8863`APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
'BUI L -DI NO PROJECT I DENTI FICATION
APPLICATION & PERMIT
BUILDING - ELECTRICAL- PLUMBING - MECHANICAL
PERMITNUMBER
8863
BUILDING L
iC ve_
OWNER's
ME
PIS W ^IPNONE
OTY. ELECTRIC PERMIT FEE
PLAN CHECK VALIDATION
DATE OF APPLICATION
NAMEERacroas
S 2t. LIc No.
,- UTLETS- SWITCHES -RECEP 10.00/1,00 �L
LIGHTING FIXTURES 10.00/1.00 .2-
moo esGroR's -'
NE9 "7
PND��
% PPLIANCES- RESIDENTIAL 4.00
PANELS 10.00
p
oncHl ECT SO -3w-IS I^;,a
ENGINEER
uo No.
...- PANELS (OVER 200 AMP) 20.00
LAN CHECK FEE P.C. NO.
SIGNS TRANS. 3.00 •
ADDDRESS ervU.
ZIP
SPECIAL CIRCUIT 5.00�U�
PERMIT VALIDATION
^
ISSUANCE DATE
BLDG. ELECT. PLG. MECH.
R1 I El LEI
ITEMP. METER OR POLE INS. 20.00
ADDRESSTs
MOTORS SEE FEE SCH. -
SERVICE CHANGE 20.00
LICENSED CONTRACTORS DECLARATION
I hereby affirm that I am licensed under provisions of Chapter 9
(commencing with Section 7000) of Division 3 oft a Business and
Professions Cod✓gn Tv license is in full fo t
License Class 7 GG V Lie. Number0
Date /_r.Contractor n
OWNER -BUILDER DECLARATION
I hereby affirm that I am exempt from the Contractor's License
Law for the following reason. (Sec. 7031.5, Business and Professions
Cade: 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
Low (Chapter 9 (commencing with Section 7000) of Division 3 of the
Business and Professions Code) ar that he is exempt therefrom and
the basis for the alleged exemption. Any violation of Section 7031.5
by any applicant for a permit subjects the applicant to a civil penalty
oft of
fnot more than five hundred dollars ($500L):
❑ I, as owner of the property, or my employees wish 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-
Bratsarenetintendedorofferedforsale. If, however the building
or 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 of sale.).
1, aso
❑ f, as ownernee purpose of the property, am exclusively contracting with
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
contracts for such projects with a contractor(s) licensed pursuant to
the Contractor's License Law.
❑ I am exempt under Sec.-, B.&P.C. for this
reason
TEMP. POLE PAID30.00
�) ) a
.L
city CU ertlno
BUILDING PERMIT
INFORMATION
MISC. - REFER TO ORD
PERMIT ISSUANCE 10.00
VALUATION
$/FT.
ELEC. CONTR. LIC. NO.
ELEC, s n�
TOTAL O'-FJ-�
PERMIT TO
Z
FL C /
CITY. PLUMBING PERMIT FEE
STORIES
TYPE CONSTR.
ALTER -DRAIN -WATER (EA.) 5.00
BACK FLOW PROTECT. DEVICE 4.00
OCC. GROUP
REN. urvtTS
DRAINS -FLOOR, ROOF, AREA, COND. 5.00
F IXTUR ES - PER TRAP 5.00
GAS - EA. SYSTEM -11 NC.4 OUTLETS 6.00
SD. FT. FLOOR AREA
TOTAL ACREAGE
GAS - EA. SYSTEM - OVER 4 (EA.) 2.00
BUILDING USE
O IND CON 'O ot❑nar
INDUSTRIAL WASTE INTER. 30.00
LAWN SPRINKLERS- 1 INC 5 V.B. 6.00
LAWN SPRINKLERS - OVER 5 (EA.) 1.00
ASSESSORS PARCEL NO.
SEWER -SAN Y -STORM EA. 200ft/10.00
TRACT NO.
PARCEL NO.
WATER HEATER WIVENT 6.00
Owner Date
WATER SYSTEM 5.00
WORK ERS'COMPENSATION DECLARATION
1 hereby affirm that I have a certificate of consent to selbinsure,
or a certificate of Workers' Compensation Insurance, or a certified
copy the n�fpJFL'&j1J011,.Pimy-mss y�41n
Policy N o, Lamy- 14 9
❑ Certified copy is hereby furnished.
C it -'icI Co y is filed Itb the City inspection di J ion.
ppplicanr/_`�/'�)^,%'y'�`'`'^'- XJ/n�
ACC.DATE
ACC. FILE NO.
WATER TREATING EQUIP. 5.00
ZONING
ENG. SITE NO.
FIRE SPRINK
Y N
❑ ❑
ENERGY T 34
v N
❑ ❑
MISC.- REFER TO ORD.
C-RTII4CP A'f F:OI'IiXI: PPVTION,FROM WORK ERS'
COMPENSATION INSURANCE
(This section need not be completed if the permit is for one
hundred dollars IS 100) or less.)
1 certify that in the performance of tilt 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.
Date Applicant
PERMIT ISSUANCE 10.00
FLOOD ZONE
Y ❑ N�
A.Lu,C.
Y ❑ NC]
PLG. CONTR. LIC. NO.
PLG.
TOTAL
QTY. MECHANICAL PERMIT FEE
FEE SUMMARY
BUILDING
ALTER OR ADD TO MECH. 5.00
NOTICE TO APPLICANT: If, after making this Certificate of Ex-
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.
CONSTRUCTION LENDING AGENCY
1 hereby affirm (flat there is a construction Icnding agency for
Ibe performance of the work for which this permit is issued (Sec.
3097, Civ.C.).
Lender's Name
Lender's Address
I certify that I have read this application and stale that IAc above
information is correct. I agree to comply with all city and county
ordinances and state laws relating to building construction, unit
hereby authorize representatives moves of on city es enter upon IIIc
above-mentioned property forinspof(h i purposes.
(We) agree to save, indemnify and keep hamllele the City of
Cupertino against liabilities, judgments, costs and expenses which
may in any way acerae u Gins[ said City in consequence of the
gm tip Of this permit.MECH,
_S
APPLIANCE 5,00
PLAN CHECK
FEE
AIR HANDLING UNIT (TO 10,000C.F.M.) 4.00
AIR HANDLING UNIT(OVER 10=C.F.M.) 6.00
SEISMIC FEE
EXHAUST HOOD (WITH DUCT) 5.00
MICROFILM
HEATING UNIT (TO 100,000 B.T.U.) 8.00
HEATING UNIT (OVER 100,000 B.T.U.) 9.50
ELECTRIC
cza
VENTILATION FAN (SINGLE) 4,00
PLUMBING
BOILER -COMP (3 H.P. Or 100,000 B.T.U.) 6.00
BOILER -COMP (Over 100,000 BTUI SEE FEE SCH.
MECHANICAL
MISC. - REFER TO ORD.
PERMIT ISSUANCE 10.00
CONST. TAX
CONT. LIC. N0. MECH.
TOTAL
TOTAL
ignature of pplcant/Contractor Date
OFFICE COPY