8429LICANT TO.FILL�N INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
BUILDING PROJECT IDENTIFICATION
APPLICATION & PERMIT
BUILDING - ELECTRICAL -PLUMBING -MECHANICAL
PERMIT NUMBER
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8429
SUI LDING
ADDRESS
N
NAME
QTY. ELECTRIC PERMIT FEE
PLAN CHECK VALIDATION
WakI)vHorvE
NAME cT E
UTLETS-SWITCHES-RECEP 10.00/1.00
LIC. NO.
ILIGHTING FIXTURES 10.00/1.00
CONTRACTOR:
ADDRESS
APPLIANCES RESIDENTIAL 4.00
PANELS 16,00
PRONE
DATE OF APPLICATION
A RI ECT"is
OR
ENGINCER l
LIC. NO. &:
PANELS (OVER 200 AMP) 20.00 m�
PLAN CHECK FEE P.C. No.
SIGNS TRANS. 3.00
AARCH OR
DDRESS" EEG
SPECIAL CIRCUIT $,OO
PERMIT VALIDATION
EMP. METER OR POLE INS. 20.00
New/}e zIv
AvvucANrs
AODREss
MOTORS SEE FEE SCH.
SERVICE CHANGE 20.00
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LICENSED CONTRACTORS DECLARATION
TEMP. POLE 30.00
hereby affirm that I am licensed under provisions of Chapter 9
(cIommenCing with Section 7000) of Division 3 of the Business and
Professions Code,.nd ni license is in full fare" J e' t,�
Liccmm Class Sf" Lic. Numbed 6Ur
ISSUANCE DATE
BLDG. ELECT. PLG. MECH.
❑ ❑ ❑
.Date d=�- B Contractor
BUILDING PERMIT
INFORMATION
OWNER -BUILDER DIiCt.n Rn'170Id
1 helnby uCIIo that I am exempt from the ConirinnIP, hicens°
Luw for the following mason. (Sec. 7031.5, Business anA Professions
Code: Any city or wanly which requires a permit to construct, alter,
MISC.- REFERTOORD
PERMIT ISSUANCE 10.00
VALUATION
$/FT.
ELEG. CONTE. LIC. N0.
ELEC. �r/�
TOTAL 15
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
QTY. PLUMBING PERMIT FEE
Law (Chapter 9 (emnmeneing will, Section 700() of Division 3 of the
Business and Professions 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 (a, a permit subjects the applicant to a civil penalty
of not more than five hundred dollars (S500)J:
ALTER -DRAIN -WATER (EA.) 5.00
❑ 1, 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, CONE). 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
SO. FT, FLOOR AREA
TOTAL ACREAGE
property who builds or improves thereon, and who does such work
himself or through his own employees, provided that such improve-
memsare natintendedoroffered for sale, l f, however, the building
GAS-EA.SYSTEM-l1NC.4OUTLETS 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-
poZfor moposcofsal°.1.
❑ I, as owner of the properly, am exclusively contracting with
GAS - EA. SYSTEM -OVER 4 (EA.) 2.00
BUILDING USE
RES IND CON PB Ooh,,
0 ❑ ❑ ❑ 0
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 lin owner of property who builds or improves thereon, and who
LAWN SPRINKLERS -I INC 5 V.B. 6.00
ASSESSORS PARCEL NO.
LAWN SPRINKLERS - OVER 5 (EA.) 1.00
contracts fur such projects with a contmein (s) licensed pursuant to
the Contract.,', License Law.
SEWER -SANITARY -STORM EA. 200ft/10.00
TRACT NO.
PARCEL NO.
❑ I am exempt under Sec. , B.&P.C. Ibr this
reason
WATER HEATER W/VENT 6.00
Owner Date
WATER SYSTEM 5.00
ACC. DATE
ACC, FILE NO.
WATER TREATING EQUIP. 5.00
WORKERS'COMPENSATION DECLARATION
-
I hereby .(firm 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.)./j
Policy No. Compan, 4IFC.V .IQ bl�y�.S,
`
i
MISC.- REFER TO ORD.
FIRE SPRINK
YE NEJ
ENERGY T-24
Y❑ No
❑ Certified copy is he furnished. (
�1Cerlified c f d with the 'ity �'M7ell, In divOdW
njipBiae- ,If
t CERTIFICATE Lq, px Em P'rlON FROM WORKERS'
t COMPFNSATION INSURANCE
(This sectiuin need not be completed if the permit is for one
PERMIT ISSUANCE 10.00
FLOOD ZONE
v N
A.L.u,G.
Y ❑ N EI
PLG. CONTE. LIC. NO.
PLG.
TOTAL
hundred dollars IS 100) or less.)
I certify that in the performance of the work for which this per-
mit is issued, I shall not 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.
Date Applicant
ALTER OR ADD TO MECH. 5.00
NOTICE TO APPLICANT: If, after making this Certificate of Ex-
APPLIANCE 5.00
PLAN CHECK
emption, you should become subject to the Worker' Compensation
provisions of the Labor Code, you must forthwith comply with
such provisions or this permit shall be deemed revoked.
AIR HANDLING UNIT (TO 10MC.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 Icndieg agency for
EXHAUST HOOD (WITH DUCT) 5.00
the performance of the work for which this permit is issued (Sec.
3097, Cie.C.).
MICROFILM
HEATING UNIT (TO 100,000 B.T.U.) 8.00
Lender's Name
Lender's Ne dress
HEATING UNIT (OVER 100,000 B.T.U.)9.50
ELECTRIC
Cd
_
I certify that I have read this application and state that ihuabove
VENTILATION FAN (SINGLE) 4.00
information is correct, I agree to comply with un
all city and cut
nrdinencos and slate laws relating to building construction, and
PLUMBING
- BOILER-COMP13 H. P. Or 100,000 B.T.U.) 6.00
BOILER -COMP I Over 100,000 STU) SEE FEE SCH.
MECHANICAL
hereby authorize representatives of this city to enter upon the
above-mentioned property for inspection purpous.
MISC. - REFER TO ORD.
(We) agree to save, indemnify and keep harmless the City of
Cupertino against liabilities, judgments, costs air 'd expenses which
may in any crue agai t Said City in conseemeace of the ac
grmilin f is ,mil.
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CONST. TAX
PERMIT ISSUANCE 10.00
MECH. CONT. LIC. NO.
MECH.
TOTAL
TOTAL
J
Sign;iso
urc pimc Door ctor °
mate
INSPECTOR COPY
4
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