8636APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
BUILDING PROJECT IDENTIFICATION
APPLICATION & PERMIT
UILDING- ELECTRICAL- PLUMBING - MECHANICAL
PERMIT NUMBER
/�
8636 C ,J C
ofVl VI BVI
BUILDING
ADDRESS
O O CoFc Gi,•
OWNER'S
PLAN CHECK VALIDATION
AmE
N';14L7� ,>, PHDNE
QTY. ELECTRIC PERMIT FEE
NAM>ERACTofls -
UTLETS - SWITCHES - RECEP 10.00/1.00
6LQ GLGL7 LIE No
LIGHTING FIXTURES 10.00 /100
rorrRAcroR'
-3a^
ARJSt
APPLIANCES- RESIDENTIAL
dGe 111roPRONE tlj576 (•
PANELS 10.00
DATE OF APPLICATION
CHrtELT
OR
ENGINEER
ua No.
PANELS I OVER 200 AMP) 20,00
PLAN CHECK FEE P. C. NO.
SIGNS TRANS. 3.00
nooe[ss ENG.
SPECIAL CIRCUIT -5.00
PERMIT VALIDATION
EMP. METER OR POLE INS. 20.00
• ZIP
r
J
APPLICANT $
ADDRESS
MOTORS SEE FEE SCH,
-
SERVICE CHANGE 20.00
LICENSED CONTRACTORS DECLARATION
TEMP. POLE 30.00
1 hereby affirm that 1 am licensed under provisions of Chapter 9
(commencing with Section 7000) of Division 3 of the Business and
1'rofessions Code, and mry license is in full lore, and effect.
d,iccnsu Class 4 -Z,2 Lic. Number Ir 3, v-�
U.m 5-_/W1 Conitnetor )• s 4o^ 1,
ISSUANCE DATE
BLDG.
❑
ELECT.
❑
PLG. MECH.
❑ ❑
BUILDING PERMIT
INFORMATION
OWNER -BUILDER DBCLARA I]ON
I hereby affirm that 1 am exempt from the Contractor's License
Law for the following reason. (Sec. 7031.5. 1iusinessand Professions
Code: Any city or county which reyuireta permit to construct, alter,
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 fcommencing with Section 7000) of Division 3 of the
Business and Professions Code) or that he is exempt therefrom and
MISC.- REFER TO ORD
PERMIT ISSUANCE '� 14,00 �.
VALUATION
s' -
S/FT.
ELEC. CONTE. - LIC. NO.
ELEC. �t
TOTAL O�
PERMIT TO
_
QTY. PLUMBING PERMIT FEE
STORIES
TYPE CONSTR.
the basis for the alleged exemption. Any violation of Section 7031.5
by any applicant for a permit s ubjects the applicant ma civil penalty
of not mom than five hundred dollar, ($5001.):
ALTER -DRAIN -WATER IEA.) 5.00
❑ I, as owner of the property, or my employees with wages as
their sole compensation, will do the work, and lire structure is not
BACK FLOW PROTECT. DEVICE 4.00
OCC. GROUP
RES. UNITS
DRAINS -FLOOR, ROOF, AR EA, COND. 5.00
intended or offered for sale (Sec. 7044, Business and Professions
Code: The Contractors License Law does our apply to a,, wner of
property who builds orimproves themon, and who does such work
himself or through his own employees, provided that such improve-
mentsarenotintendedorofferedforsale, If, however, the building
FIXTURES - PER TRAP 5.00
SO. FT. FLOOR AREA
TOTALACREAGE
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 im-
prove for propose ofsal,.).INDUSTRIAL
❑ I, as owner of the property, am exclusively contracting with
GAS - EA. SYSTEM -OVER 4 IEA.) 2.00
BUILDING USE
RES IND CON Pa Omer
❑ ❑ ❑ ❑ ❑
WASTE INTER. 30.00
licensed contractors to construct the project (Sec. 7044, Business
and Professions Code: The Contractor's License Law dues not apply
to an owner of property who builds or improves themon, and who
LAWN SPRINKLERS - 1 INC 5 V.B. 6.00
' LAWN SPRINKLERS - OVER 5 (EA.) 1.00
ASSESSORSPARCEL NO.
contracts for such projects with a contractorls) licensed pursuant to
the Contractors License Law.
SEWER -SAN V -STORM EA. 2001t/10.00
TRACT NO.
PARCEL NO.
❑, I am exempt under Sec.-,li.&KC. For flus'
reason
WATER HEATER W/VENT 6.00
Owner Date
WATER SYSTEM 5.00
ACC.DATE
ACC. FILE NO.
WATER TREATING EQUIP, 5.00
v WORKERS'COMPENSAT ION DECLARATION
1 hereby arinn that I have a cerlilicutc of'onttnl to self-insum,
or a c,r1iricam of Workers' Compensation Insurance, or a certified
ZONING
ENG. SITE NO.
copy lhemirl(Sec. 3800 ayy q
I'olicY Nr{.t1C 7Gbp4' do KG®/•+Q r/7-
.
❑ Cmilletl copyj; hereby furnished.
❑ Ccrt il'iedYcypg 9 I; wit the city inspection division.
Applicant e��
FIRE SPRINK
V N
EJ • ❑
ENERGY T$4
V N
❑ E]
MISC. - REFER TO ORD.
CERTIFICATE OF EXEMPTION PROM WORKERS'
PERMIT ISSUANCE 10400
FLOOD ZONE
A.L.U.C.
PLG. CONTE. LIC. NO.
PLG.
TOTAL
COMPENSATION INSURANCE
('I his section need not be completed if the permit is for one
-: �,❑ N❑
V❑ N❑
hundred dollars IS 100) or less)
I cerlity that in the performance of the work for which this per-
mtil is issued, I shall not employ any person in any manner so as to
OTY. MECHANICAL PERMIT FEE
FEE SUMMARY
BUILDING
become subject to the Workers' Compensation Laws of California.
Daft Applicant
NO'IICE 'I'O APPLICANT: If, after making this Certi(icat, of Ex-
ALTER,OR ADD TO MECH. 5.00
APPLIANCE 5.00
PLAN CHECK
emption, you should become subject to the Workers'Compensation
provisions of the Labor Code, you most forthwith comply with
such provisions or this permit shall be deemed revoked.
FEE
AIR HANDLING UNIT (TO 10=CF.M.) 4.00
AIR HANDLING UNIT (OVER 1000GEM.) 6100
SEISMIC FEE
CONSTRUCTION LENDING AG17NCY
I her,hy affirm that there is a construction Inuring agency. or
the performance of the work for which this permit is issued (Sec.MICROFILM
3097, Civ.C.L
EXHAUST HOOD (WITH DUCT) 1' 5.00
HEATING UNIT (TO 100,000 B.T.U.) 1'8.00
Lender's Name
Lender's Address
HEATING UNIT (OVER 100,000 B.T.U.)9.50
ELECTRIC
I cerlily that I have read this application and nate that the above
VENTILATION FAN (SINGLE) 4,00
int'orriafion is correct. I agree to comply with all city and county
ordinances and state laws relating to building construction, and
hereby authorize representatives of this city to enter upon the
above mentioned property for inspection purposes.
PLUMBING
BOILER-COMP(3 H.P. or 100,000 B.T.U.) 6.00
BOILER -COMP (Over 100,000BTU)SEE FEESCH.
MECHANICALY
MISC. - REFER TO ORD.
(We) agree to save, indemnify and keep harmless the City of
Cupertino against liabilities, judgments, costs and expenses which
Indy in any way accrue against 'aid C' y In consequence of the
CONST. TAX
PERMIT ISSUANCE 10.00
gmntin f fill effort
MECH. CONT. LIC. NO.
TOTAL
TOTAL
"n ru of Applicant/Contractor )ate '
INSPECTOR COPY