C8189APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
BUI LD1 NG PROJECT 1 DENTI FICATI ON
APPLICATION & PERMIT
BUILDING - ELECTRICAL- PLUMBING - MECHANICAL
PERMIT NUMBER
BUILDING / / ) ) w
ADDRESS 0 (p 0{ O` • d✓f/�G LJ r/ �ti
i V 1 Y
Ow ER'5
NAME
QTY. ELECTRIC PERMIT FEE
PLAN CHECK VALIDATION
PHONE
NAMERACTOR'S
OUTLETS-SWITCHES-RECEP 10.00/1.00
LIGHTING FIXTURES 10.00/1.00
L /i LC. No,
DATE OF APPLICATION
NTRACTOR's
ADDRESS 767 '13 Y L y
� ) SPHANE
L.
PPLIANCES- RESIDENTIAL 4.00
PANELS 10.00
ARC
OR
ENGINEER
LIC. No.
PANELS (OVER 200 AMP) 20.00
PLAN CHECK FEE P.C. NO.
SIGNS TRANS. 3.00
ARCH,OR ENG'
SPECIAL CI RT 5,00
PERMIT VALIDATION
EMP. METER OR POLE INS. 20.00
zADDRESSlP
V
APPLICANT s
ADDRESS
MOTORS SEE FEE SCH.
SERVICE CHANGE - ',20.00
LICENSE 1) CON TRACT ORS DECLARATION
TEMP. POLE 30.00
I hereby affirm (hat I am licensed under provisions of Chapter 9
(commencing with Section 7000) of Division 3 of the Business and
Professions Code, and my license is in full force and effect.
Class Lie N ornber,__jy3s
IS LANCE DATE
BLDG.
El
ELECT.
1:1
PLG. I MECH.
1:1 ElLicense
Dale ,11.6h�_rG_� Contractor6
BUILDING PERMIT
INFORMATION -
OWNER -BUILDER DECLARATION
1 hereby collo that I so exempt from the Contractor', r License
Law for the followingreason.(Sec.uires a Businessand Professions
Code: Any city or county which requires a Permit m is construct, aIle,,
improv., tlenmlish, or repair any 5hucturc, Prior to its isswurce 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(c.nmencing with Seclinn 7000)of Division 3o fthe
Business and Professions Code) or that hu is exempt therefrom and
MISC.- REFER TO ORD
PERMIT ISSUANCE '10.00
VALUATION
/ -
S/FT.
ELEC. CONTR. LIC. NO.
ELEC.
TOTAL
PERMIT TO
g
'st '741,,l
� J
OTY. PLUMBING PERMIT FEE
STORIES
TYPE CONSTR.
the basis for the alleged exemption. Any violation of Section 7031.$
by any applicant for a permit subjects the applicant to a civil penalty
of not more than five hundred dollars (S500).):
ALTER -DRAIN -WATER (EA.) 5.00
❑ 1, as owner of the property, or my employees with wages as
their sole compensation, will do (he work. and the structure is not
BACK FLOW PROTECT. DEVICE 4.00
OCC. GROUP
RES. UNITS
DRAINS -FLOOR, ROOF, AREA, COND. 5.00
intended or offered for sale (Sec. 7044, Business and Professions
Code: The Con(mmor's License Law docs not apply to an owner of
property who builds or innpinves thereon, and whit does such work
himself or through his own employees. provided that such improve-
tonsurenotintendedorofferedforsale. If, however, the building
F IXTURES - PER TRAP 5.00
s0. FT. FLOOR AREA
TOTAL ACREAGE
GAS - EA. SYSTEM - I INC -4 OUTLETS 6.00
or improvement is sold within one year of completion, the owner-
builder will have the burden of proving that h e did not huild or ins
prove for purpose ofsaleJ.
❑ I, as owner oI the property, am exclusively contracting with
. ,.
GAS - EASYSTEM -OVER 4 (EA) 200
BUILDING USE
RES IND BON PB Omer
❑ ❑ ❑ ❑ ❑
.
INDUSTRIAL WASTE INTER30.00
I icansvd contractors to construct the prnjuet (Sec. 7044, Business
and Professions Code: The Contract.,', License Law does not apply
to an owner of property who builds or innprov'es thereon. ;red who
LAWN SPRINKLERS - 1 INC 5 V.B. 6.00
ASSESSORS PARCEL NO.
LAWN SPR IN KLERS - OVER 5 (EA.) 1.00
contracts for such projects with a contractor(s) licensed pursuant to
lire Con_Ir7d`Fs'Licerse,Law,�.,
SEWER-SANITAR V -STORM EA. 200ft/10.00
TRACT NO.
PARCEL NO.
❑ I am exemP1 under Site ,BAPI C. Iii this
WATER HEATER W/VENT 6.00
reason
Owner.., Date
WATER SYSTEM 5.00
ACC.OATE
ACC. FILE NO.
WATER TREATING EQUIP. 5.00
WORKERS'COSIPEN'SATION DLCLARAHON
1 hereby affirm that I have a certificate of consent to self.insure,
or a certificate of Workers' Compensation Insurance, or a certified
ZONING
ENG. SITE NO.
copy thereof (See 3800, Lab .C.I /
Policy No. Company f
FIRE SPRINK
Y ❑ NE]Y
ENERGY T 24
❑ N❑
❑ Certified copy i, hereby furnished.
❑ Certified copy is filed with plecity inspection division.
Applicant _A
MISC. - REFER TO ORD.
_
CERTIFICATE Of EXEMPTION I7ROM WORKERS'
PERMIT ISSUANCE 10.00
FLOOD ZONE
A.L.U.C.
PLG. CONTR. LIC. NO.
I.G.P
TOTAL
COMPENSATION INSURANCE
('Phis ,e,film need ..I be completed if (he permit is for one
Y ❑ N❑
Y EJ N❑
hundred dollars (S 100) or less.)
I certify thin in the performance of the work for which this per-
mit is issued, 1 sinll not employ any person in any manner so as to
OTV MECHANICAL PERMIT FEE
FEE SUMMARY
BUILDING
at. 1Z
/
become subject to the Workers' Compensation Laws of California.
Date ApplicantALTER
NO"I'ICH TO APPLICANT: It, after making this Certificate of Ex-
OR ADD TO MECH. 5.00
APPLIANCE 5.00
PLAN CHECK
.
enl prion, you should become subp,cl to lire Worked Conpeneation
provisions of the Labor Code, you must forthwith comply with
such provisions or this permit shall be deemed revoked.
FEE
AIR HANDLING UNIT (TO 10=C.F.M.) 4.00
AIR HANDLING UNIT (OVER 10=C.EM.) 6.00
SEISMIC FEE
/fit
3
CONSTRUCTION LENDING AGENCY
1 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
3097, Civ.C.).
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 Addle ss
I certify that I have read this application and slate that the above
VENTILATION FAN (SINGLE) 4.00
information is correct. I agree to comply with all city and county
ordinances trod state laws relating to building construction, and
PLUMBING
80ILER-COMP(3H.P.or100,000B.T.U.) 6.00
BOILER -COMP (Over 100,000 BTU) SEE FEESCH.
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 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
CONST. TAX
PERMIT ISSUANCE 10.00
Bunning of this permit.
MECH. CONT. LIC, NO.
MECH.
/� _ t M� �- /� - 5
TOTAL
TOTAL
SC�V__
�
Sr ata o ApphL (/ nlrmck)[ Dane
INSPECTOR COPY