C8143APPLICANT TO FILL IN INFORMATION WITHIN REDLINES - USE BALL POINT PEN ONLY
BUILDING PROJECT IDENTIFICATION
I -x
APPLICATION & PERMIT
BUILDING - ELIECTRICAL- PLUMBING - MECHANICAL
PERMIT NUMBER
/7
C_/ 8143
aLIILDING
AOOREss
. Gie� J
OW 'S
NAME
7,„T,r ra/A Pe1�E
� - _ _ _
OTY. ELECTRIC PERMIT FEE
PLAN CHECK VALIDATION
J �, rJ
61? % 27 (��
,yG
CONTRACTOR'S
NAME
OUTLETS - SWITCHES -RECEP 10.00/1.00
LIGHTING FIXTURES 10.00/1.00
r,
Ess ,
ADDRESS
, APPLIANCES: RESIDENTIAL 4.00
DATE OF APPLICATION
PANELS 10.00
RRCHITECT
O
E INEE
/,�y,;JLIC. NO.
PANELS (OVER 200 AMP) 20.00
PLAN CHECK FEE FC,
SIGNS TRANS. 3.00
ADDRESS ENc� I '
173 ♦�i rr 1�c /Nr .lase (%l. ZIP 47r//2,
SPECIAL CIRCUIT 5.00
PERMIT VALIDATION
^ 4
rrEMP, METER OR POLE INS. 20.00
A
ADDRESS s
ADDRESS
MOTORS SEE FEE SCH.
SERVICE CHANGE 20.00
_ .
J•
LICENSED CONTRACTORS DECLARATION
TEMP. POLE 30.00 •�//��
r
1 hereby affirm that I am licensed under provisions of Chapter 9
(commencing with Section 7000) of Division 3 of the Business and
Professions Code and my license is in full fore, and c'f ct.
License Class Ell. NuUocr 4 2.9
ISSUANCE DATE
BLD
ELECT.
PLG, MECH.
Date '_1s Contractor
OWNERTUILDER DECLARATInPRO G't fir'
1 hereby affirm that 1 am exempt from fie Contractor's License
' Law for the following reason, (Sec. 7031.5, Business and Profusions
Code: Any city orecunty which requires a permit to coast...Letter,
BUILDING PERMIT
INFORMATION
MISC. - REFER TO ORD
PERMIT ISSUANCE 10.00
VALUATION$/FT.
2("]�/ a,DO
�•�
ELEC. CONTR. LIC, N0,
TE LET
TOTALI
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
Law (Chapter 9 (commencing with Section 7000) of Division 3 of the
Business and Professions Code) or that he is exempt therefrom and
J��((�% 0
PERM I TO
QTY, PLUMBING PERMIT FEE
STORIES
TYPE CONSTR.
the basis for the alleged exemption. Any violation of Section 703 LS
by any applicant for it permit subjects the applicant to a civil penalty
of not more than five hundred dollars (8500),):
_
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 F LOW PROTECT. DEV ICE 4.00
OCC. GROUP
RES. UNITS
DRAINS -FLOOR, ROOF, AR EA, COND- 5.00
intended or ofle ed 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 does such work
himself or through his own employees, provided that such improve-
ments are not intended or offered for sale. If, however, the building
F IXTUR ES - PER TRAP 5.00
SO. ET. FLOOR AREA
TOTAL ACREAGE
'
GAS-EA.SVSTEM-11NC.40UTLETS 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 am-
prove for purpose of sale.).
❑ 1, as owner of the property, am exclusively contracting with
GAS - EA. SYSTEM - OVER 4 (EA.) 2.00
BUILDING USE
REs IND PB Other
10:1 ❑ ❑
INDUSTRIAL WASTE INTER. 30.00
licensed contractors to construct tire project (See. 7044, Business
and Procciums Code: The Contractors License Law does not apply
to all 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
ASSESSOR v RCEL NO. -
contracts for such projects with a contractor(s) licensed pursuant to
the Contractor's License Law.-
SEWER -SANITARY -STORM EA. 200ft/10.00 -
TRACT NO.
PARCEL NO.
❑ 1 in exempt Linder Sec.-, B &P.C, for this
reason
WATER HEATER W/VENT 6.00
Owner Dote
WORK 17 RS'COMPENSATION DECLARATION
WATER SYSTEM 5.00
ACC. GATE
ACC. FILE NO.,
WATER TREATING EQUIP. 5.00
I hereby affirm that I have a certificate orensent to'elf -Insure,
or a certificate of W.,!,v�,si usation Insurance, or a certified
ZONING
ENG. SITE NO.
-
copy the Un
Polly -N66'' `�C�`o`m /Ln a.;rrry3-4 gJ
FIRE SPRINK
Y ❑ N ❑
ENERGY T 24
v ❑ N❑
O Certified copy is hereby furnished.
❑ Certlfle o,y is fled with the City inspection division.
Applicant i%'tom
MISC. - REFER TO ORD.
CGRTI ICATLOP EXEMPTION PROM WORKERS'
PERMIT ISSUANCE 10.00 �
FL60D ZONE
A.L.U. C.
COMPENSATION INSURANCE
(This section need not be completed if the Permit is for one
PLG.CONTR. LIC. NO.PLG.
TOTAL
Y ❑ N❑
Y ❑ N❑
hundred dollars IS 100) Orlrs,)
-
I certify flat at tire performance of tine work I., which 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.
Data Applicant
s ALTER OR ADD TO MECH. 5.00
NOTICI7 TO APPLICANT`. If, after making this Certificate of Ex-
APPLIANCE 5.00
PLAN CHECK
emption, you should become subject to tire Workers' Compensation
provisions of the Labor Code, you nwst forthwith Comply with
such provisions or this permit shall he deemed revoked.
FEE
AIR HANDLING UNIT (TO 10=C.F.M.) 4.00
AIR HANDLING UNIT(OVER 10=C.F.M.) 6.00.
SEISMIC FEE
CONSTRUCTION LENDING AGENCY
1 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.)9.50
ELECTRIC
I certify that I have read this application and state that Lie above
VENTILATION FAN (SINGLE) 4.00
information is correct I agree to comply with all city and county
a
oNinnces and stat, laws relating 1. building construction, and
PLUMBING -4
BOILER-COMP(3 H.P. or t00,0006.T.U.) 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.
(We) agree to save, indemnify and keep harmless the City of
MISC. - REFER TO ORD.
Cupertino against liabilities, judgments, costs and expenses which
may in any way accrue against said City in consequence of the
PERMIT ISSUANCE 10.00
CONST. TAX
grsn[ing of his permit
MECH. CONT, LIC. NO.
MECH.
OTAL
TOTAL
p�
Signature of App lontrulcontractorX Ogle
INSPECTOR COPY