8215APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
BU I LDING PROJECT I DENTIFICATI ON
APPLICATION &PERMIT
BUILDING - ELECTRICAL -PLUMBING -MECHANICAL
PERMIT NUMBER
A w
BULLRING
DORESS
Mnliq1*r"a or
14 0 r
.NE
NAME
A PHONE
QTY. ELECTRIC PERMIT FEE
PLAN CHECK VALIDATION
l % 3�„ (J
�`"-=,`Vf _
/�/5
NAME
OUTLETS OUTLETS-SWITCHES-RECEP 10.00/1.00
LIGHTING FIXTURES 10.00/1.00
Jer VM ' LIC.No.
'/
CONTRA TOR'S a(��I T3�
PPLIANCES- RESIDENTIAL 4.00
PANELS 10.00
vNONE
DATE OF APPLICATION
OCT
R
ENGIry EER
uc. No.
PANELS (OVER 200 AMP) 20.00
PLAN CHECK FEE D.C.NO.
SIGNS TRANS. 3.00
ReH
ADDRESS E a INS tA07
SPECIAL CIRCUIT 5,00
PERMIT VALIDATION
EMP. METER OR POLE INS. 20.00
A160044011MA11 Cl�� zIP9(1 CIllf
fI
Ars
ADDRESS
MOTORS SEE FEE SCH.
SERVICE CHANGE 20.00
�
LICENSED CON'T'RACTORS DECLARATION
TEMP. POLE 30.00
I hereby affirm that 1 am licensed under provisions of Clmpter (I
(commencing with Section 7000) of Division 3 of the Business and
Provisions Codeyind my license IS In full force and effect.
License Class- Lie. Number
�.�
ISSUANCE DATE
BLDG.
ELECT.
PLG. MECH.
Date ComfaClor�n✓.��
BUILDING E MIT
INFORMATION
OWNER -BUILDER DECLARATION
1 hereby affirm That I am exempt from the Contractor s License
e
Law for the following Taxon. (Sea 7031.5, BusinessanJ Professions
Code: Any cityor count y which requires a permit to construct, atter,
ina"mee, 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
D ivision3of the
Law (Chapter 9 (commencing with Section 7 exempt
Business and Code) or that he is exempt therefrom and
REFER TO ORD
PERMIT ISSUANCE 10.00
VALUATION
/ V
S/FT.
ELEC. CONTE. LIC. NO.
ELEC.
TOTAL
PERMIT TO
QTY. PLUMBING PERMIT FEE
STORIES
T1`PE CONSTR.
he alleged
the basis for the alleged exemption. Any violation
t Inaction malty
by any eOMthaf five hemi dollars S500).he liwnuoacivil penalty
of not mon than five hundred dollars (S 500).]:
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
ROOF, AREA,COND. 5.00
intended or offered for sale (Sem 7044, Business and Professions
Code:
Code: film` Cnnlracter s License Law doe's 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 im prove-
nnents arc not intended or offered for sale. If, however, the building
GAS-EA.SVSTEM-11NC.40UTLETS 6.00
or innprovemeat is sold within one year of completion, the owner-
builder will have the burden of proving that he did not build or im
prove for purpose ofs:de.).
❑ I, as owner of the property, am exclusively contracting with
GAS - EA. SYSTEM -OVER 4 (EA.) 2.00
BUILDING USE
R IND CON PB Omer
❑ ❑ ❑ ❑
INDUSTRIAL WASTE INTER. 30.00
licensed contractors to construct the project (Sec 7044, BusinessLAWN
and Professions Code: The Contractor's License Law does not apply
to an owner of property who builds or improves thereon, and who
SPRINKLERS - 1 INC 5 V.B. 6.00
LAWN SPRINKLERS - OVER 5 (EA.) 1.00
ASSESSORS PARCEL NO.
contracts for such projects with a commelons) licensed pursuant to
the Contractors License Law.
SEWER -SANITARY -STORM EA. 200fi/10.00
TRACT NO.
PARCEL NO.
❑ lam exempt under Sec. .B.&P.C. for this
reason
WATER HEATER W/VENT 6.00
Owner Date
WATER SYSTEM 5,00
ACC. DATE
ACC. FILE NO.
WATER TREATING EQUIP. 5.00
W'ORKERS'COMPENSATION DECLARATION
I 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 NO.
copy Ihereof(Sce. 3800, Lab C.).
Policy No. Court, (10TRS6I�qp
}L7 A
❑ Certified copy is hereby furnished. A ifjp ,JidlT USC N/1
❑ Certified �opy is filed with the It dsP /d❑ III'11Ioa
Applicanl---Jct al
FIRE SPRINK
Y ❑ N❑
ENERGY T 24
Y ❑ N❑
MISC. - REFER TO ORD.
CER'TFICATI:OI' I'M MPTION FROM WORKERS'
PERMIT ISSUANCE /. 0..
FLOOD ZONE
A. L.0 c.
COMITNSA'fION INSURANCE
Cthis section need not he completed if the,peonit is for one
hundred dollars ($100)o, less.)
Y ❑ N❑
I xy ❑ N,❑
PLG. CONTR. LIC. NO.
PLG. '
TOTAL 1 '
I certify that in the performance of the work for which this per-
mil is issued, I shall not employ any person in any manner so as to
QTY. MECHANICAL PERMIT FEE
FEE SUMMARY
BUILDING
SQ f7V
became subject to the Workers' Compensation Laws of California.
Date Applicant
ALTER OR ADD TO MECH. 5.00
NOTIC17 TO APPLICANT: If, after making this Certificate of Ex-
APPLIANCE 5.00
AIR HANDLING UNIT (TO 10=C.F.M) 4.00
PLAN CHECK
FEE
emption, you should become subject to the Workeri Compensation
provisions of the Labor Code, you must forthwith comply with
such provisions or this permit shall be deemed revoked.
AIR HANDLING UNIT(OVER 10=C.F.M.) 6.00
SEISMIC FEE
P `
CONSTRUCTION LENDING AGENCY
EXHAUST HOOD (WITH DUCT) 5.00
1 hereby affirm that there is a construction lending agency for
the performance of the work for which this permit is issued (Sec.
3097, Civ.C.).
MICROFILM
HEATING UNIT (TO 100,000 B.T.U.) 8.00
Lender's Name
Lcndcr's Name
HEATINGUN IT (OVER 100,000 B.T.U.) 9.50
ELECTRIC
VENTILATION FAN (SINGLE) 4.00
I cerfil'y that l have read this application and state that the above
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 100,000 BTU( SEE FEE SCH.
MECHANICAL
hereby authorize representatives of this city to'emcr upon the
above-mentioned for inspection purposes.
pmperfy
MISC. - REFER TO ORD.
PERMIT ISSUANCE 10.00
CONST. TAX
(We),ngrec 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
granfingofthis permit.
MECH. CONT. LIC. NO.
MECH.
yy�--.'�// �
Sorin .a. rr' �P+i fl;/ [�-°6" 4/1fl- sl
Slgnalurco f Appbcan Contract, c
TOTAL.
TOTAL
INSPECTOR COPY