C8729 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
BU LD1 NG PROJECT I DENTI FICATI ON PERMIT NUMBER
BUILDING APPLICATION & PERMIT
ADDRESS
BUILDING - ELECTRICAL-PLUMBING-MECHANICAL 8729
OWNER'S 1 PLAN CHECK VALIDATION
NAME973-14' l OTV. ELECTRIC PERMIT FEE
ONE
CONTRACTOR'S UTLETS-SWITCHES-RECEP 10.00/1.00
NAME �E 2�533v G53
Jt Llc LIGHTING FIXTURES 10.00/1.00
CONTRACTORS APPLIANCES-RESIDENTIAL 4.00
ADDRESS � �J �/
Z rlA 4/AvPHONE7�(4 PANELS 10.00 DATE OF APPLICATION
ARCHITECT PLAN CHECK FEE P.C.N0:1
OR �iQ�r'E q�` ) nQa5._. PANELS(OVER 200 AMP) 20.00 J
ENGINEER �•-i 1"'( i4 O. N
uc.rvo. SIGNS TRANS. 3.00
AARC
DDRESS ENG. SPECIAL CIRCUIT 5,QQ F-PS(Ij�LICATION
ZIP EMP.METER OR POLE INS. 20.00 ��
Ar'S
ADDDRESSDAVSS MOTORS SEE FEE SCH. -JUN 141905
Z505 S . 5&-rtc,epo _ SERVICE CHANGE 20.00
w o o LICENSED CONTRACTORS DECLARATION TEMP.POLE 30.00 CifJl Of Cupertino
u L~j I hereby Alien far I um licensed under provisiuus of Chapter 9 ISSUANCE DATE -
w < y (commencing with Section 7000)of Division 3 of the Business and -/ BLOC ELEC PLG. MECH.
v, w z Professions Conde,and my license is in full force and effect. '
i 0 m License Claus Lic.Number
oH w Uate L_L Conlracmr
- BUIL ING P EMIT
i<w a OWNER-BUILDER DECL nT10N INFORMATION
F oA0 MISC.- REFER TO ORD
w 3 LL I hereby affirm that I am exempt from the Contractor's License VALUATION
u0� Low for tm tisllowing reason. 7031.5,Bmincssund Professions PERMIT ISSUANCE 10.00 S/FT.
� - 0 Code:Any city or county which requir va permit toconstruct,aller,
rtLa¢ < improve,demolish,or repair any structure,prior to its issuance,also ELEC CONTR. LIC.NO. ELEC.
E e is rcyuires the applicant for such permit to file a signet)statement that TOTAL 1� EMI
a m he is licensed pursuant to the provisions of the Contractor's License
Fzi Law.(Chapter 9(commencing with Section 7000)of Division 3 ofthe
4 Business and Professions Code)or that he is exempt therefrom and QTY. PLUMBING PERMIT FEE
r c the basis for the alleged exemption.Any violation ol'Section 7031.5 STOR S T ONSTR.
n ;m by any applicant for a permit subjects the applicant toacivilpenalty ALTER-DRAIN& VENT-WATER (EA.) 5.00
of not shore than live hundred dollars(S500).):
❑ I,as than
of the property,or my employeeswith wages as BACK FI-OW PROTECT. DEVICE 4.00 OCC.GROUP RES.UNITS
their sole cum Presidium,will do the work,and the structure is nut
intended or offered for sale (Sec 7044, Business and Professions DRAINS-FLOOR,ROOF,AREA.COND. 5.00
Code:The 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 ACREAGE
himself ments n through his own offered
for sale.Provided that such im ilding
himefo throuot gh his onemrcd res.provided that suhcbulldimg GAS-EA.SYSTEM-11NC.40UTLETS 6.00
or improvement is sold within one year of completion, - . .) 2.00 the owner- GAS EASYSTEM-OVER 4 (EABUILDING USE
builder will hove the burden of proving that he did nod)mild or im-
prove for Purpose ofsaleJ. INDUSTRIAL WASTE INTER. 30.00 RES IND CON PB C$mer '
❑ 1,as owner of the property,am exclusively contracting with ❑ Eh- ❑ ❑
liceon
used contractors to construed the project(Sec.7044,Bsin
uess LAWN SPRINKLERS- 1 INC 5 V.B. 6.00 ASSESSORS PARCEL NO.
and Professions Code:The Contractor's License Law does not apply
to an owner of properly who builds or improves thereon.and who •'� LAWN SPR IN KLERS-OVER 5 (EA.) 1.00
contracts for such projects with a contowtods)licensed pursuant to SEWER-SANITARY-STORM EA.200ft/10.00
the Contractors License Law. TRACT NO. PARCEL NO.
❑ l me exempt under See' ,B.&PC.for this WATER HEATER W/VENT 6.00
Omason
wner Date WATER SYSTEM 5.00 ACC:DATE ACC.FILE NO,
WORK IiRS'COMPENSATION DECLARATION L WATER TREATING EQUIP. 5.00
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 N0,
copy thereof(Sec.3800,Lab.C.). /� (�
-,--
policy Ns4l Puny�L2�.,,..�q��
Q ❑ Cert'III I�oSSc__up�y is hereby tun e'lt d. W� • FIRE SPRINK ENERGY T-4<
Z Z .¢ Certified is f •d with the city inspection Division. MISC.- REFER TO ORD. ❑ ❑ ❑ ❑
O A P cwU V N V N
CC CIS IPICATE OF ENEMPTI 'FROM WORKERS' PERMIT ISSUANCE s1 10.00 FLOOD ZONE WL.U.C.
LU > COMPENSATION I "URANCE PLG.CONTE. ❑c.NO. PLO. v El N❑ v[:] NEI
CL 0 (This section need nod he complc ed if the permit is for one kTOTAL
hundred dollars IS 100)or less_I
U O 1 certify Ihm in the perforumn,c of the woe .]or which this per- CITY MECHANICAL PERMIT FEE FEE SUMMARY
U_ F mil is issued,I shall not employ any person in any manner so as to
U become subject to the Workeri Compensation La`sof California.
0 a Uale Applicant ALTER OR ADD TO MECH. 5.00 BUILDING
} m NOTICE TO APPLICANT: If,after making this •ertdicade of Ex-
F Z emption,you should become subject to the Worke 'Compensation APPLIANCE 5.00 PLAN CHECK /
provisions of dile Labor Code, you must forthw III comply with FEE
U such provisions or this permit shall be deemed rcvnl�cd, AIR HANDLING UNIT(TO 10=C.F.M.) 4.00
CONSTRUCTION LENDING AGEN AIR HANDLING UNIT,(OVER 10=C.F.M.) 6.004 . SEISMIC FEE
1 hereby affirm that there is a construction lending agency for EXHAUST HOOD (WITH DUCT) 5.00 V
this perfornhancc of the work for which this permit is issued(Sec. MICROFILM j
3097,Civ.C.). H EATING UN IT(TO 100,000 B.T.U.) 8.00
Lender's Nater HEATING UNIT(OVER 100.000 B.T.U.)9.50
Lender's NAllen,ames ELECTRIC
I certify that l have read this application and scute lllat the above V ENTILATION 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-OOfs4P(3 H.P.or 100,000 B.T.U.) 6.00
hereby authorize representatives of this city to ender upon the BOILER-COMP (Over 100.00OBTUISEEFEESCH. MECHANICAL
above-mentioned property for inspection purpous.
(We) agree to save, indemnifyy
and keep harmless the Cit of MISC.- REFER TO ORD.
Cupertino against liabilities,judgments, vests and expenses which PERMIT ISSUANCE 10.00 CONST.TAX
may in any way accrue against said City in consequence of the
gmnlinh Ihisp nut. MECH.CONT. LIG NO. MECH. 'l
TOTAL 0_,0--d
, - TOTAL
Si a r A and Contractor ae
INSPECTOR COPY