C8496APPLICANT TO*I,LL'IWAN_ FORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
BU I LDING PROJECT IDENTIFICATION
APPLICATION & PERMIT
BUILDING -ELECTRICAL -PLUMBING -MECHANICAL
PERMIT NUMBER
$496
BUILDING
ADDRESS
�-
0 MER
NAME s,,e (y
PHONE
DTV. ELECTRIC PERMIT FEE
PLAN CHECK VALIDATION
'
DATE OF APPLICATION
NAME PC ORs
LIC. NO.
UTLETS-SWITCHES-RECEP 10.00/1.00
LIGHTING FIXTURES 10.00/1.00
ADDRESS Cr1aff
PHONC r
APPLIANCES- RESIDENTIAL 4.00
PANELS 10.00
ogcnrtsc
ENGINEER
LIC NO.
PANELS (OVER 200 AMP) 20,00
PLAN CHECK FEE P.C. NO.
'
SIGNS TRANS. •i 3.00
ARCH OR
ADDRESS ENG
ZIP
$P ECIAL CIRCUIT 5.00
PERMIT VALIDATION
ISSUANCE DATE
EMP. METER OR POLE INS. 20.00 '
APPLICANT'S
ADORE SS
MOTORS- SEE FEE SCH.
SERVICE CHANGE 20.00
LICIiNSIiD CONTRACTORS U CLARATION
I hereby III'finn that I um licensed under provisions of Chapter
(commencing with Section 7000) of Division 3 of the Business and
Professions Code. .,,it my license is in full force and effeCL
License Class 6 J>!f Lia Num bel
Date Cotitracto"',
i
. OWNER -BUILDER DECLARATION
I hereby affirm that I am exempt from the Contractor's License
Law for the following reason, (Sec. 7031.5. Business and Professions
Code: An cit or Count -
Any y y it any stru tune, prior to constructaheq
improve,demolish.or repair any structure,priorn its issuance, also
requires the applicant for such permit to file a signed statement that
he is licensed 9(copursuant to the provisions of the )ofDodDr•s License
of Division 3 of the
Law (Chapter 9 (commencing with Section is exempt
Business and Pe alleged a empt on that he is fSectiefrom a.5
the bask for tate alleged exemption. Any violation t toa cion malty
by any applicant fora permit subjects th5000.)mnuoacivil penalty
of not more than five hundred dollars (5500).7
❑ I, as owner Of till property, or my employees with wages as
their sole conmensation, will do the work, and the structure I, not
intended Or offered for sale (Sec. 7044, Business and Professions
Code: The Conlrtwlur'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 employers, provided that
nsuch improve-
ments are lot intended oroffercd for sale. If, however the building
or inlprovensent is sold within One year of completion, the owner
budder will have the harden of proving that he did not build or im-
prove for purpose ofsale.).
❑ 1, as owner of the property, am exclusively Contracting with
licensed contractors to construe the project (Sec. 7044, BusinessLAWN
and Professions Code: The Contractor's License Law does not apply
to an owner of property who builds or improves thereon, and who
contracts for such projects with a cm IrLdorto licensed pursuant to
the Contractor's License Law.
❑ I am exempt under Sec. , B.&P.C. for this
reason
TEMP. POLE 30.00
.S
BLDG. ELECT.
O
PLG. MECH.
❑ El
BUILDING PERMIT
INFORMATION
MISC. - REFER TO ORD
PERMIT ISSUANCE 10.00
VALUATION
p♦
/ '}
$/FT.
ELEC. CONTR. LIC. NO.
ELEC.
TOTAL
PERMIT TO
MOOT/ -
f�QL ->ajli N. ✓1;'
DTV. PLUMBING PERMIT FEE
ALTER-DRAIN-WATER(EA.) 5.00
STORIES
TYPE CONSTM.
BACK FLOW PROTECT. DEVICE 4.00
OCC. GROUP
RES. UNITS
DRAINS -FLOOR, ROOF, AREA,CON D. 5.00
F IXTURES - PER TRAP 5.00
GAS EA. SYSTEM -1 INC.4 OUTLETS 6.00
SO. FT. FLOOR AREA
TOTAL ACREAGE
GAS - EA. SYSTEM -OVER 4 (EA.) 2.00
BUILDING USE
RES IND CON PB Other
INDUSTRIAL WASTE INTER. 30.00
SPRINKLERS- 1 INC 5 V.B. 6.00
ASSESSORS PARCEL NO.
LAWN SPRINKLERS - OVER 5 (EA.) 1.00
SEWER -SANITARY -STORM EA. 200ft/10.00TRA.CTNO.
PARCELNO.
WATER HEATER W/VENT 6.00
Owner Date
WORK ERS'COMPENSATION DECLARATION
1 hereby affirm that ]-have a certificate of consent to self -insure.
Or a certificate Of Workers' Compensation Insurance, or a certified
copy thereof(Sce. 3800, La .C.).
['.troy N.. -Company
WATER SYSTEM 5.00
ACC.OATE
ACG FILE NO.
WATER TREATING EQUIP. 5.00
ZONING
ENG. SITE NO.
MISC- REFER TO ORD.
❑ Certified,pY "s hrraby fshc
C'Ri0•d co is fled with the Ity nspcction division.
A,',�rc;ull
CI:R'a'II:ICCfIi OI'IAI'MPTION17ROMWORKI?RS'
COMNiNSA'I'ION INSURANCE.
(Phis section need not he completed if the permit is for .,Ie
handled dollars IS 100) Or less.)
I certify that in the performance of the work for which this per.
mit is issued, I shall not employ any person in any manner so as to
become subject to the Workers' Compensation Laws of California.
Date Applicant
FIRE SPRINK
YF] NE]
ENERGY T -Z4
YE] NE]
PERMIT ISSUANCE 10.00
FLOOD ZONE
Y IN
A.L.U.O.
Y [:J N�
PLG. CONSR. LIC. NO.PLG.
TOTAL
OTV MECHANICAL PERMIT FEE
FEE SUMMARY
BUILDING
!�
ALTER OR ADD TO MECH. 5.00
NOTICE; [0 APPLICANT': If. after making this Certificate of Ex-
emption, you should become subject to tire Workers' Compensation
provisions of the Labor Code, you ryrst forthwith comply with
such provisions or this permit shall be deemed revoked.
CONSTRUCTION LENDING AGENCY
I hereby affirm that there is a construction lending agency for
the performance of the work for which this permit is issued (Sec.
3097, Cie.C.).
Lender's Wme_/,�,�
Lender'sAddress
I Certify that 1 have read this application and state that the above
information is correct I agree to comply with all city and county
ordinances and ,all laws relating to building construction, and
hereby
hereby authorise roperty latices of this city to enter upon the
above-mentioned property ativeor sp of this
purposes '
(We) agree to save, indemnify and keep harmless the City of
Cupertino against liabilities, judgments, costs and expenses which
may in any way accrue against said City in consequence of the
granting of this pc oro it.
99e--- (�
I aturco I I AW/Contractor a
APPLIANCE , 5.00
PLAN CHECK
FEE
AIR HANDLING UNIT (TO 10=C.F.M.) 4.00
AIR HANDLING UNIT(OVER 10=C.F.M.) 6.00
SEISMIC FEE
aSv
EXHAUST HOOD (WITH DUCT) 5.00
HEATING UNIT (TO 100,000 B.T.U.) 8.00
MICROFILM
HEATING UNIT (OVER100,000 B.T.U.) 9.50
ELECTRIC
VENTILATION FAN (SINGLE) 4.00
BOILER-OOMP(3 H.P. or 100,000 B.T.U.) 6.00
PLUMBING
BOILER -COMP (Over 100,000 BTU) SEE FEE SCH. "
MECHANICAL
MISC. - REFER TO ORD.
PERMIT ISSUANCE 10.00
CONST. TAX
MECH. CONT. LIC. NO.
MECH.
TOTAL
TOTAL
7
INSPECTUH UUI