8856 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
BW LDING PROJECT IDENTIFICATIONA
PERMIT NUMBER
APPLICATION & PERMIT
eu'ass 8856
WRE
V'Q BUILDING—ELECTRICAL—PLUMBING—MECHANICAL
I OWNER'S - PLAN CHECK VALIDATION
ME QTY. ELECTRIC PERMIT FEE
. J 1 PHON —
CONTRACTORs
I OUTLETS-SWITCHES-RECEP 10.00/1.00
S UC.NO44-7 LIGHTING FIXTURES 10.00/1.00
CONTRACTo 's o .-r APPLIANCES-RESIDENTIAL 4.00
ADDRESS 1. iq�l15 ^
PHON 8 _ .x-. PANELS 10.00 DATE OF APPLICATION
OR
EC —� PANELS (OVER 200 AMPI 20.00 PLAN CHECK FEEP.C.NO.
R
ENGINEER
uc,NO ISIGNS TRANS. 3,00
ARCH.OR ENG. r1 PERMIT VALIDATION
ADDRESS ISPECIALCIRCUIT 5.00 V
ZIP TEMP.METER OR POLE INS. 20.00
APPLICANTS ADDRCss MOTORS SEE FEE SCH. ��L✓"'
SERVICECHANGE PAID 20.00 '
w o o LICENSED CONTRACTORS DECLARATION TEMP.POLE 30,00
rt u w I hereby affirm that I urn licensed under provisions of Cbapler 9 JUN I) I:;O J ISSUANCE DATE
N <H (commencing with Section 7000)of Division 3 of the Business and BLDG. ELECT. PLG. MECH.
r N z Professions CoJP- n y license is in full fo f 1
z o m Liccns Clu `` Lic.Numbc I City of Cupertino ❑ ®, ❑ ❑
o m = Dem Contractor
a sa s BUILDING PERMIT
OWNER-BUILDER DECLARATION INFORMATION
X ;LL i_ I hereby affirm that I am exempt from the Contractor's License MISC.— REFER TO ORD
r a_ 04 Law for the following reason.(Sec.7031,5,Businessand Professions PERMIT ISSUANCE VALUATION 5/FT.
Code:Any city orcounty which requires u permit to construct,alter, 10.00
¢ ¢ 0 improve,demolish,or repair any structure,prior to its issuance,also FLEC.CONTR. LIC.NO. ELEC. +l n/
w0 Q requires the applicant for such permit to Ille a signed atalelnent that TOTAL O<(/(O PERMIT TO
m he is licensed pursuant to the provisions of the Contractor's License
Fi >
Law(Chapter 9(commencing with Section 7000)ofDivision3ofthe E[�/G7
< Business and Professions Code)or that he isexempt therefrom and DTV. PLUMBING PERMIT FEE
r o the basis for the alleged exemption.Any violation of Section 7031.5 STORIES TYPE CONSTR.
n3 � by any applicant for a Permil subjects the applicant toa civil penalty ALTER-DRAIN -WATER IEA.) 5.00
of not more than five hundred dollars($500).1
❑ I,as owner of the property,or my employees with wages as BACK FLOW PROTECT. DEVICE 4.00
their sale compensation,will do the work,anti the structure is not OCC.GROUP RES.UNITS
intended or offered for sale (Sec. 7044, Business and Professions DRAINS-FLOOR,ROOF,AREA,COND. 5.00
Code:The Contractor's License Law does not apply to an owner of
property who builds or improves thereon,and who does such work FIXTURES-PER TRAP 5.00• SO.FT.FLOOR AREA TOTAL ACREAGE himself or through his own employees,provided that such improve- _
ments are not intended or offered for sale.If,however,the building GAS-EA.SYSTEM-11NC.40UTLETS 6.00
or improvement is sold within one year of completion, the owner. GAS-EA.SYSTEM-OVER 4 IEA.) 2.00
builder will have the burden of proving that he did not build or inn. BUILDING USE
prove for purpose of sale.). INDUSTRIAL WASTE INTER3000 RES ' IND CON PB Other
. .
❑ I,as owner of the property,am exclusively contracting with ❑ ❑ ❑ ❑ ❑
licensed contractors to construct the project(Sec.7044,Business LAWN SPRINKLERS-1 INC 5 V.B. 6.00 ASSESSORS PARCEL NO.
and Professions Code:'I'he Contractor's License Law does not apply
to an owner of properly who builds or improves thereon,and who LAWN SPRINKLERS-OVER 5(EA.) 1.00
contracts for such projects with a contractor(.,)licensed pursuant 10 SEWER-SANITARY-STORM EA.200ft/10,00
the Contractor's License Law. TRACT NO, PARCEL NO.
❑ I um exempt under Sec. ,B.&P.C.for this
reason WATER HEATER W/VENT 6.00
Owner Date WATER SYSTEM 5.00 ACC.DATE ACC.FILE NO.
WORK FRS'COMPENSATION DECLARATION WATERTREATING EQUIP. 5.00
1 hemby mffurn that 1 have u certillcute of ennsem to self-insune,
or a certificate of Workers'Compensation Insurance,or a certified ZONING ENG.SITE NO.
copy 1 he,N.; f{SnhejSOQ Lub.G)/r
Policy Non_ ,0,LWy
O ❑ Certified copy is hereby furnished. FIRE SPR INK ENERGY T-24
Z Z �^CeItiP d coy is Oled with he city inspection div
I- i ion.
p I6Pteam / MISC.- REFER TO ORD. Y N❑ Y ❑ N❑
W ,lR'fIFICATE 017 EXEMPTION 17IZOM WORKERS' PERMIT ISSUANCE 10,00 FLOOD ZONE A.L.D.C.
LU , (This section need not be INSURANCE P
completed if hepermit is for one LG.CONTR. LIC.NO.
0. o TOTAL Y❑ N❑ Y❑ IN[]IN[]LU
::� Z hundred dollars(S 100)or less.)
U O 1 certify that in the performance of the work for which this per- OTY. MECHANICAL PERMIT FEE FEE SUMMARY
LL 1- mit is issued,I shall not employ any person in any manner so as to
O w become subject to the Workers'Compensation Laws of California.
Date Applicant ALTER OR ADD TO MECH. 5.00 BUILDING
>_ 0 NO'T'ICE 1'0 APPLICANT': If,after making this Certificate of Ex- '
f— Z emption,you should become subject to he Workers Compensation APPLIANCE 5.00 PLAN CHECK
provisions of the Labor Code, you must forthwith comply with FEE
CJ such provisions or this permit shall be deemed revoked. AIR HANDLING UNIT(TO 1Op00C.F.NL) 4.00
CONSTRUCTION LENDING AGENCY AIR HANDLING UNIT(OVER 10=C.EM.) 6.00 SEISMIC FEE
I hereby affirm that there is a construction lending agency for EXHAUST HOOD (WITH DUCT) 5.00
the performance of the work for which this Permit is issued(Sec. MICROFILM
3097,CieC.). HEATING UNIT(TO 100,000 B.T.U.) 8.00
Lender's Name HEATING UNIT(OV ER 100,000 B.T.U.)9.50 020,
Lender's Address ELECTRIC
I certify fiat I have read Ibis application and ,are that the above VENTILATION FAN (SINGLE) 4,00
. information is correct. I agree to Comply with all city and county PLUMBING
ordinances and state laws relating to building construction, and BOILER-COMP(3 H.P.or 100,000 B.T.U.) 6,00
hereby authorize this
representatives of this city to enter upon the
above-mentioned property for representatives
inspectionpurpos
BOILER-COMP Over 100,000 BTU)SEE FEE SCH. MECHANICAL
es.
(We) agree to save, indemnify and keep harmless the City of MISC.- REFER TO ORD.
Cupertino against liabilities,judgments, costs and expenses which PERMIT ISSUANCE 10.00 CONST.TAX
y in any way.acerae age'nsl said City in consequence of the
giant g0 this permit I MECH.CONT. LIC.NO. MECH.
Jots
TOTAL TOTAL
rgnal ure of Applicant Contractor Data
OFFICE COPY