8519APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
BU LDI NG PROJECT I DENTI FICATI ON
APPLICATION & PERMIT
BUILDING - ELECTRICAL- PLUMBING - MECHANICAL
PERMIT NUMBER
8519
BUILDING ^�
ADORES LrA is 1i CIS l L.CIILJCI PIQC�
OWNER'S
-
PLAN CHECK VALIDATION
"AME
CITY. ELECTRIC PERMIT FEE
PHONE
M
NOMEEacTous1
OUTLETSHT-SWITCHES-RECEP 10.0011.00
LIGING FIXTURES 10.00/1.00 '
"TR
ADDRESS
PPLIANCES-RESIDENTIAL 4.00
PANELS 10.00
C
\rPHONE
DATE OF APPLICATION
o cHhTEC
off
ENGINEER
uc. No.
PANELS(OVER 200 AMP) 20.00
PLAN CHECK FEE P.C. NO.
SIGNS TRANS. 3.00
ARCH.
oo Ess ENG.
CIRCUIT 5.00
PERMIT
PERMIT VALIDATION
TEMP. METEh OR POLE INS. 20.00
ZIP
APPLICANT'S
ADDRESS
MOTORS SEE FEE SCH. ¢'
SERVICE CHANGE 20.00
LICENSED CONFFRACFORS DECLARATION
TEMP. POLE 30.00
I hereby affirm that 1 am licensed under provisions of Chapter 9
(commencing with Section 7000) of Division 3 of the Business an(]
Professions Cod anJ my license is in full force and effect.
License Class Lie. Number.'��j-1
ISSUANCE DATE
BLDG.
❑
ELECT.
PLG. I MECH.
❑ ❑
Dale - Contractor aE'6c6r
x,
OWNER -BUILDER DECLARATION
I hereby affirm that I am exempt from the Contractors License
Law for the following reason.(Sec. 7031,5, Business and Professions
Code'. Any city or County which requires a perch to construct, al ler
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 of to
Business and Po.I.,ions Code) or that he is exempt therefrom and
BUILDPERMIT
INFORMATION ATION
MISC.- REFER TO ORD i
VALIO
UATN
-
5/FT.
PERMIT ISSUANCE 10.OD _
ELEC. CONTE. LIC. NO.
'LEC.
TOTAL ot/
PERMIT TO
y�
/ L'-�`'7/� yJOLC-
QTY. PLUMBING PERMIT FEE
STORIES
TYPE CONSTR.
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
of not more than five hundred dollars (5500).):
ALTER -DRAIN -WATER (EA.) 5.00
O 1, as owner of the property, or my employees with wages as
their sole compensation, will do the work, and the structure is not
BACK F LOW PROTECT. DEV ICE 4.00
OCC. GROUP
RES. UNITS
DRAINS -FLOOR, ROOF, AREA,COND. 5.00
intended or offered for sale (Sec. 7044, Business and Pro(essiuns
Code The Contractor's License Law docs not apply to an owner of
property who builds or improves thereon, and who docs such work
himself' or through his own employees. provided that such improve.
ments are not intended or offered for sale. If, however, the building
'
FIXTURES - PER TRAP 5.00
SO. RT, FLOOR AREA
TOTAL ACREAGE
GAS - EA. SYSTEM - 1 1 NC. 4 OUTLETS 6.00
or improvement is sold within one year of completion, the owner-
builder will have the burden of proving that he did not build or inr
prove for purpose ofsaleJ.
❑ I, as owner of the property, am exclusively' contracting with
GAS - EA. SYSTEM -OVER 4 (EA.) 2.00
BUILDING USE
RES IND CON PB ohne,
❑ ❑ ❑ ❑
WASTE INTER. 30.00
INDUSTRIAL❑
licensed contractors to construct the project (Sec. 7044, Rosiness
and Prolessions Code: 'Tire Contractor's License Law does not apply
to an owner of property who builds or improves thereon, and who
LAWN SPRINKLERS -I INC 5 V.B. 6.00
LAWN SPRINKLERS - OVER 5 (EA.) 1.00
ASSESSORS PARCEL NO.
contracts for such projects with a contractors) licensed pursuant to
the Contractor's License Law.
SEWER -SANITARY -STORM EA. 200ft/10.00
TRACT NO.
PARCEL NO.
❑ 111111 exempt under Sec. ,B.&P.C. for this
aser
WATER HEATER W/VENT 6.00'
Owocr Date
WATER SYSTEM 5.00
ACGDATE
ACC. FILE NO,
WATER TREATING EQUIP. 5.00
WORKERS'COMPENSA'IION DECLARATION
1 hereby affirm that I have a certificate of Ixmsent to sell i .... r.
or a certificate of Workers' Compensation Insurance, or a certified
ZONING
ENG. SITE NO.
copy thereof (Sec. 3800, Lab.C.).
Policy No. Co.....airy
FIRE SPR INK,
V ❑ No
ENERGY T 2
Y ❑ N❑
❑ Cetiified copy is hereby fu ed.
JCertified copy is filed with the city inspection division.
icantp.
MISC. - REFER TO ORD.
CERTIFICATE OIr EXEMPTION PROM WORKS. RS'
PERMIT ISSUANCE 10.00
FLOOD ZONE
A.L.O.C,
COMPENSATION INSURANCE
(I his section need not be completed if the permit is for one
PLG. CONTE. LIC. NO.
PLG.
TOTAL
YE] N❑
Y❑ NO
hundred dollar, ($ 100) or less.)
I certify that in the performance of the work for whichthis per-
mit is issued. I shall not employ any person in any manner so as to
CITY. MECHANICAL PERMIT FEE
FEE SUMMARY
BUILDING
become subject to the Workers Compensation Laws of California.
Date Applicant
ALTER OR ADD TO MECH. 5.00
NOTICI7 TO APPLICANT: if, after making this Certificate of fix
eruption, you should become subject to the Workeri Compensation
APPLIANCE 5.00
PLAN CHECK
provisions of the Labor Code, you must forthwith congily with
such provisions or this permit shall be deemed revoked
AIR HANDLING UNIT (TO 10,000C.F.M.) 4.00
FEE
AIR HANDLING UNIT (OVER 10,0WC.F.M.) 6.00
SEISMIC FEE
CONSTRUCTION LENDING AGENCY
I hereby affirm that there is a construction lending agency for
EXHAUST HOOD (WITH DUCT) 5.00
e work far which this permit is issued (Sec.
the Irertor7. Cance of tire
MICROFILM
HEATING UNIT (TO 100,000 B.T.U.) 8.00
HEATING UNIT (OVER 100,000 B.T.U.)9.50
ELECTRIC
--
Lender's Name
Lender's Address
VENTILATION FAN (SINGLE) 4.00
-
I certify that I have read this application and ,at, that tie above
information is correct. I agree to comply with all city and county
ordinances and state laws relating to building construction, and
PLUMBING
BOILER-COMP(3 H.P. or 100,000 B.T.U.1 6.00
BOILER -COMP (Over 100,000 BTU) SEE FEE SCH.
MECHANICAL
hereby authorize representatives of this city to enter upon the
above-mentioned property for inspection purposes.
MISC. - REFER TO ORD.
CONST. TAX
(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 consequence of the
PERMIT ISSUANCE 10.00
granting of this Rcnnit.
MECH. CONT. LIC. NO. MECH.
SJ U
TOTAL
TOTAL
azure Applicant/ ontmctorrcr- Date -
L/ INSPECTOR COPY