8409APPLICANT 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
A A
PUILDING
ADDRESS
90 //
O ERo
NAME
QTY. ELECTRIC PERMIT FEE
PLAN CHECK VALIDATION
/ ONE
NAAMERAOT ns
OUTLETS-SWITC HES-RECEP 10.00/1.00
LIGHTING FIXTURES 10.00/1.00
on -
AD
ADDRESS
PPLIANCES- RESIDENTIAL 4.00
PANELS 10.00
- �_ PHONE 77
DATE OF APPLICATION
A
OR
ENGINEER Jf
.9,.a/I&ILIC. NO.
PANELS (OVER 200 AMP) 20.00
PLAN CHECK FEE P. C. NO.
SIGNS TRANS. 3.00
AARCH OR DDRESS Na
SPECIALCIRCUIT 5.00
PERMIT VALIDATION
EMP. METER OR POLE INS. 90 On
ZIP
APPLICANTS
ADDREss
M
EE FEE MOTORS SSCH.
SERVICE CHANGE 20.00
/
ISSUANCE PATE
/1 LICENSED CONI' RACT'ORS DECLARATION
J 1 hereby affirm that I am licensed under provisions of Chapter 9
(commencing with Section 7000) of Division 3 of the Business and
,ProfessionsCo mA my license is in full force nd effect.
License Class Li,Number 4v3 0 00 6
I
TEMP. POLE 30.00
BLDG.
El
ELECT. PLG. MECH.
El ❑
Date r - Contractor,r.r. y,t�
BU LNG PERMIT
I FORMATION
OWNER -BUILDER DECLARATION (�W�S �'
I hereby aolllo that I am exempt 31.5 the Contrud Dr's License
Law for the following reason. (Sec. 7031.5. Business andPm4ssions
Code Any city or county which requires a permit to construct, alter,
MISC.- REFER TO ORD
PERMIT ISSUANCE 10.0 !
VALUATION
SBFT.
SLED. CONTR. LIC, NO.
ELEC.
TOTAL
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 (commencing with Section 7000) o' 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 for a permit subjects the applicant to a civil penalty
of not more than five hundred dollars (8500).):
ALTER -DRAIN -WATER (EA.) 5.00
❑ I, as owner of the property, or my enpileyees 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, AR EA, COND. 5.00
intended or offered for sale (Sec. 7044, Business and Professions
Codc: The Contractor's License Law does not apply to an owner of
property who builds or improves thereon, and who does Such work
himself' or through his own employees, provided that such improve-
meats are not intended or offered for sale If, however, the building
FIXTURES - PER TRAP 5.00
SO. FT, FLOOR AREA
TOTAL ACREAGE
GAS-EA.SVSTEM-1 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 un-
prove for purpose of salc.l'
❑ I, as owner of the Property, am exclusively contracting with
GAS - EA. SYSTEM -OVER 4 (EA.) 2.00
BUILDING USE
RES IND PB Omer
ElElco ❑ ❑
INDUSTRIAL WASTE INTER. 30.00
licensed. contractors to construct the project (See. 7044, Business
and Professions Code'. Our Contractor's License Law does not apply
to an owner of property who builds or improves thereon. and who
LAWN SPRINKLERS -I INC 5 V.B. 6.00
ASSESSOR PAHCBL N0.
LAWN SPRINKLERS - OVER 5 (EA.) 1.00
contracts forseh projects with a contractors) licensed pursuant to
the Contractors License Law.
SEWER -SANITARY -STORM EA. 200ft/10.00
TRACT NO.
PARCEL NO.
❑ dant exempt under Sea ,B.&P.C. for this
reason
WATER HEATER W/VENT 6.00
Owner Date
WATER SYSTEM 5.00
ACC. DATE
ACC. FILE NO,
IWATER TREATING EQUIP. 5.00
WORKI!RS'COMPENSATION DECLARATION
I hereby allirm that I have a certificate ofconsent to self -in suN,
or a certificate of Workers' Compensation Insurance, ora verified
ZONINGfied
ENG. SITE NO.
copy thereof (Sec. 3800, LahC.)-
Policy No. Company
FIRE SPRINK
Y ❑ N ❑
ENERGY T-24
Y ❑ N❑
❑ Certified copy is,] yfinished.
-certifiedo 5( Is d£d with the city inspection division.
Applicant e i
MISC. - REFER TO ORD.
CIS IICATIS fi'XEMPT1ON PROM WORKERS'
PERMIT ISSUANCE 10.00
FLOOD ZONE
A.L.u.C.
PLG. CONTE. LIC, NO.
PLG.
TOTAL
COM l SATION INSURANCE
(This section need not be completed if the permit is for one
Y ❑ N ❑
Y ❑ N❑
hundred dollars IS 100) or less.)
I certify that in the performance of the work for which this per-
hat is issued, 1 Shall not employ any person in any manner so as to
QTY. 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 'f0 APPLICANT: If, after making this Certificate of Ex-
APPLIANCE 5.00
PLAN CHECK
'emption, you should become subject m the Workers' Compensation
provisions of the Labor Code, you must forthwith comply with.
such provisions or this permit shall be dammed revoked.
FEE
AIR HANDLING UNIT (TO 10=C.F.M.) 4.00
AIR HANDLING UNIT (OVER 10)DOOC.F.M.) 6.00
SEISMIC FEE
CONSTRUCTION LENDING AGENCY
I hereby affirm that there is a construction lending agency for
EXHAUST HOOD (WITH DUCT) 5.00
re performance
ar for itance of the work for which this pemrit is issued (Sec.
MICROFILM
HEATING UNIT (TO 100,000 6.T.11) 8.00
Lender's Name
Lender's Address
H EATING UNIT (O VER 100,000B.T.U.)9.50
ELECTRIC
I certify that l have read this application and state that the above
VENTILATION PAN (SINGLE) 4.00
information is correct. I agree to comply with all city and county
ordinances and state Taws relating to building construction, and
PLUMBING
gQILER-COMP(3 H.P. or 100,000 B.T.U.1 6.00
BOILER -COMP (Over 100,000 BTU) SEE FEE SCH.
MECHANICAL
hereby authorize representatives of this city to enter upon the
above-mentioned property for inspection purposes.
MISC. - REFER TO ORD.
(We) agree to Save, indemnify and keep harmless the City of
Cupertino against liabilities, judgments, Costs and expenses which
may in any way accrue against said City in consequence of the
CON ST. .TAX
PERMIT ISSUANCE 10.00
granting ohthiirp emfl.
MECH. CONT. UC. NO.
MECH.
eaes{
oTAL
TOTAL
%
'g lured pplic5n[/Contractor Iyate
INSPECTOR COPY