8751APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
BU LDI NG PROJECT I DENTI FICATI ON
APPLICATION &PERMIT
- ELECTRICAL -PLUMBING - MECHANICAL
PERMIT NUMBER
8751
BUILDING
BUILADDRESS
915 P411-162414BUILDING
OWNERS
N°ME-
QTY. ELECTRIC PERMIT FEE
PLAN CHECK VALIDATION
PH°NE
NAMEA °R
q(L��, A
UTLETS-SWITCHES -RECEP 10.00/1.00
ILIGHTING FIXTURES 10.00/1.00
ILA E
ADDRESS
PPLIANCES- RESIDENTIAL 4.00
PANELS 10.00
PHONE �O
DATE OF APPLICATION
OgcwrscT
ENGINEER
uc. NO.
PANELS 200 AMP) 20.00
PLAN CHECK FEE P.C. NO.
SIGNS TRANS. 3.00
ADDRESS ENG
SPECIALCIRCUIT 5.00
PERMIT VALIDATION
TEMP. METER OR POLE INS. 20.00
ZIP
^ ,
AR
ADDRESS
Ess
MOTORS SEE FEE SCH.
SERVICE CHANGE 20.00.
J
a�
60 OSS
LICENSED CONTRACTORS DFCLA RATION
TEMP. POLE 30.10d
I hereby affirm that 1 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 fur� I.
License Class Lie. Number ��
ISSUANCE DATE
BLDG. ELECT, PLG. MECH.
❑ E]❑
Date - Contractor 0 66,
BUILDING PERMIT
INFORMATION
Volh
OWNER -BUILDER DECLARATION
I hereby al firm that 1 am exempt from the Contractor's License
Law for the following reason. (Sec. 7031.5, Businessand Professions
Code: Any city orcounty which requires a permit to construct. alter,
improve, demolish, or repair any structure, prior to its issuance, also
requires the applicant for SUCK permit In NIC a Signed statement that
he is licensed pursuant to the provisimes of the Contractor's License
ofthe
Law(ChapterProcosion,Codeng with Section is exempt
Business and Professions Code) or that he is)opt therefrom and
MISC.- REFER TO ORD
VALUATION
SIFT.
PERMIT ISSUANCE 10.00
ELEC. CONTR. LIC. NO.
ELEC.
TOTAL
PERMIT TO
R�/�� � ✓`-
DTV. PLUMBING PERMIT FEE
STORIES
TYPE CONSTR.
the basis for the alleged exemption. Any violation "f Section 7031.5
by any applicant for a permit subjects the applicant to a civil penalty
of not more than five hundred dollars (S5000.)
ALTER -DRAIN -WATER (EA.) 5.00
❑ I, as owner of the properly, or my employees with wages as
their sole compensation, Will do Ole 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 dues not apply to an owner of
_
FIXTURES - PER TRAP 5.00
GAS-EA.SV$TEM-11NC.40UTLETS 6.00
SO. FT. FLOOR AREA
TOTAL ACREAGE
property who builds or improves Ibercon, and who does such work
himself or through his own employees, provided that such improve-
menu are not intended or offered for sale. If, however. the building
or improvement is sold within one year of completion, the owner-
builder will have the burden of proving that he dill not build or int-
prove for purpose of sale.).-
❑ I, as owner of the property, am exclusively contracting with
GAS - EA. SYSTEM - OVER 4 (EA.) 2.00
BUILDING USE
RES IND CON • PB One,
❑ ❑ ❑ ❑ ❑
INDUSTRIAL WASTE INTER. 30.00
licensed contractors to construct the project (Sec. 7044, Rusines,v
and Professions Code: The Contract.,', License L,w does not apply
to an owner of properly who builds or improves thereon, and who
LAWN SPRINKLERS- 1 INC 5 V.B. 6.00
LAWN SPRINKLERS - OVER 5 (EA.) 1.00
ASSESSORS PARCEL NO.
contracts for such projects with it contractons) licensed pursuant to
the Contractor's License Law.
SEWER -SANITARY -STORM EA. 200ft/10.00
TRACT NO.
PARCEL NO.
Cl lam exempt under Sec. ,It.&I'.C. tin this
reason
WATER HEATER W/VENT 6.00
Owner Date
WATER SYSTEM 5.00 ''
ACC. DATE
ACC. FILE NO.
WATER TREATING EQUIP. 5.00
WORKERS'COMPENSAT' ION DFCLAKA'I[ON
Ihereby iffirm that I have a certhicote of anu,nit.self-inSme.
ora certificate Of Workers' Compensation lion ranee, or a certified
ZONING
ENG. SITE NO.
_
copy thereof (Sec 3800. LaDC.).
POI1cy,�,/�.p�I-y{{�j
FIRE SPRINK
Y ❑ N ❑
ENERGY T 24
Y ❑ N❑
❑"letll l'eJi$I1Y 15`lleTchy urnis cd
❑ Certified copy filed with Ill, y'!ty inspection division.
Applimmfr/J�jJ
MISC. - REFER TO ORD.
'7 YJ !"�'-'"�"�r
CERTI1lCATli OI'IiX:MP1lUNPROM WORKERS'
PERMIT ISSUANCE 10.00
FLOOD ZOrvE
A. L. u.G.
COMPENSATION INSURANCE
(Phis sectionneed not be completed if the permit is for one
Y ❑ N❑
Y ❑ NE)
PLG. CONTR. LIC. NO.
PLG.
TOTAL
hundred do11ars($100) or less.)
1 certify that in the perl'unnence of the work for which thisper-
mit is issued. I shall not employ any person in any none, so as to
DTV. MECHANICAL PERMIT FEE
FEE SUMMARY
BUILDING
S O
become subject to the Workers' Compensation Lows ol'C' lilorniu.
DateApplicant
NOTICE TO APPLICANT: I , a ter ma ng n er l lea a of lix-
emption, you should become subject to the Workeri Compensation
ALTER OR ADD TO MECH. 5.00
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 10,000C.F.M.) 4.00
FEE
AIR HANDLING UNIT(OVER 10MC.F.M.) 6.00 -
SEISMIC FEE
CONSTRUCTION LENDING AGENCY
1 hereby affirm that there is a mnstruetim lending agency for
EXHAUST HOOD (WITH DUCT) 5.00
the performance of the work for which this permit is issued (Sec.
3097. Civ,C.).
r
MICROFILM
HEATING UNIT (TO 100,000 B.T.U.) 8.00
Lenders Name
Lender's Address -
HEATI NG UNIT (OVER 1_00,000 B.T.U.)9.50
ELECTRIC
I certify that I have read this application andstale that the above
VENTILATION FAWISINGLE) 4.00
information is correct. I agree to comply with all city and county
ordinances and state laws relating to building construction, and
PLUMBING
BID P. P. Or 100,000 B.T.U.1; 6.00
BOILER -COMP (Over 100.000 BTU) BEE'FEE SCH.
MECHANICAL
hereby authorize representatives of this city to cater upon Ute
above-mentioned property for inspection purposes.
(We) agree to save, indemnify and keep harmless the City of
Cupertino against liabiliti s, of ments, costs and expenses which
may in any way acc inst said City in consequence of the
MISC. - '` REFER TO ORD.
CONST. TAX
'...
PERMIT ISSUANCE ,., 10.00
granting Ofthis a
-
MECH. CONT. LIG NO.
MECH.
TOTAL
TOTAL
�� 0 6.
ig cant/C intrad., Uatc
INSPECTOR COPY