8744APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
BU I LDING PROJECT IDENTIFI CATION
APPLICATION &PERMIT
BUILDING - ELECTRICAL -PLUMBING -MECHANICAL
PERMIT NUMBER
8744
BUILDING
UILDIN
BDDRESS
OWNE 'S
NAME
11. 11 ONE
CITY. ELECTRIC PERMIT FEE
PLAN CHECK VALIDATION
NAME T
OUTLETS - SWITCHES -RECEP 10.00/1.00
LIGHTING FIXTURES 10.00/1.00 r
sec. No.
nDDRESs
APPLIANCES- RESIDENTIAL 4.00
PANELS 10.00
PHONE
DATE OF APPLICATION
T
OR
ENGINEER
sec. No.
PANELS (OVER 200 AMP) 20,00
PLAN CHECK FEE P.C. NO.
SIGNS TRANS. 3.00
AARCHOR DDRESS ENG.
SPECIAL CIRCUIT 5.00
PERMIT VALIDATION
EMP. METER OR POLE INS. 20.00
21P
^
S
Ars
ADDRESS
DREss
MOTORS SEE FEE SCH.
CHI
SERVICE CHA GE 20.00 i -
V�/fs"
LICENSED CONTRACTORS DECLARATION
TEMP. POLE 30.00
I hereby affirm that 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.
License Class_ _.. Lia Natant, E /2 69G!
DamContractor!
�9--8�
OWNER -BUILDER DECLARATION
I hereby affirm that I am exempt from the Contractors License
Law for the following reason. (Sec. 7031.5, Businessand Profession{pERM1T
Code: Any city or county which requires a permit to construct, alter,
ISSUANCE DATE
BLDG.
r 1�
ELECT. I
-
PLG. MECH.
❑ ❑
BUILDING PERMIT
INFORMATION
MISC. - REFER TO ORD �"
VALUATION
$/FT.
ISSUANCE 10.00
ELEC. CONTE. LIC. NO.
ELEC.
TOTAL
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
PERMIT TO
OTY. PLUMBING PERMIT FEE
Law (Chapter 9 f vminencing with Section 7000) of Division 3 ol'tbe
Business and Proless9ons Code) or that he is exempt therefrom and
STORIES
TYPE CONSTR.
the basis for the alleged exemption. Any violation of Section 7031.5
by any applicant lot a permit subjects the applicant toa civil penalty
of not more than five hundred dollars (5500).1:
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
OCC. GROUP
RES. UNITS
DRAINS -FLOOR, ROOF, AREA, COND. 5.00
intended or offered for sale (Sec. 7044. Business and Professions
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
SOL FT. FLOOR AREA
TOTAL ACREAGE
GAS-EA.SYSTEM-I 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 im-
Proveforpurposeofsale.).STRIAL
❑ I, as owner of the property, am exclusively contracting with
,GAS - EA. SYSTEM - OVER 4 (EA.) 2.00
BUILDING USE
RES IND CON PB Omer
❑ ❑ ❑ ❑ ❑
INDU WASTE INTER. 30.00
licensed contractors to construct the project ISce. 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. 6.00
LAWN SPRINKLERS - OVER 5 (EA.) 1.00
ASSESSORS PARCEL NO.
contracts forsuch projects with a contmctorls) licensed pursuant to
the Contractor's License Law.
SEWER -SAN V -STORM EA. 200ft/10.00
TRACT NO.
PARCEL NO.
❑ I em exempt under Sec. ,BAP.C. for this
WATER HEATER W/VENT 6.00
reason
Owner Date
WATER SYSTEM 5.00
ACC.DATE
ACC. FILE No.
WATER TREATING EQUIP, 5.00
WORKI:RS'COMPI:NSX FON DECLARATION
' I hereby affirm that I have A certificate ofconsent to self -insure.
or a certificate of Workers' Compensation Insurance. or a certified
ZONING
ENG. SITE NO.
copy thereof (Sce. 3800, Lab.C.).
Policy No. Company
IDCertified copy is hereby fon I c�p�p���
❑ Certified copy is filed with the Sty (��-mzperaJiI
Applicant
FIRE SPRINK
Y ❑ N ❑
ENERGY T24
Y ❑ N❑
MISC. - REFER TO ORD.
CERTIFICATIi OF EXEMPTION FROM WORKERS'
PERMIT ISSUANCE 10.00
FLOODZONE
A.L.UC.
PLG. CONTE. LIC. NO.
PLG.
TOTAL
COMPENSATION INSURANCE
This section need not be completed if the permit is for of
Y ❑ N❑
Y ❑ N❑
,
hundred dollars IS 100) or It..)
1 certify that in the performance of the work for which this per
mit is issued, I shall no[ 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.
Dam Applicant
ALTER OR ADD TO MECH. 5.00
NOTICE TO APPLICANT: If, after making this Certificate of Ex-
emption, you should become subject to the Workers' Compensation
APPLIANCE 5.00
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 JODMC.F.M.) 4.00
FEE
AIR HANDLING UNIT(OVER 10=C.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
the performance of the work for which this permit is issued (Sec.
3097, Civ.C.).
MICROFILM
H EATING UN IT ITO 100,000 B.T.U.) 8.00
H EATI N G U N IT (OVER 100,000 B.T.U.) 9.50
ELECTRIC
Lender's Name
Lender's Address
I certify that l have read this application and state that the above
VENTILATION PAN (SINGLE) 4.00
information is correct. 1 agree to comply with all city and cuunty
ordinances and stale laws relating to building construction, and
PLUMBING
130ILER-COMP(3H.P.or100,000B.T.U.) 6.00
BOILER -COMP lower 100,000 BTU) SEE FEE SCH.
MECHANICAL
hereby authorize 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
MISC. - REFER TO ORD.
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
grantingofthis permit,
MECH. CONT. LIC. NO.
MECH.
TOTAL
TOTAL
C roc
INSPECTOR COPY