C8664APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
BU LDI NG PROJECT I DENTI F[CATION
APPLICATION & PERMIT
BUILDING -ELECTRICAL- PLUMBING - MECHANICA
PERMIT NUMBER
8664
BUILDING
ADDRESS
0 'S t�
NAME ws
QTY. ELECTRIC PERMIT FEE
PLAN CHECK VALIDATION
PHONE
�a ATo s
UTLETS-SWITCHES-RECEP 10.00/1.00
LIGHTING FIXTURES 10.00/1.00
uc.No.
' ADDRESS iO S ��a( Q
PPLIANCES- RESIDENTIAL'� a 4.00
PANELS \ X10.00
P Ory 3073
DATE OF APPLICATION
OR HIT
ENGINEER
c. No.
LIC.
PANELS (OVER 200 AMN 20.00
PLAN CHECK FEE P.C. NO.
SIGNS TRANS, 3.00
ADDRESS ENG.
SPECIALCIRCUIT 5. 0
PERMIT VALIDATION
TEMP. METER OR POLE INS. 20.00
ZIP
p�
a/�("1 f
APPLICANTS
ADDRESS
��yy,,,��
Sri/I�y////
MOTORS SEE FEE SCH.
SERVICE CHANGE 20.00
LICENSED CONTRACTORS DECLARATION
TEMP. POLE 30.00
I hereby afl no that 1 um licensed under provisions it Chapter
(commencing with Section 7000) of Division 3 of the Business and
Code, and my license Is In (rill IOlC4 and effect.
Professionsla Lic
Class . Number 1?7,
L❑
ISSUANCE DATE
BLDG. ELECT. PLG. MECH.
❑ ❑ ElLicennse
Date Contractor
BUILDING PERMIT
INFORMATION
O VER -BUILDER DECLARATION
I hereby affirm that I am exempt from the Contractor's is License
Professions
Code:Low Any city countywhichng reason. e. requi3Lspermit reconstruct,
Code: Any city or nulmy which structure permit mconstract,,
MISC.- REFER TO ORD
PERMIT ISSUANCE 10.00
VALUATION
$/FT.
ELEC. CONTR. LIG. NO. TOTAL
TOTAL
QTV. PLUMBING PERMIT FEE
prior to its iateme t, Also
also
improve, demolish, or repair any permit
to life
requires the applicant for such rormit to file a Signed actor's License tient
he is licensed pursuant to the provisions of the Contractor's ion 3fthe
Law(ChapterProfessions Codeng ) or Section is 00) exempt therefoofthe
Business Professions Code) or that he is exempt therefrom and
em
PERMIT TO
MU6,VfY
fo /
V /(
,TYPE
for
the basis for the alleged exemption. Any applicant
t to ofSection malty
by any applicant for a permit dollars the 0).) am toaCMIpenally
of not more than five hundred dollars (SSOOIJ:
STORIES
CONSTR.
ALTER -DRAIN & VENT -WATER (EA.) 5.00
❑ I, as owner of the property, or my employees with wages as
their sole compensation, will do the work, and the structure Is not
BACK FLOW PROTECT. DEVICE 4.00
OCC. Ggouv
RES. UNITS
DRAINS -FLOOR, ROOF, AREA, CON D. 5.00
intended or offered for sale (Sec. 7044, Business and Professions
Code: The ponhacRu's License Law does riot apply to an owner of
FIXTUR ES - PER TRAP 5.00
GAS-EA.SVSTEM-11NC.40UTLETS 6.00
property wl o builds or improves thereon, and who dcon such work
himself or through ]its own employees, provided that such improve-
mentsarenotintendedoroffered for sale. lL however, Ole building
SQ FT. FLOOR AREA
TOTAL ACREAGE
or improvement is sold within one year of completion, the owner-
builder will have tire burden of proving that h e did not build or im-
- . -..
GAS EASYSTEM OVER 4 (EA.) 200
BUILDING USE
prove for purpose of sale.).
❑ I, as owner of the property, am exclusively contracting with
RES IND CON PB Omer
0 O ❑ ❑
INDUSTRIAL WASTE INTER. 30.00
LAWN SPRINKLERS - 1 INC 5 V.B. 6.00
licensed contractors to Construct the project (Sec. 7044, Business
and Professions Code: 'I'he Contractor's License Law does not apply
to an owner of property who builds or improves thereon, and who
ASSESSORS PARCEL NO.
LAWN SPRINKLERS - OVER 5 (EA.) 1.00
contracts for such projects with a contnlvtons) licensed pursuant to
rho Contractors License Law.
SEWER -SANITARY -STORM EA. 200ft/.10.00
TRACT NO.
PARCEL NO.
❑ I am exempt under Sea ,B.&1'.C. for this
reason
WATER HEATER W/VENT 6.00
Owner Date
WATER SYSTEM 5,00
ACGOATE
ACC. FILE NO.
WATER TREATING EQUIP. 5.00
W'ORKERS'COMPENSATION DECLARATION
1 hereby affirm that I have a certificate of consent In self -insure,
or a certificate of Workers' Compensation Insurance, or a certified
ZONING
ENG. SITE NO.
copy thereof (Sec. 3800, Lab .C.1.
policyN Co
FIRE SPRINK
y� N�
ENERGY T 24
v� N�
0Certifiedl cois hereby not hed. t
Ce i17ed y is luted with ❑w col' inspection division.
A nt
MISC.- REFER TO ORD.
,E CA'1'EOP :A EMPTION PRO,Mj WORKERS'
PERMIT ISSUANCE 10.00
PLOOOZONE
A.L.U.C.
CO.\IPF.�'$ATION INSURANCE:
(T
This section need not be completed if the permit is for one
V� NE]
V0 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 any planner so as to
QTV. MECHANICAL PERMIT FEE
FEE SUMMARY
BUILDING
Pb
hecome subject to the Workers' Compensation Laws of California.
Dem 'Applicant
ALTER OR ADD TO MECH. 500
.
NOTICE TO APPLICANT: If, alter making this Certificate of E x-
APPLIANCE 5.00
AIR HANDLING UNIT (TO 10=C.F.M0 4.00
PLAN CHECK
FEE
j.:
/a
emption, you should become subject to the Worke,i Compensation
provisions of the labor Code, you must forthwith comply with
such provisions., this permit shall be deemed Invoked.
AIR HANDLING UNIT(OVER 10MC.EM.)6.00
SEISMIC FEE
-�
CONSTRUCTION LENDING AGENCY
EXHAUST HOOD (WITH DUCT) 5.00
I hereby affirm that there is a construction lending agency for
the performance of the work for which this permit is issued (Sec
3077, Cis C.). � � '
�JWLeJC
MICROFILM
HEATING UNIT (TO 100,000 B.T.U.) 6.00
Lender's Name
Lender's Address
HEATING UNIT 100,000B.T.U.)9.50
ELECTRIC
VENTILATION FAN (SINGLE) 4.00
I certify that l have read this application and state that the above
information is correct. I agree to comply with all city and county
ordinances and state laws relating to building construction, and
PLUMBING
BOILER- DOW (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 llW,0008TU) SEE FEE SCH.
MECHANICAL
(We) agree to save, indemnify and keep harmless the City of
Cupertino against liabilities, judgments, costs :and txpeD.ces which
may in an way accrue a•'inst said City in construcnce of the
MISC. - REFER TO ORD.
PERMIT ISSUANCE 10.00
CONST. TAX
granting his permit. `
i
Si re o Ap cant/ ac or
MECH. CONT. LIC. NO,
MECH.
TOTAL
TOTAL
3 �S
1
INSPECTOR COPY