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APPLICANT TO FILL IN INFORMATION WITHIN REDLINES - USE BALLPOINT PEN ONLY
'' BUILDING PROJECT IDENTIFICATION
APPLICATION & PERMIT
BUILDING -ELECTRICAL- PLUMBING -MECHANICAL
PERMIT NUMBER
615 Z
amLDING
ADDRESS
OwNER'(/�� / CaFP
NAME Be�/�j kl "_ I ` -
i
CITY; F t, ELECTRIC PERMIT FEE'.
PLAN CHECK VALIDATION
p'
PHONE-( /3" (!
DATE OF APPLICATION
NONTRacTDRs
NAME �yIA:E� t+r ST
LIC. No.3 C;,
UTLETS-SWITCHES-RECEP 5.00/1.00
LIGHTING FIXTURES 5.00/1.00
CONTRACTOR'S - I-,,
ADDRESS,321.I "p
$D u�L C1q 4 3 PHONE 14)(,-1411
APPLIANCES RESIDENTIAL 4.00
PANELS 5.00
ARCHITECTSIGNS
OR
ENGINEER
' 'uc. NO.
6.00
PLAN CHECK FEE P.C. NO.
SIGNS TRANS. 3.00
ARC" ESS ENG'
SPECIALCIRCUIT. 5.00
PERMIT VALIDATION
EMP. METER OR POLE INS. 15.00
Zap
/B
APPLICANTS�
ADDRESS
MOTORS SEE FEE SCH.
SERVICE CHANGE 10.00
[
LICErmNSED CO1 NTRACTORS DECLARATION
I herchy affiThal am licensed under provisions of Chapter 9
(commencing with Section 7000) of Division 3 Of the Business and
I'm essmnS Code, �qd my hCem'e IS In full fOIC fleet. �
License �'I�ss __ Lic. Number a
ISSU70ATE '
BLDG.
'
ELECT. P G. MECH.
❑
Ume _ � GOnf ae(0r �Q.-
�
OWNER -BUILDER DECLARATION
1 hereby atlllo that 1 ng so exempt Goo the Contractor's fessi ns
Law for lheity or Countywhihrequiresa perminess t t0and Professions
Code: Any city or county which requirese permit tocol issuance,
improve, demolish, or repair any emit toff prior t0 its issuance, than
also
herequires the applicant for Such permit 10 file a signed itatemem that
pursuant In ing provisions of the Contractor'sivisLicense
he is (Chapter
Law (Chapter9fcommencingwith Section is7000) Division3of and
exempt
Business and Or that he is cxempl and
"BUILD }„P.ERMITg �,yy!
- 'INFOfi ATION9'?'t,
MISC.- REFER TO ORD
PERMIT ISSUANCE 6.00
VALUATION $/FT.
ELEC. CONTR. LIC. NO. EOTA
TOTAL
QTVI ." + PLUMBING=PERMIT - FEE'
RMIT TO
415w
STORIES
TYPE CONSTR.
the the exemption, caro 70
tan Mora ermit oto
action malty
by otnionc tha fora permit dollars(he0).). ant toacivil penalty
any applicant subjects
tsthAnyea plica
of not more than five hundred dollars ($500)J:
ALTER-DRAIN-WATER(EA.)4.00
❑ 1, as owner of the property, or my employees with wages as
sole compensation, will do the work, and the structure is not
BACK FLOW PROTECT. DEVICE 2,00
OCC. GROUP
RES. UNITS
DRAINS -FLOOR, ROOF, AREA, COND. 4.00
intended or offered for ale (Sec. 7044, Business and Professions
Code: The Contractor's License Law does ,of apply to as owner of
property who builds or improves thereon, and who docs such work
himself or through his own mnployces, provided that such improvu-
.cutsare 'not intended or Offered for sale. If, however, the building
-
FIXTURES - PER TRAP 4.00
$0. FT. FLOOR AF EA
TOTAL ACREAGE
GAS-EA.SYSTEM-11NC.40UTLETS q,00
Or improvement is sold within one year of completion, the owner-
builder will have the burden of proving that he did not build or am-
prove (or purpose of'sale.).
❑ I, as owner of the property, am exclusively contracting with
GAS - EA. SYSTEM -OVER 4 IEA.) 1.00
BUILDING USE
RE5 Info o PB ober
❑ ❑ ❑ ❑
INDUSTRIAL WASTE INTER. 20.00
licensed rontoctors to construct the project (Sec. 7044, Business
and Professions Code. The Contractor's License Law does not apply
to an owner of property who builds or improves thereon, and who
LAWN SPRINKLERS - 1 INC 5 V.B. 5.00
LAWN SPRINKLERS - OVER 5 (EA.) 1.00
ASSESSOR PARCEL NO.
contracts for such projects with u conlydaods) licensed pursuant to
the Contractor's License Law..
SEWER -SANITARY -STORM EA. 200ft/8.00
TRACT NO.
PARCEL NO.
❑ I am exempt under Sec.., B.&P,C. for this
reason
WATER HEATER W/VENT 4.00
Owner Dam
WATER SYSTEM 4.00
ACC.DATE
ACC. FILE NO.
IWATE R TREATING EQUIP, 4.00
WORK ERS'COMPENSA'I' ION DECLARATION
I hereby affirm that l have a certificate of comical In self -insure,
or a certificam of Workers' Compensation Insurance,. or a certified
ZONING
ENG. SITE NO.
copy thereof ec lRj�p� Lab.f,.
I'nlicY N_ jiY4"i4np:lny k dAT- 1. +A9ti�
❑ Ccrll fiey�y� Is heathy lumis
❑ Cerfi[rC•b Y filed w' rF' it io
Appbu;,,
FIRE SPRINK
v ❑ N ❑
ENERGY T44
v ❑ N❑
MISC. - REFER TO ORD.
CERT iCATIi OF EXEMPTION FROM WORKERS'
PERMIT ISSUANCE 6.00
FLOOD ZONE
A.L.U.C.
COMPENSATION INSURANCEPLG.CONTR.
(This section need not be completed if the permit is for one
,LIC. NO.
PLG,
TOTAL
Y ❑ N ❑
Y ❑ N❑
OTV. MECHANICAL'`PERMIT :`y f4_, -tFEE ''
- ,
-
- FEE,SUMMARY
- -.
'y'y, •� ,} l
It u ndred doll mss ($ 100) Or less)
I certify that in the performance of the work for which this per-
mit is issued, 1 shall not employ any pervert in any manner so as In
BUILDING
become subject to the Workers' Compensation Laws of Calil'Omid.
D:dc ApphcxnfALTER
'10
.
OR ADD TO MECH. 400
NOI ICI: APPLICANT: If, after making this Cerlificate of Fx-
emplion, you should become subject to the Workeri Compensation
APPLIANCE' 4.00
PLAN CHECK
provisions of the Labor Code, you must forthwith comply with
such provisions or this permit shall be deemed revoked.
AIR HANDLING UNIT (TO 10,000C.F.M.) 3.00
FEE
CONSl'RUCI'10N LENDING AGENCY
AIR HANDLING UNIT(OVER 10p00C.F.M.) 5.00
SEISMIC FEE
I hereby affirm that there is a construction lending agency for
EXHAUST HOOD (WITH DUCT) 2.00
the performance of the work for which this permit is issued (Sec.
3097, Cw.CJ.
MICROFILM
HEATING UNIT (TO 100,000 B.T.U.) 4.00
HEATING UN IT IOV ER 100,000 BTU .)7.50
ELECTRIC
Lender's Name -
Lender's Address
I certify that I have read this application anti stale that the above
VENTILATION FAN (SINGLE) 3.00
information is correct. I agree to comply with all city and county
ordinances and state laws relating t0 building construction, and
PLUMBING
BOILER- OOMP (3 H.P. or 100,000 B.T.U.) 4.00
BOILER-COMP .(Over 100.000 RTU( SEE FEE SCH.
MECHANICAL
herchy authorise representatives of this city to enter upon the
above-mentioned property for inspection purposes
(We) agree to save, indemnify and keep harmless the City of
Cupertino against liabilities, judgments, costs and expenses which
may in a way accru gains( -'d City in consequence of the
gra ': f his pemlit. -
a
MSC.- REFER TO ORD.
CONST. TAX
PERMIT ISSUANCE 3.00
MECH. CONT. LIG.ND. MECH.
TOTAL "
TOTAL,
i
Sig t eof Applica JCdntrII. 1
OFFICE COPY