8782APPLICANT 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
878 G
2'S
AD
ADDRESS
2:
A
"AME �
QTY. ELECTRIC PERMIT FEE
PLAN CHECK VALIDATION
ONE
NAME Ac ons
OUTLETS -SWITCHES-RECEP 10.00/1.00
Ica rvG L ALIGHTING
FIXTURES 10.0011.00
AoADDRESS.o * A oR •s T
PPLIANCES- RESIDENTIAL 4.00
PANELS 10.00
sl
PHONE
DATE OF APPLICATION
ORRcnrtsc
ENGINEER
LIC. No,
PANELS (OVER 200 AMP) 20.00
PLAN CNECK FEE P.C. NO.
SIGNS TRANS. 3.00
Roo ESSSS euc.
SPECIAL CIRCUIT 5.00
PERMIT VALIDATION
EMP. METER OR POLE INS. 20.00
ZIP
APPLICANT
MOTORS SEE FEE SCH.
SERVICE CHANGE 20.00
LICENSED CONTRACTORS DECLARATION
TEMP. POLE 30.00
I hereby afirri that I am licensed under provisions ofChapter 7
(commencing with Section 7000) of Division 3 of the Business andBLDG.
Professions Code, and my license is in full fse Clorce and eft' et
1 ic. Number
1SSUAN E DATE OO
❑
ELECT.
❑
PLG. MECH.
❑ El
Date Contractor
OWNER-BUILUf:R DEn ADON -
I hereby affirm that I am exempt from the Contractor's License
Code:Law nychyhe owingreason.(Sec Tires 5. aerminess t to construct, apes
Cade: Any city or county which requires a permit to construct alteq
BUILDING PERMIT
INFORMATION
MISC.- REFER TO ORD
PERMIT ISSUANCE 10.00
VALUATION
$/FT.
x
ELEC. CONTE. LIC. NO. ELEC.
„-_ TOTAL
QTY. PLUMBING PERMIT FEE
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 (Chaplet 9(commencingwith Section 7000) of Division 3 ofthe
Business and Professions Code) or that he is exempt therefrom and
PERMIT TO
[Z1��/"7 ,
r
STORIES
TYPE CONSTR. .
the basis for the alleged excrupNon. Any violation Of Stenon 7031.5
1
by any applicant for a permit subjects the applicant to a civil penalty
of not more than five hundred dollen 1$5001.7:
ALTER-DRAIN&yyVENT-WATER (EA.) 5.00
Y.
❑ 1, as owner of the property, or my enoloyees with wages as
their sole compensation, will do the work, and the structure is not
BACK FLOW PROTECT!DEVICE 4.00
-
OCC. GROUP
RES. ON ITS
DRAINS -FLOOR, ROOF, AR EA, CON D. 5.00
intended or offered for sale (Sec. 7044, Business and Professions
Code: The Contractor's License Law does not apply to an owner of
FIXTURES - PER TRAP 5.00 OU
so. FT. FLOOR AREA
TOTAL ACREAGE
property who builds or improves thereon, and who dues such work.
himself or through his own employees, provided that such improve-
ments are not intended or offered for sale. If, however, the budding
GAS - EA. SYSTEM - 1 INC. 4OUTLETS 600 Yu
Or improvement is sold within one year of completion, the owner-
builder will have cite burden of proving that he did not build or inr-
prove lot purpose of sale.). 1
O I, as owner of the proPcrtY, am exclusively contracting with
I GAS - EA. SYSTEM -OVER 4 (EA.) 2.00
BUILDING USE
RES IND CON PB Ome,
F-1 El El ❑ 1]
_� INDUSTRIAL WASTE INTER. 30.00
licensed contractors to construct the project (Sec 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 for such projects with a contractous) licensed pursuant to
the Conl...IOr', License Law.
SEWER -SANITARY -STORM EA. 200ft/10.00
TRACT NO.
PARCEL NO.
❑ I:un exempt under See ,B.&I'.C. for lhls
reason
WATER HEATER W/VENT 6.00
Owner Date
WATER SYSTEM 5.00
ACGDATE
ACC. FILE NO,1
WATER TREATING EQUIP. 5.00
WORT: ERS'COMPENSATION DECLARATION
1 hereby affirm That I havu a certificate of consent to sell -insure,
or a certificate of Workers: Compensation Insurance, or a certified
ZONING
ENG. SITE N0.
Copy thereof(Sec. 3800, I.A.C.).
Policy No. Company
-
FIRE $PRINK
V ❑� N❑
ENERGY T$4
v ❑ N❑
❑ Certified copy is hereby furnished.
❑ Certified copy is filed with the city inspection division.
Applicant -
MISC. - REFER TO ORD.
CFiRTIPICATE OF CXhM PTION PROM WOR KERS'
PERMIT ISSUANCE a$IIO
FLOOD ZONE
A.L.U.C.
COMPENSATION INSURANCE
(This wai6n need not be completed if the pencil is for one
PLG.CONTR. LIC, NO.
PLG.
TOTAL (�
V ❑ N❑
V ❑ N❑
hundred doll... 1$100) or Ic,,J
I certify that in the performance of the work for which this per-
mit is issued, I shall not employ any perso in any manner zn ns to
become subj cit to the WmkeriC pens' on Laws of California.
[)areTT. icam
No' li o I'PLICAN'I': m: ng I. C t 1 u c of Ex-
QTY. MECHANICAL PERMIT FEE
FEE SUMMARY
BUILDING
ALTER OR ADD TO MECH. 5.00
APPLIANCE,' 5.00
PLAN CHECK
emption, you should become subject to the Worke Compensation
provisions of the Labor Code, you must forthwith comply with
such provisions or this permit shall be deemed revoked.
AIR HANDLING UNIT (TO 10=C.F.M.) 4.00
FEE
AIR HANDLING UNIT (OVER 10=C.F.M.) 6.00
SEISMIC FEE
CONSTRUCT ION 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 (Sea.
3077, Civ.CJ.
MICROFILM
HEATING UNIT (TO 100,000 B.T.U.) 8.00
Lender's Name
Lender's Address
HEATING UNIT (OV ER 100,000 B.T.U.) 9.50
ELECTRIC
I certify that l have read this application and smte tint the above
VENTILATION FAN (SINGLE) 4.00
-
information is correct. 1 agree to comply with all city and County
ordinances and state laws relating to building construction, and
PLUMBING
!.. L -
BOILER-COMP(3 H.P.or100,000B.T.U.) 6.00
BOILER -COMP (Over t00,0008TU1 SEE FEE SCH.
MECHANICAL
hereby authorize representatives of this city to enter upon the
above-mentioned property for inspection purposes.
(We) agree to save, indenmify and keep harmless the City of
Cupertino against liabilities, judgments, costs and expenses which
may in any way cento against said City in consequence of the
MISC. - REFER TO ORD.
PERMIT ISSUANCE 10.00
CONST. TAX
granti oftlhs nnit
MECH.CONT. LIC. NO.
MECH.
TOTAL
TOTAL
Si he n on . Date
INSPECTOR COPY