C8134APPLICANTtrTO'01L IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
BUILDING PROJECT IDENTIFICATION
APPLICATION &PERMIT
PERMIT NUMBER
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%ILOING -
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BUILDING -ELECTRICAL -PLUMBING -MECHANICAL
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OWNER'S
NAME /
PHONE 73 -4�
QTY. ELECTRIC PERMIT FEE
PLAN CHECK VALIDATION
'
NAMERacTons
UTLETS- SWITCHES -RECEP 10.00/1.00
LIGHTING FIXTURES 10.00/1.00
LIC. No,
CONTRACTOR'S
ADDRESS
APPLIANCES -RESIDENTIAL 4.00
PANELS 10.00
PHONE
DATE OF APPLICATION
ARCRITECT
OR .
ENGINEER t//5,�V��q�"
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PANELS (OVER 200 AMP) 20.00
PLAN CHECK FEE P.C. NO.
SIGNS TRANS. 3.00
ARCH, OR ENG,
ADDRESS
zlv
SPECIAL CIRCUIT 5.00
PERMIT VALIDATION
TEMP. METER OR POLE INS. 20.00
ARE
ADDRESS
ss
J /v/ f/'/V- V f%i1,
MOTORS SEE FEE SCH.
ISERVICE CHANGE 20.00
LICENSED CONTRACTORS DECLARATION
TEMP. POLE 30.00
1 hereby Jfflrm that ham licensed Rude, pmviucn, of Chapter 9
(commencing with Section 7000) of Division 3 of the Business and
Professions Code, and my license is in full force and effect
License Class Lie Number
ISSUANCE DATE
BLDG. ELECT. PLG. MECH.
1 Q ❑ ❑
IYa'lI
Dale Contractor
-
' OWNER -BUILDER DECLARATION
I herebyMISC.
affirm that I am exempt from the Contractor's License
• Law (lirthe followingreason.(see .uiresa,ermit tocodProfccsions
Any curer county which structur e Permit toconstruct, kq
improvCodee, also
improve, demolish, or for such
prior toilsstatement
the applicant for such revisit t0 f to signed Smtemem that
p rmit to file
mgislicensed License
Law (Ch upier ')(commencing with Section ]OOOhd'Division3ollhe
'La is IieenmJ pursuant a Inc provisions of the ) of Division
Business and Professions Code) or that lie is exempt therefrom and
BUILDING PERMIT
INFORMATION
- REFER TO ORD
PERMIT ISSUANCE 10.00
VALUATION
-��
$/FT.
ELEG.GONTR. LIG. NO.
'
ELEC.
TOTAL
PERMIT TO
q✓w I{
I IV l
QTY. PLUMBING PERMIT FEE
thl' 113515 for the alleged a%CmpllOn. Any VIOIatIOn Of SCC(W117B3 LS
by any applicant for a permit subjects the applicant toa civil penalty
of not are than five hundred dollars (S500)J:
STORIES
TYPE CONSTR.
ALTER -DRAIN -WATER (EA.) 5.00
❑ I, as owner of the property, or my employees with wages as
their sole compensation; will do the work, and the structure is not
BACK F LOW PROTECT. DEVICE 4.00
OCC. GROUP
RES. UNITS
DRAINS -FLOOR, ROOF, AREA, COND. 5.00
intended or offered`I'or sSle (Sec. 7044, Business and Pofessions
Code: The Contractor's License Law does not apply to an owner of
FIXTURES - PER TRAP 5.00
property who builds or improves thereon, and who docs such work
himself or through his own employees, provided that such improve
mends are not intended or offered for sale. If, however. the building
SO. FT. FLOOR AREA
TOTAL ACREAGE
GAS - EA. SYSTEM -1 INC.4 OUTLETS 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 on.
GAS - EA. SYSTEM - OVER 4 (EA.) 2.00
BUILDING USE
prove for purpose ofsale.).INDUSTRIAL
❑ 1, as owner of the property, am exclusively contracting with1:1
RE5 tNO CO PB other
El El
WASTE INTER. 30.00
licensed contractors to construct the project (Sea 7044, BusinessLAWN
and Professions Code: The Contractors License Law docs not apply
m a,, owner of property who builds or improves Dlercon, and who
SPRINKLERS - 1 INC 5 V.B. 6.00
LAWN SPRINKLERS - OVER 5 (EA.) 1.00
ASSESSOR PARCEL NO.
contracts for Such projects with a contractors) licensed pursuant to
the Centraator',�Q,iccnsc Law.
❑ tun er opt and rSec. ,B.&P, lorthl
rL' ,uu
SEWER -SAN STORM EA. 200ttI10.00
TRACT NO,
PARCEL NO.
WATER HEATER W/VENT 6.00
t)W11Cf
WATERSYSTEM 5.00
ACC. DATE
ACC. FILE N0.
WATER TREATING EQUIP, 5.00
WORKERS'C MPENSATION DECLARATION
Thereby affirm that 1 have a certificate of consent to sell -insure,
or a certificate of Workers' Compensation Insurance, or a certified
copy thereof (Sec. 3800, Lab CT.
ZONI IG
ENG. SITE NO.
Policy No. Company
FIRE SPR INK
y C] N �
ENERGY T"74
YE] N�
❑ Certified copy is hereby furnished.
❑ Certified copy is filed with the tidy inspection division.
Applicant-
MISC. REFER TO ORD.
CERTI FICA,(; OF EX ENI PTION FROM WORKERS'
PERMIT ISSUANCE 10.00
FLOOD ZONE
A.L.UG.
C04ENSATION INSURANCE
This section need not be completed if the permit is for one
y� N�
Y� N�
PLG.CONTR. LIC. NO.
PLG.
TOTAL
hundred dollars IS 100) or less.)
I certify that in the purforinance of the work for which this per.
it is issued, 1 shall not employ any person to any manner so as m
DTV. MECHANICAL PERMIT FEE
FEE SUMMARY
BUILDING
r
become subject to the Workers' Compensation Laws of Culilmria.
Date Applicant
NOTICE 'TO APPLIC1N'1': If, after making this Certificate of fix.
ALTER OR ADD TO MECH. 5.00
APPLIANCE 5.00
AIR HANDLING UNIT (TO 10=C.F.M.) 4.00
PLAN CHECK
FEE
enlption, you should become subject to the Workeri Compensation
previsions of the Labor•Codc, you must lorthwith comply with
such provisions or this permit shall be deemed revoked.
AIR HANDLING UNIT(OVER 10=C.F.M.) 6.00
SEISMIC FEE
,3 raj
CONSTRUCTION LENDING AGENCY
I hereby affirm that there is a construction lending agency for
EXHAUST HOOD (WITH DUCT) 5.00
+�
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
Lender's Address
HEATING UNIT (OVER 100,000 B.T.U.)
ELECTRIC
VENTILATION FAN (SINGLE) , 4.00
I certify that I have read this application and slate that the above
information is correct. I agree to comply with all city and county
ordinances and stale laws relating to building constnmtion, and
PLUMBING
BOILER - COMP (3 H.P. or 100,000 B.T.U.) 6.00
BOI LER-COMP IOver 100,000 BTU) SEE FEE SCH.
MECHANICAL
above-mentioned property fative, ofthis city to enter upon the
hereby authorize representatives inspection purposes.
(We) agree to Save, indemnify and keep harmless the City at
Cupertino against liabilities, judgments, costs and expenecs which
may against said City in .sequence of the
gra)I If Peru fl. /
MISC. - REFER TO ORD.
PERMIT ISSUANCE 10.00
CONST. TAX
MECH,CONT. LIC. NO.
MECH.
g_ak'cum
TOTAL
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plicanl/Conhac{r DalyTOTAL
/vaUf'/i"/ V /GI/4pLG�' INSPECTOR COPY -