C8522APPLICANT TO FILL IN INFORMATION WITHIN REDILINES- USE BALL POINT PEN ONLY
. BU LDI NG PROJECT I DENTI FI CATION
APPLICATION &PERMI0-4522
BUILDING - ELECTRICAL -PLUMBING -MECHANICAL
PERMIT NUMBER
^ ^
G G
8UFLDNG
ADDRESS
_
0 "" " �" "" """ �'"' "•' ^
NAME L/�S • (415)
ELECTRIC_PERMIT FEE
PLAN CHECK VALIDATION
vHOrvE
NAME AcroRs
WTTCTT^ LIC.NO. 7Q
OUTLETS-SWITCHES-RECEP 10.00/1.00
LIGHTING FIXTURES. 10.00/1.00
C,ONTRACTOR'S '------'-"-^(415 !•"'
ADDRESS
^ppLIANCES- RESIDENTIAL 4.00
PANELS 10.00
.1011 PHONE
DATE OF APPLICATION
ARCHITECT "" - ------ ----" -'
NGINEER
wilcl LIC. No.377579
PANELS (OVER 200 AMP) 20.00
PLAN CHECK FEE P.C. NO.
SIGNS TRANS. 3.00
ARCH. OR ENG. ' "'
ADDRESS - 94025
SPECIAL CIRCUIT 5.00
PERMIT VALIDATION
1 v
TEMP.- METER OR POLE INS. 20.00
APPLICANT'S " `" "' - - "- -' ' -' '-^
ADDRESS
MOTORS SEE FEE SCH.
SERVICE CHANGE 20.00
LICENSED CONTRACTORS DECLARATION
TEMP, POLE 30.00
I hereby affirm that I am licensed under provisions of Chapter 9
(commencing with Section 7000) of Division 3 of the Business and
Profession, Code, aad my license Is In full f I
Liccnsc Class 8' Lim N.nlber1
Date Co_nt_rac[or
ISSUANCE DATE
BLD . ELECT. PLG. MECH.
�•
❑ '❑ ❑
..- ..._
BUILDING PERMIT
INFORMATION
5/30-185T-•,
#377579OWNER-BUILDER DECLARATION
1 hereby affirm Thai -Pam exernp't from thi Contractor's License
s MISC. - REFER TO ORD
Law for the following. mason. (Sec. 7031.5, Businessand ProfessionsVALUATION
Code: Any ciiy or county which requires apcnnit to construct, after,
improve, demolish, oq rtpuir any struct um, prior to its issuance, also
requires the applicant for Site]) permit to HIe a signed statement that
he is licensed Pursuanttothe provisions of the Contractor's License
PERMIT ISSUANCE 10,00
$/FT.
ELEC. CONTR. LIC. NO.
ELEC.
TOTAL
PERMIT'
Law (Chapter 9 (commencing with Section 7000) of Division 3 ofthe
Business and Professions Code) or that he is exempt therefrom and
QTY. PLUMBING PERMIT FEE
AD
the basis for the alleged exemption. Any violation of Section 7031.5
byanyapplicant for a permit subjects the applicant to a civil penalty
of not more than five. hundred dollars (8500).):
than
STORIES
PE ITSTIR.
ALTER -DRAIN -WATER IEA.) 5.00
❑ 1, as of the property, or my employees with wages as
their sole compensation, will do the work, and the structure n not
BACK F LOW PROTECT. DEV ICE 4.00
OCG GHOUIP
RES. UNITS
DRAINS -FLOOR, ROOF, AREA, COND. 5.00
intended or offered for sale (Sec 7044, Business and Professions
Code: The Contractors License Law does not apply to an owner of
FIXTURES - PER TRAP • 5.00
GAS - EA. SYSTEM -1 INC.4 OUTLETS 6.00
property who builds or improves thereon, and who does shelf work
himselfor through his own employees. provided that such improve-
ments.re not intended or ofTered for sale. If, however, the building
SD, FT. FLOOR AREA
TOTAL ACREAGE
,f
1P.
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-
GAS - EA. SYSTEM - OVER 4 (EA.) 2.00
uY
BUILDING E
prove for purpose of sale.).
❑ 1, as owner of the properly, am exclusively contracting with
RES IND CON PB Omer
11 ❑ ❑ F-1licensed
INDUSTRIAL WASTE INTER3000
. .
LAWN SPRINKLERS- 1 INC 5 VB600
V.B. .
LAWN SPRINKLERS - OVER 5 (EA.) 1.00
contractors to construct the project (Sec. 7044, Business
and Professions Code: The Contractors License Law does not apply
to an owner of properly who builds or improves thereon. and who
ASSESSOR ARCEL NO.
Contracts for Each projects with a contracto s) licensed...lYount to
the Contractor's License Law.
lb I am exempt under Sec.-, B.&P.C. for this
reason
SEWER -SANITARY -STORM EA. 200ft/10.00
TRACT NO.
PARCEL NO.
WATER HEATER W/VENT 6.00
Ow C, - Date
I
WATER SYSTEM 5.00
ACC. DATE
ACC. FILE NO.
WATER TREATING EQUIP. 5.00
• WORKERS'COMPENSATION DECLARATION
I hereby affirm that I have a certificate of consent to sell' -insure,
ZONING
ENG. SITE NO.
or a certificate of Workers' Compensation Insurance, or a certified
copy thereof (Sec. 3800, Lab.C.).
Poo. Noji(1L7n q, reb Y_pas_T.sriesfau.0 •.�pw
❑' Certl m o y l rtby f e .."'.'•"""''?b'i- Eou
❑ Certified'copy its fled with 1hIo4't1y �L1iiIL. vision.
Applicant ••...^'. _•.• ._. •. •. .. . ...-.
FIRE SPRINK
Y❑ N❑
ENERGY T-24
Y N❑
MISC.- REFER TO ORD.
CKR'1'119CATI-OF`tmmPTION' PROM WORKERS'
COMPENSATION INSURANCE!
(This weir l 6. need not be completed if the permit is for one
PERMIT ISSUANCE 10.00
FLOOD ZONE
Y ❑ N ❑
A.L.U.C.
I Y ❑ N ❑
PLG. CONTR. LIC. NO.
PLG.
TOTAL \
hundred 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 :my manner so as to
QTY. MECHANICAL PERMIT FEE
FEE SUMMARY
'become subject to the workers' Compensation Laws ofCalifornia.
ALTER OR ADD TO MECH. 5.00
D.te - Applicant
INO"I'ICE '1' a
O APPLICANT: If, after making this Certificate of Ex-
BUILDING
APPLIANCE •5.00
AIR HANDLING UNIT (TO 10=C.F.M.) 4,00
PLAN CHECK
FEE
'
emption, you should become subject to the Workers' Compensation
provisions of 1hc,Labor Code, you most forthwith comply with
such provisions or this Permit shall be deemed revoked.
AIR HANDLING UNIT (OVER I0,0WC.EM.) 6.00
SEISMIC FEE
i. CONSTRUCTION LENDING AGENCY
I I I hereby affinn`ihat there is a consmiction lending agency for
thelperlo glance of the work for which this permit is issued (Sec.
3097, Civ.CI
EXHAUST HOOD (WITH DUCT) 5.00
MICROFILM
H EATING UN IT (TO 100,000 B.T.U.) 8.00
Tfn
Lender's Nam• rt
Lender's Address gege
-
- - HEATI NG UN IT (OVER 100,000 B.T.U.) 9.50
ELECTRIC
}�
I I certify shat l have read ,aP`PGceion PA-e4Rudihc 1111
information is correct. I agree to comply with all city and county
ordinances and \DIte laws relating to building construction, and
. VENTILATION.FAN(SINGLE) 4.00
PLUMBING
BOILER- COMP (3 H.P. or 100,000 B.T.U.) 6.00
hereby authorize representatives of this city to enter upon the
above- mentioned property for inspection purposes.
BOILER -COMP (Over 100,000 BTUI SEE FEE SCH.
MECHANICAL
'
(We) agmcjto save, indemnify and keep limprIess the City of
MISC. - REFER TO ORD.
Cupertino against liabilities, judgments, costs unit expenses which
may in any way accrue against said City in consequence of the
granting of this penniL
PERMIT ISSUANCE 10.00
CONST. TAX
MECH. CONT. LIC. NO.
MECH.
TDTAL
TOTAL
Signature of Applicant/Contractor Date
INSPECTOR COPY