8997APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
BU LDI NG PROJECT I DENTI FICATI ON
APPLICATION '& PERMIT
PERMIT NUMBER
n r�
BUILDING
ADDRESSIffiQ;Q
ILDING - ELECTRICAL- PLUMBING - MECHANICAL
8997
�`j�'
OWNER'S.
NAME
HO V 7
TY. s - - ELECTRIC PERMIT r F -? 7 r ft„ Fgg `
PLAN CHECK VALIDATION
`
DATE OF APPLICATION
CONTRACTORS
'
(� N"J
UTLETS- SWITCHES -RECEP 10.00/1.00
LIGHTING FIXTURES 10.00/1.00
r, NTEAc oR �o�
aooR
PONE
APPLIANCES - RESIDENTIAL 4.00-
PANELS '`10.00
CRCHITEc
CR
ENGINEER
uc. No:
PANELS (OVER 200 AMP) 20.00
PLAN CHECK FEE P.C. N0.
SIGNS TRANS. 3.00
aoARC" ess ENG.
SPECIAL CIRCUIT 5.00
PERMIT VALIDATION
TEMP. METER OR POLE INS. - 20.00
. ZIP
/l/i<'�r•'.-/�'-
A
ADDRoREBB ss
MOTORS SEE FEE SCH.
SERVICECHANGE 20.00
V
LICENSED CONTRACTORS DECLARATION
TEMP. POLE 30.00
1 hereby affirm that 1 am licensed under provisions of Chaptet 9
(commencing gyth S tion 7000) of Division 3 of the Business and
Professions COED 4 licenseIs'n f II for[ e fe
Wcense I ss li L'c N tuber '
- ISSUANCE DATE
_
BLDG. ELECT. PLG. MECH.
❑ ❑ ❑
OJtC Contractor
' 'BUIL`DING,tPERMIT "`
` INEORMATIONI 1
"
O ER -BUILDER DECLARATION
1 hereby affirm that I am exempt from the Contractor's License
Law for the following reason. (Sec. 7031.5, Business and Professions
Code: Any city or county which requires a permit to construct, alter,
MISC. - REFER TO ORD
PERMIT ISSUANCE 10.00
VALUATION
$/FT.
ELEC. CONTE. LIC. NO.
ELEC.
TOTAL
improve, demolish, or repair any structure, prior to its issuance, also
requires the applicant for such permit to file'a signed statement that
he is licensed parmart IO the provisions Of ilia Contractor's License
Law (Chapter 9(Commencing with Section 7000) o'Division 3 oflhe
Business and Professions Code) or that he is exempt therefrom and
PERMIT TO
-
�L,a (r..
- •;
DTV, PLUMBING PERMIT
STORIES
TYPE CONSTR.
the basis for lire alleged exemption. Any violation of Section 7031.5
by any applicant for a permit subjects the applicant to a civil penalty
COBOL more than five hundred dollars ($500).1:
- ALTER -DRAIN & VENT -WATER (EA.) 5,00 .
❑ I, as owner of the property„or my employees with wages as
their sole compensation, will do the work, and the structure is not
BACK FLOW PROTECT. DEVICE - 4.00
OCC, GROUP
RES. UNITS
DRAINS -FLOOR, ROOF,'AR EA,COND. 5.00
intended or offered for sale (Sec. 7044, business and Professions
Code: The Contractor's License Law does not apply to an owner of
FIXTURES - PER TRAP 5.00
SO, FT, FLOOR AREA
TOTAL ACREAGE
property who builds or improves Visteon, and who does such work
himself or through his own employees, provided that such improve-
mentsurenot intended oroffered for sale, If, however, the building
GAS-EA.SYSTEM-l1NC.4OUTLETS 6.00
or improvement is sold within one year of completion, lire owner-
builder will have the burdeu,of proving that Ire did not build or im-
GAS EASYSTEM -OVER 4 (EA) 200
- . ..
BUILDING USE '
prove for purpose ofsale). . I
❑ I, as owner of the property, am exclusively contracting with
RES IND CON PB Omer
❑ ❑ ❑ ❑ D.
INDUSTRIALWASTE INTER. 30.00
LAWN SPRINKLERS- 1 INC 5 V.B. 6.00
e project (Sec. 7044, Buness
licensed contractors to constructthsi
and Professions Code: The Contractor's License Law does not apply
to an owner of property who builds or improves thereon, and who
ASSESSORS PARCEL NO.
LAWN SPRINKLERS - OVER 5 (EA.) 1.00
contracts for such projects with a contractors) licensed pursuant to
the Contractors License Law.
SEWER -SANITARY -STORM EA. 200ftI10.00
TRACT NO.
PARCEL NO.
❑ I am exempt under Sec. ;B.&P.0-fur this
'
WATER HEATER W/VENT 6.00'
reason -
Owner pate
WATER SYSTEM 5.00
ACC.DATE
ACC. FILE NO.
WATER TREATING EO IP. .00
WORKF.RS'COMPGNSATION DECLARATION-
I hereby affirm that 1 have a certificate of consent to self -insure,
or a c tlfunile of Workers' +Compensation Insu-ran`ce, a cerhi lied
S c.
t% '
ZONING
ENG. SITE NO.
P c nrb�
Cr 1 By is ur she
Cl Ceoifi py is file It le city inspecfi 'vision.
Applic:ml
�0
FIRESPRINK
-y❑ NO
ENERGY T24
Y NO
MISC- T D.
CE TIF CATEO E PION FROM WORKERS'
PERMIT ISSUANCE 0 J111 11,
FLOOD ZONE
A.L.U.C.
COMPENSATION INSURANCE.
(This se i' 1 need not be completed if the permit is for one
PLG. CONTR. LIC. NO.' PLG.
-
- TOTAL
Y ❑ N❑
Y ❑ N
hundred dol ars($100) orless)
Icertify that in the performance of the work for which this per-
ant is is issued, I shall not employ any person in any manner so as to
-
DTV. .MECHANICAL PERMIT . FEE f
,
-
FEE3Sl1MMARV t
BUILDING
become subject to the Workers' Compensation Laws of California.
Date Applicant
NOTICE TO APPLICANT'. If, after making this Certificate of Ex-
-
ALTER OR ADD TO MECH. 5.00
APPLIANCE 5,00
AIR HANDLING UNIT (TO 10WOC.F.M.) 4.00
PLAN CHECK
FEE
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.
AIR HANDLING UNIT (OVER 1O 16C.F.M.) 6.00
SEISMIC FEE
CONSTRUCTION LENDING AGENCY
I hereby affirm that there Is a emistmction lending agency for
EXHAUST HOOD (WITH DUCT) 5.00
tlm performance of the work for which this permit is issued (Sec.
3097, Civ.C).
MICROFILM
HEATING UNIT (TO 100,000 B.T.U.) 8.00
bender's Name
Lede's Address
H EATI NG U N IT (OV ER 100,000 B.T.U.) 9.50
ELECTRIC
VENTILATION FAN (SINGLE) 4.00
I certify that I have read this application and state that the above
information is correct. 1 agree to comply with all city anti county
ordinances and slate laws relating to building construction, and
PLUMBING
BOILER- COMP(3 H.P. or 100,000 B.T.U.) 6.00
BOILER -COMP (Over 100,000 BTU) SEE FEE SCH.
MECHANICAL
hereby authorize representatives ec this city to enter upon the
above-mentioned property forinspection hipurposes.
(We) agree .to save, indemnify and keep harmless the City of
MISC. - REFER TO ORD.
Cupertino against liabilities, judgments; costs and expenses which
may in n way accrue against said Cit i consequence of the
PERMIT ISSUANCE 10.00
CONST. TAX
BID f is permit
MECH. CONT. LIC. NO. MECH.
TOTAL
TOTAL
i at Ircanl o rector a
OFFICE COPY