvo.
pANELS(OVER 200 AMP) 20.00
PLANCHECKFEE P.C.NO.
-
SIGNS TRANS... 3.00
ADDRESS Ervc.
ZIP
SPECIALCIRCUIT' 5.00
PERMIT VALIDATION
_ ISSUANCE DATE
SLOG. ELEC PLG. MECH.
❑ ❑ ❑
TEMP. METER OR POLE INS. 20.00
APPLICANT'S
ADDRESS
qy�!//: p 40 SP (' 19 95-11f
M OTORS SEE FEE SCH.
SERVICE CHANGE 20.00
LICENSEDCON- FRACTORS DECLARATION
I hereby aftinn that I am licensed antler provisions of Chapter 9
(commencing with Section 7000) of Division 3 of the Business and
Professions Code and my license is in full force and a fe
Licens` Class -e2 Lic. Numher�
Date �f0 •- .1Q_= Conlractor,er,.
OWNER- RUILDER DECLARATION
• I hereby affirm that 1 am exempt from the( License
Law for the following reason. (Sec. 7031.5, Businessand Professions
Code: Any city or county which requiresa permit loconslrucpalter,
improve, demolish, or repair any structure, prior to its issuance, also
requires the applicant for such permit to file a signed statement that
lie is licensed pursuant to the provisions of the Contractor's License
Law (Chapter 9 (commencing with Section 7000) of Division 3 of the
Business and Professions Code) or Gmt he is exempt therefrom and
I lie basis for the alleged exemption. Any violation of Section 7031.5
by any applicant fora permit subjects$500N.licant to a civil penalty
of not more than five hundred dollars (5500)J:
❑ I, as owner of the property, or my employees wi0i wages as
their sole compensation, will do the work, and the structure is not
intended or offered for sale (Sec., 7044, Business and Professions
Code: The Contractor's License Law does not apply to'an owner of
property who builds or improves thereon, and who does such work
himself or through his own employees, provided that such improve-
ment s are not intended or offered for sale. If, however, the building
S for 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, am exclusively contracting with
licensed contractors to construct the project (Sec.•7044, Business
and Professions Code: The Coritmetor's License Law does not apply
to an owner of property who builds or improves thereon, and who
contracts fOFSLICh projects with a contractor(s) licensed pursuant to
the Contractor's License Law.
❑ 1 a exempt under Sec. ,B. &1'.C. for this
reason
TEMP; POLE 30.00
•= 3
- '
BUI DING PERMIT
I FORMATION
MISC. - REFER TO ORD-
"-
PERMIT ISSUANCE _ 10.00
VALUATION
E /FT.
ELEC. CONTR. LIC. NO.
ELEC.
TOTAL
PERMIT TO
r
QTY.
PLUMBING PERM T
EE
.TYPE CONSTR.
ALTER- DRAIN - WATER(EA.) 5,00
BACK FLOW PROTECT. DEVICE 4.00
OCC. GROUP
RES. UNITS
'•
'
Dfl DRAINS-FLOOR, ROOF, AREA, CON D. 5.00
FIXTURES - PER TRAP 5.00
GAS- EA.SYSTEM- 1 1NC.4OUTLETS 6.00
SO_ FT. FLOOR AREA
TOTAL ACREAGE
GAS - EA. SYSTEM -OVER 4 (EA.) 2.00
BUILDING USE
11 I❑ N 1:1 D ❑r
INDUSTRIAL WASTE INTER. 30.00
LAWN SPRINKLERS -I INC 5 V.B. 6.00
LAWN SPRINKLERS - OVER 5 (EA.) 1.00
ASSIESSO T CELNO.
S EWER - SANITARY -STORM EA. 200ft /10.00
TRACT NO,
PARCEL NO.
WATER HEATER W /VENT 6.00
Owner Date
WORKERS'COMPENSAnON DECLARATION
I hereby affirm that I have a certificate ofconsent to self- insure,
or a certificate of Workers' Compensation Insurance, or a certified
copy thereof (Svc. 3500, Lah.C.).
Policy No. Company_A!�caaef
WATER SYSTEM _ _ 5.00
ACC. DATE
"
ACC. FILE NO.
WATER TREATING EQUIP. ' • 5.00
ZONING
ENG. SITE NO. "
MISC.. REFER TO ORD.
(Certified copy is hereby furnis d.
❑ Certified co filed 'lh the sty- inspection division.
Applicant J41
FIRE SPRINK
Y� .'N�
ENERGY T24
YE .N[:]
CERTWICATI: OF EXEMPTION FROM WORKERS'
', COMPENSATION INSURANCE
(This section need not be Completed if the permit is for One
hundred dollar, IS 100) or lass,)
I certily that in the performance of the work for which this per-
mit is issued, 1 shall not employ any person in any manner so as to
become subject to the Workers' Compensation Laws of California.
Dale Applicant
NOTICE TO APPLICANT: If, after making this Certificate of h:x -
maptim,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.
CONSTRUCTION LENDING AGENCY
I. hereby affirm that there is a construction lending agency for
the performance of the work far which this permit is issued (Sec.
3097, Civ.C.).
Lenders Name
PERMIT ISSUANCE 10.00
FLOOD ZONE
Y N�
A. L. U.C.
Y NE]
PLG. CONTR, L1C. NO.
PLG:
TOTAL
QTY.
-
MECHANICAL PERMIT,
,
FEE
"FEE SUMMARY
BUILDING
ALTER OR ADD TO MECH. 5,00
-
'APPLIANCE
5.00
AIR HANDLING UNIT (TO 1Q000C,F.PA) 4.00
PLAN CHECK
FEE
AIR HANDLING UNIT (OVER 10,000C.F.M.) 6.00
SEISMIC FEE
EXHAUST HOOD (WITH DUCT) 5.00
MICROFILM
HEATING UNIT (TO 100,000 B.T.U.) 8.00
Lender's Address
I certify that I have read this application and state that the above
info tied is coricct. I agree to comply with all city and county
nrdinances and state laws relating to building construction, and
,hereby authorize representatives of this city es eater upon the
u craby authoriz preperty fative, of purposes. r
(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
granting oft is re
HEATI NG UNIT (OVER 100,000 B.T.U.)9.50
ELECTRIC
VENTILATION FAN (SINGLE) ' 4.00
PLUMBING
-
BOILER- ODMP13 H. P, or 100,000 B.T.U.) 6.00
BOILER -COMP (Over 100,000 BTU) SEE FEE SCH.
MECHANICAL'
MISC. - REFER TO ORD.
PERMIT ISSUANCE 10.00
CONST. TAX
MECH. CONT. LIL. NO.
'
MECH.
TOTAL
TOTAL
rJ
Lrl
Signature o Applica Contractor r Date
OFFICE COPY.