8930•
LY
APPLICANT TO FILL IN INFORMATION WITHIN LINES - USE BALL POINT PEN ONLY
BU I LDING PROJECT I DENTIFICATI ON
APPLICATION & PERMIT
BUILDING -ELECTRICAL -PLUMBING -MECHANICAL
. PERMIT NUMBER
8930
BUILDING
ADDRESS
7_3 d A-
N; err
-Y-t,
PTY. ELECTRIC PERMIT ,FEE,
PLAN CHECK VALIDATION
DATE OF APPLICATION
CONTRACTOR 5
NA''E/
. 7111elis, LIC,NGL:XyS00
OUTLETS -SWITCHES- RECEP 10.00/1.00
LIGHTING FIXTURES 10.00/1.00
CONTRACTORS
ADDRESS
APPLIANCES -RESIDENTIAL 4.00
PANELS 10.00
ARCHITECT
OR
ENGINEER LIC. NO.
PANELS (OVER 200 AMP) 20.00
PLAN CHECK F7 P.C. NO,
SIGNS TRANS. 3.00
ARCH. DR ENG.
ADDRESS
ZIP
SPECIAL CIRCUIT 5.00
PERMIJ_VALIOATION
APR
TEMP. METER 08 POLE INS. 20.00
APPLICANT S
ADDRESS
MOTORS SEE FEE SCH.
SERVICE CHANGE 20.00
7 1986
CII.. of
LICENSED CONTRACTORS DECLARATION
TEMP. POLE 30.00
I hereby affirm that I am licensed under provisions of Chapter 9
(commencing with Section 7000) of Division 3 of the Business and
Professions Code y license is in full force t�o/
License Lic. Number A
cupepo
ISSUANCE DAT
BLDG. ELECT. MECH.
El E3 El
Date Contractor
OWNER -BUILDER DECLARATION
I hereby affirm that I am exempt from the Contractor's License
Law forthe followingreason, (See, 7031.5. Business and ProfessionsPERMIT
Code: Any city or county which requires a permit to construct, alter,
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 pursuant to the provisions of the Contractor's License
Law (Chapter 9 (commencing with Section 7000) of Division 3 ofthe
Business and Professions Code) or that he is exempt therefrom, and
the basis for'he alleged exemption. Any violation of Section 703 1.5
by any applicant fora permit subjects the applicant to a civil Penalty
of not more than five hundred dollars (5500).):
n --'KB ILDINRMIT.-,%,-ji�
ATIONI
A. -R,
MISC. - REFER TO ORD
ISSUANCE 10.00
VALUATION
ELEC. CONTR. LIC. NO.
ELEC.
TOTAL
PERMI
QTY. PERMIT_.`�, ,.FEE
ST IES
TYPE CONSTR.
ALTER -DRAIN & VENT -WATER (EA.) 5.00
0 1, as owner of the property, or my employees with wages as
their Sale compensation, will do the work, and the Structure is not
BACK FLOW PROTECT. DEVICE 4.00
OCC. GROUP
RES. UNITS
DRAINS -FLOOR, ROOF, AREq COND. 5.00
intended or offered for sale (Sec. 7044, Business and Professions
Code: The Contractor's License Law don not apply to an owner of
FIXTURES - PER TRAP 5.00
GAS - EA. SYSTEM - 1 INC. 4 OUTLETS 6.00 •QC
SO FT. FLOOR AREA
TOTAL ACREAGE
property who builds or improves thereon, and who does such work
himself or through his own employees, provided that such prove"
I'M 0
mems not intended or offered for .1.. If. however, the Irpldi`.`Ig"
or Improvement is mid within one year of completion, the owner.
It
builder will ... the burden of proving that he did not build or im.
GAS � EA. SYSTEM -OVER 4 (EA.) 2.00
BUILDING USE
prove far purpose of Sale.).
Cl 1, as owner of the property, am exclusively contracting with
IND CON PB OHIH.,
a 0 D El 1:1
INDUSTRIAL WASTE INTER. 30.00
'
LAWN SPRINKLERS. 1 INC 5 V.S. 6.00
LAWN SPRINKLERS -OVER 5 (EA.) 1.00
licensed Contractors to construct the project (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
ASSESSORS PARCEL No.
contracts for such projects with a contraclor( a) licensed pursuant to
the Contractor's License Law.
0 lam exempt under Sec. . BAP.C. for this
mason
SEWER -SANITARY -STORM EA. 200ft/I 0.00
TRACT NO..
PARCEL NO.
WATER HEATER W/VENT 6.00
Owner Date
WATER SYSTEM 5.00
ACG DATE
ACC. FILE NO.
I WORKERS'COMPENSATION DECLARATION
WATER TREATING EQUIP. 5.00
lhe y affirm that I have a certificate of consent to self -insure.
or a c lificate of Workers' Compensation Insurance, or a certified
op hireof (Sec. 3800. Lab.C.).
cy No..Company-
ZONING
ENG. SITE NO.
FIRE SPRINK
NE]
ENERGY T 24
Y [3 N[]
"i C y
rlified copy is h Peby f rushed,
.s4
c
ed it file 411h it It
r
Applicant 401 . .....
Applicant
MISC. REFER T R
R I T OF 'EM
TIFICATE OF EXEMPTION FROM WO& E
LANCE
PERMIT ISS 10.00
FLOODZONE
A.4.1).C.
COMPENSATION INSURANCE
(This section need not be completed if the permit is for one
❑ N CD
Y ❑ N Cj
PLG. CONTR. LIC. NO.
PLG.V
TOTA I/
hundred dollars IS I DO) or less.)
I certify that in the performance of the work for which this per.
mit is issued. I shall not employ any person in any manner so as to
OTY. _I,, IMECHANICAILPFRMIT FEE
✓ 'FEE SUMMARY,".-
BUILDING
become subject to the WorkerCompensation Laws of California.
Dam Applicant
NOTICE TO APPLICANT: If, after making this Certificate or Es.
ALTER OR ADD TO MECH. 5.00
APPLIANCE 5.00
AIR HANDLING UNIT (TO 10,000C 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 10=C.F.M.) 6.00
SEISMIC FEE
CONSTRUCTION LENDING AGENCY
I hereby affirm that there is a construction lending agency for
the performance of the work for which this permit is issued ISce.
3097, Civ.C.).
EXHAUST HOOD (WITH DUCT) 5.00
MICROFILM
HEATING UNIT (TO 100,000 B.T.U.) 8.00
Lender's Name
Lender's Address
H EAT] NG UN IT (OVE R 100,000 B.T.U.) 9.50
ELECTRIC
I certify that I have read this application and state that the above
VENTILATION FAN (SINGLE) 4.00
information is correct. I agree to comply with all city and county
Ordinances and state laws relating to building construction. and
hereby authorize representatives of this city to enter upon the
above-mentioned property for inspection purposes.
PLUMBING
BOILER- COMP(3 H.P. or 100,000 B.T.U.) 6.00
BOILER -COMP lova, 100,000 BTU) SEE FEE BCH.
MECHANICAL
(We) agree to Save, indemnify and keep harmless the City of
Cupertino against liabilities, judgments. costs and expenses which
may in any ecc against said City in consequence of the
"y'
MISC. - REFER TO ORD.
CONST. TAX
PERMIT ISSUANCE 10.0F
alm 'this p
Me
�11
MECH CONT LIC. NO.
MECH.
TOTAL
.;1To-rAU_- -.-
7..,
rihi m IAPI iTem, Dare
OFFICE COPY