9283 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES- USE BALL POINT PEN ONLY
BUILDING PROJECT I DENTIFICATI ON PERMIT NUMBER
BUILDING APPLICATION & PERMIT 8283
ADDRESS
BUILD G - ELECTRICAL-PLUMBING-MECHANICAL
OwNER'S -' PLAN CHECK VALIDATION
V NAME Cup,121% rNCZ. 716 • k1Q/XrQ� QTY. ELECTRIC PERMIT FEE
• QP y
worvE [
RAW WT. OUTLETS
-SWITCHES-RECEP 10.00/1.00
LIC.No. LIGHTING FIXTURES 10.00/1.00
CONTRADDRESS ors APPLIANCES-RESIDENTIAL 4.00
AS
\, PHONE PANELS 10.00 DATE OF APPLICATION
I!* ARCHITECT \ PANELS (OVER 200 AMP) 20,00 PLAN CHECK FEE P.C.NO.
OR
ENGINEER
' Is LIC.No. SIGNS TRANS. 3.00 PAID
AARCHOR DDRESS ENG SPECIAL CIRCUIT 5.00 PERMIT VALIDATION
zu, TEMP. METER OR POLE INS. 20.00 JUS 15 1965
ARSMOTORS SEE FEE SCH. '
ADDRESS
SERVICE CHANGE 20.00 City of Cupertino
woo LICENSED CONTRACTORS DECLARATION TEMP.POLE 30.00
¢ .U I hereby affirm that I am licensed under provisions of Chapter 9 ISSUANCE DATE
wa w (commencing with Section 7000)of Division 3 of the Business and BDG. ELECT. PLG. MECH.
F H z Professions Code,and my license is in full force and effect I
z O m - License Class Lie.Number \ ❑ ❑ p
o L Date Contractor
a m f - BU NG PERMIT
¢ a OWNER-BUILUF-R DECLARA'f10N
a o a " MISC.- REFER TO ORD FORMATION
wS LL H 1 hereby affirm that I am exempt from the Contractors License
.. o Law for the following reason.(Sec.7031.5,14t,sinessand Professions PERMIT ISSUANCE 10.00 Vn DATION $/FT.
Code:Any city orcounty which reyuiresa permit to construct,alter,
¢ ¢3 improve,demolish,or repair any structure,prior to its issuance,also ELEC.CONTR. LIC.NO. ELEC.
0¢ requires the applicant for Such permit to file a signed statement that TOTAL PERMIT TO
u ht
e is licensed pursuant ,the provisions of the Contractor's License
w m , '-
F z at
Law(Chapter 9(commencing with Section 7000)of Division 3 of the
f 4 o Business and Professions Code)or that he is exempt therefrom and OTY. PLUMBING PERMIT FEE
¢ I- o the basis for the alleged exemption.Any violation of Section 7031.5 STORIES TYPE CON .
ate _ by any upplicnnt for.permit subjects the applicant to a civil penalty -
ofnot more than five hundred dollars(5500).): ALTER-DRAIN&VENT-WATER (EA.) 5.00 ,
❑ I,as'owner of the property,or my employees with wages as BACK F LOW PROTECT. DEVICE 4.00
mG
their sole compensation,will do the work,and the structure is not OC RES.UNIT
intended or offered,for sale (Sec. 7044, Business and Professions DRAINS-FLOOR,ROOF,AR EA,COND. 5.00 T
Code'file 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 ACREA
himself or through his own employees,provided that such improve-
mentsare not intended oroffered for sale,If,however,the building GAS-EA.SYSTEM-11NC.40UTLETS 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 if, -EA.SYSTEM-OVER 4 (EA.) 2.00 BUILDING USE
prove for purpose of sale.). INDUSTRIAL WASTE INTER. 30.00 RES IND CON PB Om.,
❑ I,as owner o1 the property,am exclusively contracting with ❑ ❑ ❑ ❑
licensed contractors m construct the project(Sec.7044.Business LAWN SPRINKLERS- 1 INC 5 V.B. 6.00 14ASSESSORS PARCEL NO.
and Professions Code:The Contractors 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 enntractons)licensed pursuant to
the Contract,,,',License Law. SEWER-SANITARY-STORM EA.200ft/10.00 / TRACT NO. PARCEL NO.
❑ lam exempt under See ,B.&I'.C.for this WATER HEATER W/VENT 6.00
reason
Owner Date WATER SYSTEM 5.00 ACC.DATE ACG FILE NO.
WORKERS'COMPENSA'IION DECLARATION WATER TREATING EQUIP. 5.00
I hereby affirm that I have a certificate of consent to self-insure. ZONING
or a certificate of Workers Compensation Insurance,or a certified ENG.SITE NO.
copy thereof(Sec.3800,Lab.CAV
Policy No, Company
O Certified copy is hnreb_v orals ed.
`q� J FIRE BPRINK ENERGY T24
z 2 t,7 Ceti cop til t) pre nspcnion division.
MISC.- REFER TO ORD.
0 Applica V❑ N❑ Y ❑ N❑
k PERMIT ISSUANCE 10.00
N .OI I'
112
1 N-ORKfikS• FLOOD ZONE ALU.C.
W CO M P EN.ATION IN UkANCE PLG.CONTR. LIC.NO. PLG.
CL 0 (P
CL 0 his section need not be completed if Ills permit is for one TOTAL Y❑ N❑ Y [:D No
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
W I- mit is issued.I slmll not employ any person in any...nncr so as to
O w become subject to the Workers'Compensation Laws of California.
Date Applicant BUILDING
a tp ALTER OR ADD TO MECH. 5.00
} to NOTICE TO APPLICANT: If,after making this Certificate of Ex-
F Z_ emption,you should become subject to the Workers Compensation APPLIANCE 5.00 PLAN CHECK
provisions of the Labor Code, you must forthwith comply with - FEE
U such provisions or this permit shall be deemed revoked AIR HANDLING UNIT(TO 10=CF.M.) 4.00
CONSTRUCTION LENDING AGENCY AIR HANDLING UNIT(OVER 10=C.F.M.) 6.00 SEISMIC FEE
I hereby afirm that there is a c.nStrudinn lauding agency for EXHAUST HOOD(WITH DUCT) 5.00
the performance of the work for which this permit is issued(Sec. MICROFILM
3097,Civ.C.). I HEATING UNIT(TO 100,000 B.T.U.) 8.00
Lender's Name
Lender's Adores, HEATING UNIT(OVER 100,000 B.T.U.)9.50 ELECTRIC
I certify that I have read this application and state 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 representatives of this city to enter upon the
above-mentioned property for inspection purposes. ,OILER-COMP (Over 100,000 BTU)SEE FEE SCH. MECHANICAL
(We) agree to save, indemnify and keep hmenless the City of MISC.- REFER TO ORD.
Cupertino .,.just liabilities,judgments, costs and peroses which CONST.TAX
may in any way accrue BE st said.e' r luence of the PERMIT ISSUANCE 10.00
gra,,lmof thron,. L% MECH.CONT. LIC.NO. MECH.
/ 7/7
/ rorgL TOTAL '^-
\�
Date
INSPECTOR COPY