8289APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
BUILDING PROJECT IDENTIFICATION
�p�t APPLICATION & PERMIT
PERMIT NUMBER
BonLGING
ADDRESS
BUILDING - ELECTRICAL -PLUMBING -MECHANICAL8289
D ry R'
PLAN CHECK VALIDATION
N"MEQTY.
ELECTRIC PERMIT FEE
PHONE
D o s
NAME
OUTLETS -SWITCHES-RECEP 10.00/1.00 -
LIGHTING FIXTURES 10.00/1.00 i
LIC. NO.
CONTRACTOR'S -
ADDRESS
F PPLIANCES-RESIDENTIAL 4.00
- PANELS 10 Op)
PHONE
DATE OF APPLICATION
ARCHITECTPANELS(
OR
ENGINEER
Llc. no.
OVER 200 AMP) 20.00
PLAN CHECK FEE P.C. NO.
SIGNS TRANS. 3.00
ARC Ess ENG.
ADDRZIP
SPECIAL CIRCUIT 5,00
PERMIT VALIDATION
TEMP. METER OR POLE INS. 20.00
nooRes TS
MOTORS SEE FEE SCH.
SERVICE CHANGE 20.00
_ -
3�a
LICENSED CON "TRACTORS DECLARATION
TEMP. POLE 30.00
-
1 hcrehy iftirin that I ;un licensed underprovisions of Chapter 9
ISSUA CE DATE
(con or a re in, with Section 7000) of Division 3 of the Business and
Pfessions Code, and my license is in full force and effect.
c cro Class Lie. Nllinbe[
BLDG.
❑
ELECT.
El❑
PLG. MECH.
1:1LIro
Dufc Contractor
l
BUILDING PERMIT
OWNER -BUILDER DIiCLARA'I']ON
License
1 hereby collo ingfinI mil exalt. 7 from ilia i mss a and
Lew for the hollowing reason. (Sec. 7031.5. liusinessand ProPossions
Code: Any city oreounty which requires a permit to construct,alter,
improve, demolish, or repair any structure, prior to its issuance, also
regmres file applicant for such permit to file a sighed Statement that
he is licensed pursuant to the provisions of the Contractor's License
Low (Chapter 9 (commencing with Section 7000) of Division 3 of the
Business and Professions Code) or that he is exempt therefrom andQTY.
INFORMATION
MISC.- REFER TO ORD
VALUATION
/
$/FT.
PERMIT ISSUANCE 10SQ
ELEC. CONTR. LIC. NO.
ELEC,
TOTAL / O
PERMIT
�Cf
IT
PLUMBING PERMIT FEE
PE CONSTR.
the basis for the alleged exemption. Any violation of Section 703 LS
by any applicant for a permit subjects the applicant too civil penalty
of not more than live 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 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 or through his own employees, provided that such ToPose-
mentsare not intended oroffered for sals. If. however. the building
GAS - EA. SYSTEM -1 INC.4 OUTLETS 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 Lot
prove for purpose of sale.).
❑ 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
❑ ❑ ❑ ❑ ❑
INDUSTRIAL WASTE I NTE R. 30.00
LAWN SPRINKLERS - 1 INC 5 V.B. 6.00
ASSESSORS PARCEL NO.
licensed contractors to construct ilia 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 - OVER 5 (EA.) 1.00
contracts fill such projects with a contractor(s) licensed pursuant to
the Contractors License Law.
SEWER -SANITARY -STORM EA. 200ft/10.00
TRACT NO.
PARCEL NO.
❑ I am exempt under Sac.-, B.&P.C. for this
reason
WATER HEATER W/VENT 6.00
Owner- n fey♦�§,5 (9b'l45 Dale -tJ<
„V'_ - Y
WATER SYSTEM 5.00
ACC. DATE
ACC. FILE N0.
WORK ERS'COMPENSA"TION DECLARATION
WATER TREATING EQUIP. 5.00
hereby affirm that I have a certificate of consent to self -insure.
or a certificate of Workers' Compensation Insurance, or a certilied
ZONING
ENG. SITE NO.
copy Iherast (Sec, 3800, Lab.C.).
Policy Nn. Company
❑ Certified copy is hereby luntPhed,
❑ Certified copy is fled with the city inspection division.
Applicant
FIRE SPRINK
Y❑ No,
ENERGY T-24
Y N❑
MISC.- REFER TO ORD.
CERIFIFICA'I'F 01: EXEMPTION FROM WOR KI
PERMIT ISSUANCE 10.00
FLOOD ZONE
A. L. U. C.
PLG. CONTR. LIC. NO.
PLG.
TOTAL
COMP17NSA1ION INSURANCE
action need not be completed if the permit is for one
v❑ NE]
Y❑ NE]
hundred dollars IS 100) or It,,.)
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
QTY. MECHANICAL PERMIT FEE
FEE SUMMARY
BUILDING
O C% -S-
become subject to the Workers'Compensation Laws of California.
Dme Applicant
N'OT'ICE 'TO APPLICANT: If, after making this Certificate of Ex-
ALTER OR ADD TO MECH. 5.00
APPLIANCE 5.00
PLAN CHECK
emption, you should become Subject to the Workers'Compensation
provisions of the Labor Code, you most forthwith comply with
such provisions or this permit shall be deemed revoked.
FEE
AIR HANDLING UNIT (TO 10,000C.F.M,) 4.00
AIR HANDLING UNIT (OVER 10=C.EM.)6.00
SEISMIC FEE
S�
CONSTRUCTION LENDING AGENCY
I hereby affirm that there is a construction lending agency for
EXHAUST HOOD (WITH DUCT) 5.00
the e. of the work for which this permit is issued (Sec
MICROFILM
HEATING UNIT (TO 100,000 B.T.U.) 8.00
HEATING UN 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 FAN (SINGLE) 4.00
information is correct. I agree to comply with all city and county
ordinances and state laws relating to building construction, and
PLUMBING
BOILER -COMP (3 H.P. or 100,000 B.T.U.) 6.00
BOILER -COMP (Over 100,000BTU) SEE FEESCH,
MECHANICAL
hereby aWhoriec representatives of this city to enter upon the
above-mentioned property for inspection purposes.
MISC. - REFER TO ORD.
(We) agree to save, indemnity and keep Imrnless the City of
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
granting of"this permit
MECH. CONT. LIC. NO.
MECH.
//
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TOTAL
TOTAL
p 4Z sa
3
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INSPECTOR COPY