8848APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
BUILDING PROJECT I DENTIFICATI
APPLICATION & PERI•
BUILDING - ELECTRICAL- PLUMBING - MECHANICAL
_ PERMIT NUMBER
8848
BUILDING
DRESSA
j.
NER'S
AME
NE
Lp PHONE
QTY, ELECTRIC PERMIT FEE
CHECK VALIDATION
DATE OF APPLICATION
CONTRACTOR'S
NAME
5 IQ(( LIC N-4
FZ UTLETS-SWITCHES -RECEP 10.00/1.00 eZQ7-
LIGHTING FIXTURES 10.00/1.00
nooeeesiTOR3 y ^
Ap 1 FRONE ga
2, PPLIANCES- RESIDENTIAL 4.00
PANELS 10.00 -
ARCHITECT -44 -P ITS 0-v
on �V J`-' ('j J,)
PANELS (OVER 200 AMPI 20.00
PLAN CHECK FEE . NO.
ENGINEER
LIC. NO.
SIGNS TRANS. 3.00
ADH. DRESS OR END,
SPECIAL CIRCUIT 5.00 �
PERMIT VALIDATION
- TEMP. METER OR POLE INS. 20.00
ZIP
APPLICANTS
ADDRESS
MOTORS SEE FEE SCH.
SERVICE CHANGE 20.00
LICENSED CON' I' RACTORS DECLARATION
TEMP. POLE 30.00
I hereby affirm that I am licensed under provisions of Chapter 9
(cammennng with Section 7000) Of Division 3 Of the Business and
Professions CoJvyo�mIrPsyy(( license is in fall for pp11 ��(eep 1-�
License Class ISS Lie. Number In `� I �J
ISSUANCE DATE
BLDG. ELECT. PLG. MECH.
❑ ❑ ❑
cityof cup
C11Y
Dale ,LB -34 Contractor zza�,
OWNER -BUILDER DECLARATION
I hereby affirm that I am exempt from the Contractor's essliLicense
Law for Anycity or, countywhih re 7iresa Binit to construct, alans
Code: Any city or county which requiresa fkmlit to construct,,
BUILDING PERMIT
BUILDING
INFORMATION
MISC-- REFER TO ORD-
PERMIT ISSUANCE
VALUATION
5/FT.
ELEC. CONTE. LIG NO.
ELEC.
C.
TOTAL
ah,D
requimprires, helapplic, or repair any strut to Ci pilar n its that
requires tic the applicant for such permit to of t a signed actor's i Inst
he is licensed pursuant to the provisions of the Contractor's License
Law (Chapter 9 (co with Section 7s of Division 3 of the
PERMIT TO
�GEL7
Nosiness and Pra
ProfessionsCod exe
Code) or that he is exempt therefrom and
QTY. PLUMBING PERMIT FEE
pestes
the basis for the alleged exemption. Any violation ppca of Section malty
by any applicant fora u pennit dollars lee applicant W a civil penalty
of not more than flue hundred dollars (S500).):
STORIES
TYPE CONSTR,
ALTER -DRAIN & VENT -WATER (EA.) 5.00
❑ 1, as owner of the property, or my employees with wages as
their sole compemation, will do the work, and the structure Is not
BACK FLOW PROTECT. DEVICE 4.00
OCC, GROUP
RES. UNITS
intended or offered for sale (Sec. 7044. Busine3s and Professions
Code: The Contractor's License taw docs not apply to an owner of
DRAINS -FLOOR, ROOF, AREA, COND. 5.00
FIXTURES - PER TRAP 5.00
GAS - EA. SYSTEM -1 INC.4 OUTLETS 6.00
property who builds or improves thereon, and who does such work
himself or through his own employees, provided that such improve.
meats are not intended or offered for sale. If, however, the building
SD. FT. FLOOR AREA
TOTAL ACREAGE
or improvement i3 sold within one year of completion, the owner
builder will have the burden of proving that he did not build or im-
GAS - EA. SYSTEM -OVER 4 (EA.) 2.00
BUILDING USE
Prove for purpose of sale.).
❑ 1, as owner of the property, am exclusively contracting with
RES IND CON PB Other
INDUSTRIAL WASTE INTER. 30.00
licensed Contractors to construct the project (Sec. 7044, BusinnsLAWN
and Professions Code: 1'he Contractors License Law does not apply
to an owner of properly who builds or improves thereon, and who
SPRINKLERS - 1 INC 5 V.B.00
. .
ASSESSORSPARCEL NO.
LAWN SPRINKLERS - OVER 5 (EA.) 1.00
contracts for such projects with a contractors) licensed pursuant to
the Contractors License Law.
❑ lam exempt ander Sec.., B &P,C. for this
reason
SEWER -SANITARY -STORM EA. 2008/10.00
TRACT NO.
PARCEL NO.
WATER HEATER W/VENT 6.00
Owner Dale
WATER SYSTEM 5.00
ALC.DATE
ACC. FILE NO.
WORKERS'COMPENSATION DECLARATION
WATER TREATING EQUIP. 5.00
1 hereby affirm that I have a certificate of consent m self -insure,
ZONING
ENG. SITE NO.
or a certificate of Workers' Compensation Insurance, or a certifieJ
copy the,, Lab.
Policy No. y
e�QmC' K -1 bD +__M
❑ CenifKd Copy is herebyftz1 J'
` � Cerlif�copyM1is Iced with
h nC. l'lly in3 nion diVi3ion.
Applicanr�K/< ryt�_%n��1)r,L / �'
MISC.- REFER TO ORD.
FIRE SPRINK
YE] NE]
ENERGY T 24
YEJ No
Cb(RTIFICATEOFE%EMPTION FROM WORKERS'
COIdPF-NSATION INSURANCE
I'ITfs section need not be completed if the permit is for one
PERMIT ISSUANCE 10.00
FLOOD ZONE
Y ❑ N
A.L.U, C.
Y C1 N
PLG. CONTE. LIC. NO.
PLG.
TOTAL
hundred dollars ($ UX) 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 mm�ncr so as to
QTV MECHANICAL PERMIT FEE
FEE SUMMARY
become subject to the Workers' Compensation fawn of Califomiu.
Dale Applicant
ALTER OR ADD TO MECH. 5.00
BUILDING
NOTICE TO APPLICANT: If, after making this Certificate of lix-
APPLIANCE 5.00
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 pCmtit shall he deemed revoked.
AIR HANDLING UNIT (TO 10=CF.NL) 4.00
AIR HANDLING UNTF(OVER I0,000CF.M.) 6.00
SEISMIC FEE
CONSTRUCTION LENDING AGENCY
I hereby affirm that there is a construction lending agency for
the perlommance of the work I'or which this permit is issued (Sea
3097, Civ.C.),
EXHAUST HOOD (WITH DUCT) 5.00
MICROFILM
HEATING UNIT (TO 100,000 B.T.U.) 8.00
Lender's Name
Landde Address
HEATI NG UNIT (OVER 100,000 B.T.U.) 9.50
ELECTRIC
_
U
VENTILATION FAN (SINGLE) 4.00
1 certify that I have read this application and state that the above
information is correct. I agree to comply with all city and county
ordinances and state laws relating to building construelion, and
hereby authorize representatives of this city to enter upon the
above-mentioned property for inspection purposes.
PLUMBING
BOILER- COMPOH.P. or 100,000 B.T.U.) 6.00
BOI LER-COMP (Over 100,000 BTU) SEE FEE SCH.
MECHANICAL
(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 c nscyuence of the
o I f thit p nniL
MISC. - REFER TO ORD.
PERMIT ISSUANCE 10,00
CONST. TAX
MECH. CONT. LIC. NO.
MECH.
/
TOTAL
TOTAL
Signature of Applicant Contractor Da c
OFFICE COPY