8651APPLICANT TO FILL IN INFORMATION WITHIN RED LINES -USE BALL POINT PEN ONLY
BUILDING PROJECT lDENTIFICATION
APPLICATION & PERMIT
BUILDING - ELECTRICAL- PLUMBING - MECHANICAL
PERMIT NUMBER
8651
BUILDING
a0GRE5lo 5 /•h
GINNER'S
-
PLAN CHECK VALIDATION
NAME
PRONE
QTY. ELECTRIC PERMIT FEE
NAME acTORs
UTLETS- SWITCHES -RECEP 10.00/1.00
G.2 ELGG/ ua No, /S3(v2.5
DATE OF APPLICATION
LIGHTING FIXTURES 10.00/1.00
r, NTRacTGRs
ADDRESS
T [ cc
{ 6✓ �� I'RGNE S / 2 GOO
PPLIANCES- RESIDENTIAL 'il
PANELS 10.00
ORARCHITECT
ENGINEER
LIC. NO,
PANELS (OVER 200 AMP) 20,00
PLAN CHECK FEE P.C. NO.
SIGNS TRANS. 3.00
ARCH etc Enc'
SPECIALCIRCUIT 5.00
PERMIT VALIDATION
rFEMP. METER OR POLE INS. 20.00
Zip
n /JS
ADDRESS rs
-MOTORS SEE FEE SCH.
SERVICE CHANGE 20.00
'
LICENSED CONTRACTORS DECLARATION
TEMP. POLE 30.00
1 hereby affirm that I am licensed under provisions of Chapter 9
(commencing with Section 7000) of Division 3 of the Rosiness and
Professions Code, and my license is in full force nd effect
License Class n anv�.7 Lic. Number
Date .[�Contmetor '
ISSUANCE DATE
BLDG.
EJ❑
ELECT.
PLG. MECH.
El 1:1//-
OWNNF''R-BUILDER DECLARATION
I hereby affirm that I am exempt from the Contractors License
Law for the following reason. (Sec. 7031.5. Business and Prolessions
Code: Any Any city or county which requires a permit to construct, alteq
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 Contraelor'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
BUILDING PERMIT
INFORMATION
M ISC.- REFER TO ORD
VALUATION 5/FT.
PERI TIT ISSUANCE
E EC. CONTR. LIC. NO.
ELEC.
TOTAL
PERMIT TO
_
CITY. PLUMBING PERMIT FEE
STORIES
TYPE CONSTR.
the basis for the alleged exmnption. Any violation of Section 7031.5
by any applicant for a permit subjects Die applicant to a civil penalty
of not more than live hundred dollars (5500).):
ALTER -DRAIN -WATER IEA.) 5.00
❑ I, as owner of the property, or my nnployee,s with wages as
Sole compensation, will do the work, and the structure I, not
BACK FLOW PROTECT. DEVICE 4.00
UCC. GROUP
RES. UNITS
DRAINS -FLOOR, ROOF, AREA, COND. 5.00
intended or offered For sale (Sac. 7044, ]RUiness and I'ro1'essions
'
Code'. The Contractor's License Low 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 tial such improves
men is are not intended or offered for sale. I L however, tie building
FIXTURES - PER TRAP 5.00
$0. FT. FLOOR AREA
TOTAL ACREAGE
GAS-EA.SYSTEM-11NC.40UTLETS 6.00
or improvement is sold within one year of completion, the owner-
builder will have the burden Of proving that he did not build or ire -
prove for purpose of sale.).
❑ I, as owner of lire property, am exclusively contracting with
. -..
GAS - EASYSTEM OVER 4 (EA) 200
BUILDING USE
RES IND CON PB Omar
❑ ❑ ❑ ❑ ❑
INDUSTRIALWASTE INTER. 30.00
licensed contractors to construet the project (Sue. 7044, liusiness
and professions Code: The Contractor's Llecnw Law does not apply
to an owner of properly who builds or improves thereon, and who
LAWN SPRINKLERS- I INC 5 V.B. 6.00
LAWN SPRINKLERS- OVER 5 (EA.) -1.00
ASSESSORS PARCEL NO.
contracts prr such projects with a contractors) licensed pursuant to
the Contractors License Low.
SEWER -SANITARY -STORM EA. 200ft110.00
TRACT NO.
PARCEL NO.
❑ 1 am exempt under Sec. , B.&P.C. for this
reason
WATER HEATER W/VENT 6.00
Owner Dale
WATER SYSTEM 5.00
ACC.OATE
ACC. FILE NO.
WATER TREATING EQUIP. 5.00
WORKF:R$'COMPEN$A I ION LECLARATION
I hereby affirm that I have a certificate ofconsent to self -insure.
or a certificate of Workers' Compensation Insurance or a certified
ZONING
ENG. SITE N0.
copy thereof (See. 3800, Lab.C.).
Policy No. Com Par .
FIRE SPRINK
Y ❑ IN
ENERGY T-24
Y ❑ N❑
❑ Certified copy is hereby urmshed.
❑ Certified�./ -opy is filed with Dm city inspection division.
Applicant �T>GLd S�Sy� �' ( 6g"-
MISC. - REFER TO ORD.
CFRTIFICATI! 01: EXEMPTION FROM WORKERS'
PERMIT ISSUANCE 10.00
FLOOD ZONE
A.L.V.C.
CO.\1PENSAT10N INSURANCE
section need not be completed if the permit is for one
PLG. CONTR. LIC. NO.PLG.
TOTAL
Y❑ N❑
Y❑ NE]
hundred dollars (S I OO) or less.)
I certify that in the performance of the work for which this per-
mit is issued, I shall nut employ any person in any manner so as to
CITY. MECHANICAL PERMIT FEE
FEE SUMMARY
BUILDING
become subject to the Workers' Compensa l ion Laws of California.
Dale Applicant
ALTER OR ADD TO MECH. 5.00
NOTICE TO APPLICANT: If, after making this Certificate of E..
emption, you Should become subject to the Workers' Compensation
APPLIANCE 5.00
PLAN CHECK
provisions of lire Labor Code, you must forthwith comply with
such provisions or this permit shall be 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
I hereby affirm that there is a construction lending agency for
EXHAUST HOOD (WITH DUCT) 5.00
.the performance of life work lir 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
0.6
I certify that 1 have read this application and state Mat the above
VENTILATION FAN (SINGLE) 4.00
information is correct, I agree to comply with all oily and comlly
ordinances and state laws relating to buildingaLxonstrmtion, anJ
PLUMBING
BOILER-COMP(3 H.P. or 100,000 B.T.U.) 6.00
BOILER -COMP (Over 100000 BTU) SEE FEE SCH.
MECHANICAL
aenelly enlioned properly fative,or .1 this
this city i6 enter upon the
hereby authorize representatives inspection purposes
(We) agree to one, indemnify and keep file ss Ihu Cily of
Cupertino agar 'avliabilities, judlfrients, costs and expenses which
may iv y uy accrue ugui ai it in cunuquunce of the
MISC. - REFER TO ORD.
CONST. TAX
PERMIT ISSUANCE 10.00
gmntln • hitt permit
MECH. CONT. LIG NO.
MECH.
TOTAL
TOTAL
gA' uR, of Afpplicanf;dmidctor Date
INSPECTOR COPY