8568APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
BUILDING PROJECT IDENTIFICATION
& PERMIT
BUILDING - ELECTRICAL- PLUMBING - MECHANICAL
PERMIT NUMBER
85 T4(�y
8568
BUILDINGAPPLICATION
ADDRESS
C _ I
OW 'B
PLAN CHECKIKVALIDATION
NAME
QTY. ELECTRIC PERMIT FEE
ONE _.
NCON`FAAMFAC R
UTLETS-SWITCHES-RECEP 10.00/1.00
LIGHTING FIXTURES 10.00/1.00
lie No,
CONTRACT R's 7V/0
ADDRESS
PPLIANCES- RESIDENTIAL 4.00
PANELS 10.00
l it E
DATE OF APPLICATION
ARRIEC
OR
ENGINEER
LIC. No,
PANELS (OVER 200 AMP) 20.00
PLAN CHECK FEE P.C. NO.
SIGNS TRANS. 3.00
ADDRESSS E"O'
SPECIAL CIRCUIT 5.00
PERMIT VALIDATION
TEMP. METER OR POLE INS. 20.00
ZIP
q
9 /v _L_G Q_a..
l.o "" _
APPLICANT
ADDRESS
MOTORS SEE FEE SCH.
SERVICE CHANGE 20.00
/
'J/�S /�1'/
V LICENSIi DCON'1' RACTORS DECLARATION
TEMP. POLE 30.00
I hereby affirm th at I am licensed under provisions of Cha pter')
(dommineing with Section 7000) of Division 3 of the Business and
I'mm sions Code, and my license is in full force and eff (
License Clas -�1 Lie.No bar
ISSUANCE GATE
BLDG.
❑
ELECT.
❑
rl
1:1PLG. MECH.
li."A'
Data COnLNGI()r
BUILDING PERMIT -
INFORMATION
OWNER -BUILDER DECLARATION
I hereby affirm that I am exempt Iron the Contractor's License
Low ferny cityfollowing reason, tywli(Sec.7031.S,Buiit t,,,,n P,o,t,,lmts
Code: Any city or wr rep which requires a perm it to construct, dace,
improve, demolish, or repair any structure, prior to its issuance, also
requires the applicant for such permit to III, a signed statement that
he is licensed pursuant to the provisions of the Contractor's License
MISC.- REFER TO ORD
VALUATION
S/FT.
PERMIT ISSUANCE 10.00
ELEC. CONTR. LIC. rv0.
FLEC.
TOTAL
PERMIT TO
(ITY. PLUMBING PERMIT FEE
Law (Chapter 9 (commencing with Section 7000) of Division 3 (it the
Business and Prolesslons Collet or that he is exempt therefrom and
L
STORIES
TYPE CONSTR.
the basis'for the alleged exemption. Any violation of Section 7031.5
by any applicant for a permit subjects the applicant toa civil penalty
of not more than Ove hundred dollars (5500).):
ALTER -DRAIN -WATER IEA.) 5.00
❑ I, as owner of the property, or my employees with wages as
their sole nom Pensafion, will do the work, and fit,simctlim Is nm
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 docs such work
himself or through his own employees. provided that such improve-
ments are not intended or offered for all, If, however, the building
FIXTURES - PER TRAP 5.00
SO. FT, FLOOR AREA
TOTAL ACREAGE
GAS-EA.SVSTEM-11NC.40UTLETS 6.00
or improventem is sold within one year of completion, the owner-
builder will have the burden of proving that he did not build or im-
ProveforpurposeasaleJ.
El 1, 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 INTER. 30.00
licensed contractors m construct the project (Sec. 7044, Business
and Professions Code The Contractor's License Law does not apply
lm m owner of property 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 forsuch projects with a contractiI licensed pursuant to
the Contractor's License Law.
SEWER -SANITARY -STORM EA. 200ft/10.00
TRACT NO.
PARCEL NO.
❑ I am exempt under Scc. ,BARO. 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
WORK E-RS'CO.MPENSATION DECLARATION
I hereby affirm that 1 have a certificate of consem m self-insure.Elf a
of Workers' Compensation Insurance, or a certified
ZONINGcertificate
ENG. SITE NO.
copy thereof (Sec.38.).
�000,Lmuby.0
�
IIop_ys pabnYfm-cd�
Q�Certificd ropy is filed with the city inspection division.
Applmart(z_�(�•(t�re�
FIRE $PRINK
Y❑ N❑
ENERGY T 24
Y❑ N❑
MISC.- REFER TO ORD.
CERTIFICATE OI: EXEMPTION FROM WORKERS
PERMIT ISSUANCE 10.00
FLOOD ZONE
A. L. u.c.
^"'Ir COAIPENSAT'ION' INSURANCE
section need not be completed if the permit is for one
PLG. CONTR. LIC. No.
PLG.
TOTAL
v❑ N❑
v❑ NEI
hundred dollars (S 100) or Icn.)
I certify that in the performance of the work fur whim this per
mit is issued, I 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.
Dam Appli°ant
ALTER OR ADD TO MECH. 5.00
NOTICE: TO APPLICANT: IL after making this Certificate of Ex-
emplion, you should become subject to aro Workers' Compensation
APPLIANCE 5.00
PLAN CHECK
provisions of the Labor Code, you must forthwith comply with
such provisions or this permit shall be deemed revoked.
FEE
AIR HANDLING UNIT (TO 10MOC.F.NL) 4.00
AIR HANDLING UNIT (OVER 10=C.F.M.) 6.00
SEISMIC FEE
CONSTRUCTION LENDING AGENCY
I hereby affirm that there is o construction lending agency for
EXHAUST HOOD (WITH DUCT) 5.00
the performance of the work lot which this permit is issued (Sec.
3097, Civ.C.).
MICROFILM
HEATING UNIT (TO 100,000 B.T.U.) 8.00
HEATING UNIT (OV ER 100,000 B.T.U.) 9.50
ELECTRIC
Lender's Name
Lender's Address
1 certify that I have read this application and stain that the above
VENTILATION FAN (SINGLE) 4.00
Information is correct. 1 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
- /"V
hereby authorize representatives of this city to enter upon the
above-mentioned property for inspection p.rpoas.
(We) agree m save, indeannify and keep hunoless the City of
MISC. - REFER TO ORD.
Cupertino against liabilities, judgments, costs aid expenses which
may in any way accrue against said City in consequence of the
CONST. TAX
PERMIT ISSUANCE 10.00
grvrling of this permit.
_' �-
MECH. CONT. LIG NO.
I
Z C
MECH.
TOTAL --
TOTAL
Signolu o Apphcanl/Conti 'tor -.Uote
/ INSPECTOR COPY
A