8311APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
BUILDING PROJECT IDENTIFICATION
APPLICATION & PERMIT
BUILDING - ELECTRICAL- PLUMBING - MECHANICAL
PERMIT NUMBER
8311
BOILDING
AOOR-/ i�. L
G•
OWNERS
PLAN CHECK VALIDATION
NAM
QTY. ELECTRIC PERMIT FEE
orvE
DATE OF APPLICATION
CONTRACTORS
NAME
OUTLETS -SWITCHES -RECEP 10.00/1.00
LIGHTING FIXTURES 10.00/1.00 �P
CONTRACTOR
ADDRESS offs
S C.Q. ILM I E,91- S2.3
APPLIANCES- RESIDENTIAL 4.00
PANELS 10.00
ARCHITECT
OR
PANELS (OVER 200 AMP) 20.00
PLAN CHECK FEE P.c. No.
SIGNS TRANS. 3.00
ENGINEER
LIC. NO.
oCH. 09 ENG.
SS
SPECIAL CIRCUIT 5.00 -
PERMIT VALIDATION
EMP. METER OR POLE INS. 20.00
Zlv
ooRess Ta
MOTORS SEE FEE SCH.
SERVICE CHANGE 20.00 -�
q
3 d P/ S
LICENSED CON"TRACTORS DECIARA'T ION
TEMP.POLE 30.00
1 hereby affrm that I am licensed under provisions of C11apicr 9
ISSUA CE DATE
(nornmenaing with Section 7000) of Division 3 of (he Business andBLOC.
Professions Cod � and n license is in full force am ff 6
License CWss Lie Number
❑
ELECT.
PLG. MECH.
❑ ❑
Date Contractor
BUILDING PERMIT
OWNER -BUILDER DECLARATION
I hereby affirm that I am exempt front ilia Contractors License
Law for the following reason.(Sce, 7031.5, Business and Pmfassinns
Code: Any city or county which requires a permit t0 cons[mcL alter,
improve, demolish, or repair any structure, prior to its issuance, a15o
requires the applicant for such permit to file a signed statement Thal
he is licensed pursuant to the provisions of the Contractor's License
INFORMATION
MISC.- REFER TO ORD
VALUATION
2
$)FT.
'
PERMIT ISSUANCE 1-QA0
ELEC. CONTE. LIC. NO.
ELEC.
TOTAL 33
PERMIT TO
QTY. PLUMBING PERMIT FEE
Law (Chapter 9 (commencing with Section 7000) o' Division 3 of the
Business and Professions Codc) or that he is exempt therefrom and
�-
STORIES
TYPE CONSTR.
the basis for the alleged exemption. Any violation of5ection 7031.5
by any applicant for a permit subjects the applicant to a civil penally
of not more than five hundred dollar.(S500):)'.
ALTER -DRAIN -WATER IEA.) 5.00
❑ I, as owner of the property, or my employees with wages as
their sole compensation, will do the work, and the structure Is not
BACK FLOW PROTECT. DEVICE 4.00
OCG GROUP
RES. UNITS
DRAINS -FLOOR, ROOF, AR EA, COND. 5.00
intended or offered for sale (Sec. 7044, Business and Professions
Code: The Contractor's License Law does not apply io 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 impmvc-
mcntsarenolirltendedorofferedforsale. If, however, the building
GAS - EA. SYSTEM -1 INC.4 OUTLETS 6.00
or improvement is sold within one year of completion, the owner-
builder will have the burden of proving that lin did not build or hit-
provefor purpose ofsale.).
❑ 1, as owner of the property, am exclusively contracting with
GAS - EA. SYSTEM -OVER 4 IEA.) 2.00
BUILDING USE
RES IND CON PS ome,
❑ ❑ ❑ ❑ ❑
INDUSTRIAL WASTE INTER. 30.00
LAWN SPRINKLERS- 1 INC 5 V.B. 6.00
ASSESSORS PARCEL NO.
licensed contractors In construct the project (Sec. 7044, Business
and Professions Coda:'I'he Contractor's License Law does riot apply
to an owner of property who builds or improves thereon. and who
LAWN SPRINKLERS - OVER 5 (EA.) 1.00
-
contracts for such projects with a contractor(s) licensed pursuant to
theContractor'sLicenseLaw.
SEWER -SANITARY -STORM EA. 200fU10.00
TRACT No.
PARCELNO.
❑ lam exempt under Sec.-, B &P.C. for this
rcuzor
WATER HEATER W/VENT 6.00
Owner Dale
WATER SYSTEM 5.00
ACC. GATE
ACC. FILE N0.
WATER TREATING EQUIP. 5.00
. WORK E RS'COMPIiNSATION DECLARATION
I hereby affirm that 1 have a certificate of consent to sell -insure.
or a certificate of Workers' Compensation Insurance, or a certified
ZONING
ENG. SITE NO.
(copy thurcofl Scc. 3800, Lab.C.). ,
Policy Nn. Company
FIRE SPRINK
Y ❑ N❑
ENERGY T24
Y ❑ N❑
❑ Certified copy is hereby fumishad.
❑ Certified copy is fled with the city inspection division.
Applicant
MISC.- REFER TO ORD.
CERTIFICATE OF I'XEMRI[ON FROM WORKF. RS'
PERMIT ISSUANCE 10.00
FLOOD ZONE
A.L.U.C.
PLG. CONTE. ❑C. NO.
PLG.
TOTAL
' COMPENSATION INSURANCE
(This section need not be completed if the permit is for one
Y ❑ N ❑
Y ❑ N ❑
hundred dollars IS 100) or less. )
1 certify that in ilia performance of the work for which this per,
mil is issued, I shall not employ any person in any natter so as to
QTY. MECHANICAL PERMIT FEE
FEE SUMMARY
BUILDING
hecomasubjeetlo ryWphcker Contpcns I nLnws of Caldron,
Dale - - ICANT: I 11 Nficele iix
NOTI TO APPLICANT: If, ler
ALTER OR ADD TO MECH. 5.00
APPLIANCE 5.00
PLAN CHECK
h sa
envision you should become to thears'Compensation
must
provisions of the labor Code, you dee d Rv. lh comply with
e, Yo ho
such provisions or this permit shall be deemed revoked.
FEE
AIR HANDLING UNIT (TO 10,0000F.M) 4.00
AIR HANDLING UNIT (OVER IQOODC.F.M.) 6.00
SEISMIC FEE
CONS'T'RUCTION LENDING AGENCY
I hereby affirm that there is a construction Tending agency for
EXHAUST HOOD (WITH DUCT) 5.00
ilia 3097. Ce.C-) ae of the work for which this permit is issued IS",
MICROFILM
HEATING UNIT (TO 100,000 B.T.U.) 8.00
HEATING UNIT (OVER 100,000 B.T.U.)9.50
ELECTRIC
..33 fa
,.mss
Lender's Name
Lender's Address
I certify tbai I have read this application and state that the above
information is correct. I agree to comply with a1I city anA county
ordinances and state laws relating to building cunstrunion, and
VENTILATION FAN (SINGLE) 4.00
PLUMBING
BOILER-COMP(3 H. Ror100,D00B.T.U.) 6.00
BOILER-COMP(Over100,000BTUPSEEFEESCH.
MECHANICAL
hereby authorize representatives of this city to enter upon the
above-mentioned property for inspection purposes.
MISC. - REFER TO ORD.
-
(We) agree to save, indemnify ,,it kacp harmless ilia City of
Cupertino against liabilities, judgments, costs and expensos which
may in any way accrue against said City in consequence of the
CONST. TAX
PERMIT ISSUANCE 10.00
g ming of This nuL
MECH. CONT. LIC. N0.
MECH.
-
TOTAL
TOTAL
Signature of Appbam C n ctor 1 ate
INSPECTOR COPY