8749APPLICANT 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
8749
D
AUR LOI
ADRESSN
OWNER'S
NAME
QTY. ELECTRIC PERMIT FEE
PLAN CHECK VALIDATION
PHONE
NAMERAcroH s /1
OUTLETS -SWITCHES- RECEP 10.00/1.00
LIGHTING FIXTURES 10.00/1.00
p r L`'�!'��-��111�
DATE OF APPLICATION
CONTRAcro
ADDRESS /^ �1y �1r1 �O�1Q
Q Con�Pi�V t t L�� PHONE% fTl OfrD
PPLIANCES- RESIDENTIAL 4.00
PANELS 10.00
ARCH
DR j � �
ENGINEER
No.
PANELS (OVER 200 AMP) 20.00
PLAN CHECK FEE P.C. NO.
SIGNS TRANS. 3.00
ADDRESS ErvG. '\h
Cy":
SPECIAL CIRCUIT 5.00
PERMIT VALIDATION
ZIP
EMP. METER OR POLE INS. 20.00
APPLICANT'S
ADDRESS
MOTORS SEE FEE SEH.
SERVICE CHANGE 20.00
J
LICENSED CONTRACTORS DECLARATION
TEMP. POLE 30.00
_
I hereby affirm Ilial Pam licensed under provisions of Chapwr'I
I sennnencing with Section 7000) of Division 3 of the Business and
Pruf"slons Code and my license is in full force and effect a
License Class _'Lic. Number �� III
ISSUANCE DATE
BLDG. ELECT. PLG. MECH.
❑ ❑ 1:1 ❑
Dal, Cmd"ctor
'
BUILDING PERMIT
INFORMATION
-
OWNER -BUILDER DECLARATION
I hereby affirm that I am exempt fromthe Contractor's License
Law for the following reason. (Sec. 7031.5. Businessvnd Professions
Code: Any city or county which reyuiresa permit toconstruct,alter,
nlprole, 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
MISC. - REFER TO ORD
PERMIT ISSUANCE 10.00
VALUATION
$/FT.
ELEC. CONTR. LIC. NO. ELEC.
TOTAL
PERMIT TO
Law (Chapter 9 (commencing with Section 7000) of Division 3 ol'the
Business and Professions Code) or that he is exempt therefrom and
OTY. PLUMBING PERMIT FEE
/R d-
the basis for the alleged exemption. Any violation of Section 7031.5
by any applicant lot a permit subjects the applicant to a Civil penult
of not more than five caudad dollars (8500).): /
STORIES
TYPE CONSTR.
ALTER -DRAIN (EA.) 5.00
❑ I, as owner or the properly, or my employees with wages as
their sole compensation, will do the work, and the structure is -not
BACK F LOW PROTECT. DEV ICE 4.00
OCG GROUP
RES. UNITS
DRAINS -FLOOR, ROOF, AR EA, COND. 5.00
intended or offered for sale (Sec. 7044, Business and Professions
Code: The Contractor's License Law does not apply t0 an Owner of
FIXTURES - PER TRAP 5.00
GAS - EA. SYSTEM -1 INC.4 OUTLETS 6.00
property who builds or improves thereon, and who docs such work
himscllor through his own employees, provided that such improve
ments are not intended or offered for sale. If, however, the building
SO, FT. FLOOR AREA
TOTAL ACREAGE
or improvement 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 ofsale.).INDUSTRIAL
❑ I, as owner of the property, aexclusively contracting with
m
GAS EASYSTEM OVER 4 (EA) 200
- . -..
BUILDING USE
'RES IND CON' PS OUR.,
El El El El 1
. .
WASTE INTER3000
LAWN SPRINKLERS- 1 INC 5 V.B. "6.00
hccnscd canGoclm, to construct the project (Sec. 7044, Business
and Professions Code:'fhe Contractor's License Law does not apply
ASSESSORS PARCEL NO.
to an owner of property who builds or improves thereon, and who
LAWN SPRINKLERS - OVER 5 (EA.) 1.00 '
contracts for such projects with a cOntractous) licensed pursuant 10
the Contractors License Law.
SEWER -SAN EA. 200ft/10.00
TRACT NO.
PARCEL NO.
❑ l am exempt under Sec. ,B.&BC. for this
reason
WATER HEATER W/VENT 6.00
Owner Dule
WATER SYSTEM 5.00
ACC.DATE
ACG FILE No.
WORKERS'COMPENSAT'ION DECLARATION
WATER TREATING EQUIP, 5.00
1 hereby affirm that I have a certificate of consent to self -insure.
or a cenificate of Workers' Compensation Insurance, or a cerlifieJ
ZONING
ENG. SITE NO.
of N'
hemol'(See 38 J,qh�) y�
PolicY'N'oII3L_1(..G 4P1L41 M6,A NAVA I tCKn
FIRE SPRINK
y N
❑
ENERGY T 24
v N
Y. ❑
❑ Cc fl[TiC`�J `copy is hereby %ished.
❑ Ctlftified copy ,i�file �)JiDa Me ty inspection division.
Applicanll�lf AVE
MISC. - REFER TO ORD.
C4RT�IJCAIF OF EXEMPTION F (1LI WORKERS'
PERMIT ISSUANCE 10.00
FLOOD ZONE
A.L.UG.
�j COMPENSA'I ION INSURANCE
(This section need not be completed if the permit is for one
Y [:] N�
V [] N�
PLG. CONTR, LIC. NO.PLG.
TOTAL
hundred dollars IS 100) or IessJ
1 certify that in the performance of the work for which this per-
mil is issued, I scull not employ any person in any mmneer so as to
CITY. MECHANICAL PERMIT FEE
FEE SUMMARY
become subject to the Workers' Compensation Laws of California.
ALTER OR ADD TO MECH. 5.00
Date Applicant
BUILDING
-oU
NOTICE TO APPLICANT: If, after making this Certificate of fix-
APPLIANCE 5.00
PLAN CHECK
FEE
�6
emption, you should become subject 10 the Workers' Compensation
provisions of the Labor Code, you must forthwith comply with
such provisions or this permit shall be deemed revoked.
AIR HANDLING UNIT (TO 10=C.F.M.) 4.00
AIR HANDLING UNIT(OVER 10=C.F.M.) 6.00
SEISMIC FEE
CONS'fRUC'I'ION LENDING AGENCY
EXHAUST HOOD (WITH DUCT) 5.00
MICROFILM
1 hereby affirm that there is a construction lending agency for
Dsn performance of the work for which this permit is issued (See.
3097, Civ.C.).
HEATING UNIT (TO 100,000 B.T.U.) 8.00
Lender's Name
Leelm
nder's Address
HEATING UNIT (OVER 100,000 B.T.U.)9.50
ELECTRIC
I certify that I have read this application and scute 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 $CH.
MECHANICAL
hereby authorize representatives of this city to enter upon the
above-mentioned property for inspection purposes.
(We) agree to save, indpa ofy and keep harmless the City of
Cupertino against liuhiliti S, j Jgments, costs and expenses which
Tay in any way usque agai st said -ly in cons quence of the
Coling of this pe r /
MISC. - REFER TO ORD.
pERM1T ISSUANCE 10.00
CONST. TAX
MECH.CONT. LIC. NO,
MECH.
OTA`
TOTAL
Slgm arc o'Applicant/Contmc PIT
INSPECTOR COPY