C8665APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
BUILDING PROJECT IDENTIFICATION -
f"� 1
APPLICATION & PERMIT V
BUILDING - ELECTRICAL- PLUMBING -MECHANICAL
PERMIT NUMBER
8665
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A oo RESS
OWNE 'S .
NAME s D C�g�
-
QTY. ELECTRIC PERMIT FEE
PLAN CHECK VALIDATION
PHONE _
NAME o's
OUTLETS -SWITCHES -RECEP 10.00/1.00
LIGHTING FIXTURES 10.00/1.00
LIC, ND.
DATE OF APPLICATION
ADDRESS Das
PAP0 I 4P D, ���1p �7 �y'S)
FlII'*P� _
PPLIANCES- RESIDENTIAL 4.00
PANELS 10.00
ARCH T
PANELS (OVER 200 AMP) 20.00
PLAN CHECK FEE P.C. NO.
ENGINEER
LIC. No.
SIGNS TRANS. 3.00
ADD Ess ENO' -
ZIP
SPECIAL CIRCUIT 5.00
PERMIT VALIDATION
a
Cl
TEMP. METER OR POLE INS. 20.00
APPLICANTS
ADDDRESSDRESS
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MOTORS SEE FEE SCH.
SERVICE CHANGE 20.00
LICENSED CONTRACTORS DECLARATION
TEMP. POLE 30.00
1 hereby affirm that 1 um licensed under provisions of Chapter 9.
(commencing with Section 7000) of Division 3 of the Business and
L seaS'RO;S Code, and m license is in full force' nd effect.
License Class_e�_�._ Lie Number
ISSUANCE DATE
BL
ELECT.
❑
PLG. MECH.
❑ ❑
Contrucmr�
UILDIPERMIT
1' INFORMATION ATION
WN
OWM1'Ii R -BUILDER DECLARATION
I hereby affirm that I am exempt from the Contractor's License
Law Forthe following reason.(See. 7031.5. Businessandrrofessions
Code_ Any city or county which requasia purnt it to ma
canst, alter,
requires helap ilia or for repair any structure prior to its iatement also
for the rovNt t0 filof to signed
requires licensed
Ilsedp pursuant ont statactor's Lit that
hr is pursuant the provisions of the Contractors License
MISC. - REFER TO ORD
PERMIT ISSUANCE 10.00
VALUATION
_
$/FT.
ELEC. CONTR. UC. N0. ELEC.
TOTAL
PERMIT TO -
�orn�
(Chapter en of Division 3 of the
Law (Chapter 9 (commencing with Section is exempt
Business and Code) or that h is exempt t and
QTY. PLUMBING PERMIT FEE
/
file ,li,Rons
the basis for the alleged
alleged Anyviolationof Section
i
ES
NS q.
by any applicant fore permit subjects the applicant toacivil penalty
permit malty
of not more than five hundred dollars (5500).):
ALTER-DRAINSt VENT -WATER (EA.) 5.00
❑ I, es owner of the property, or my employees with wages as
n, will do the work, and the stcture is not
their role'cnnlp.ociiuru
BACK F LOW PROTECT. DEV ICE 4.00
OCC. GROUP
RES. UNITS
DRAINS -FLOOR, ROOF, AREA, COND. 5.00
intended or offered for sale (Sec. 7044. Business and Professions
Code: The Contractor's License Law does not apply to as owner of
FIXTURES -.•,PER TRAP 5.00
GAS - EA. SYSTEM - I INC.4 OUTLETS 6.00
SO, FT. FLOOR AREA
TOTAL ACREAGE
Property who builds or improves thereon, and who dors such work
himself or through his own employees, provided that such iligno c-
mentsarenotintendedorofferedfursale. ll', however, the building
or improvement is sold within one year of completionthe owner -
builder will have the burden of proving that he did not, build or im-
GAS - EA. SYSTEM -OVER 4 (EA.) 2.00
BUILDIN USE
prove for purpose of self).
❑ 1, as owner of the property, am exclusively contracling with
RES. IND co 11 PB oma,
❑ ❑ ❑ ❑
INDUSTRIAL WASTE INTER. 30.00
LAWN SPRINKLERS - 1 INC 5 V.B. 6.00
LAWN SPRINKLERS - OV ER 5 (EA.) 1.00
licensed contractors to construct the project (Sec. 7044, Business
and Professions Code: The Contractor's License Law does not apply
to an owner of propeny who builds or Improves therron. and who
ASSESSORS CEL NO.
contracts for such projects with a contractimo licensed pursuant to
the Contractor's License law.
SEWER -SANITARY -STORM EA. 2001t/10.00 /
TRACT NO.
PARCEL No. -
❑ tum exempt lender Sec. ,B&P.C. Ibr this
reason
WATER HEATER W/VENT 6.00 '
Owner Date
WATER SYSTEM 5.00
ACC. DATE
ACC. FILE NO.
WORKBRS'COMPFNSAT ION DECLARATION
WATER TREATING EQUIP. 5.00
1 hereby affirm that I have a ctn ilicale of consent to sell -insure,
or a certificate of Workers' Compensation Insurance, or a certified
ZONING
ENG. SITE NO.
copy thereof (Sec. 3800, Lab C -j...
Policy mpm,ylon pa.
MISC. - REFER TO ORD.
I,
❑ Cenrnifierl copy is hereby rens
�Q' Certified Copy is filed with the city inspection division.
AI'Olicant
FIRE SPgINK
Y N
E]❑
ENERGY T 2
V N
C]❑
CERTIFICATE OF EXEMPTION FROM WORKERS
PERMIT ISSUANCE 10.00
FLOOD ZONE
A.L.u.C.
COM1IPENSATION INSURANCE
t'I'his seclilin need nut be completed if the permit is for one
Y
Y [:] NE]
PLG. CONTR. LIC. No.
PLG.
TOTAL
hundred dollars 1$100) or Tess-)
I certify that in the performance of the work for which Onix per-
mit is issued, I shall not employ any person in any manner so as to
QTY. MECHANICAL PERMIT FEE
FEE SUMMARY
BUILDING
become subject to the Workers' Compensation Laws of California.
Date Applicant
NOTICE TO APPLICANT: If, after making this Certificate of Ex-
ALTER OR ADD TO MECH. 5.00
APPLIANCE 5.00
PLAN CHECK
FEE
CmPOon, you should become subject to the Workers'Compensation
provisions of the Labor Code, you must forthwith comply with
such provisions or this permit shall be deemed revoked
AIR HANDLING UNIT (TO 10=C.F.M.) 4.00
AIR HANDLING UNIT(OVER 10=C.EM.) 6.00
SEISMIC FEE
its
CONSTRUCT ION LEN'DIN'G ACENCY
-I.hereby ufl'inn that there is a construction lending ageneY for
the parroWamee of the work for which this permit is issued (Sec.
3097, Civ Com,
EXHAUST HOOD (WITH DUCT) 5.00
MICROFILM
HEATING UNIT (TO 100,000 B.T.U.) 8.00
Lender's Name Ch
�� I�
U mILendcr's NameAddress
HEATING UNIT ER 100,000 B.T.U.)9.50
ELECTRIC
VENTILATION FAN (SINGLE) 4.00
1 certify that I have read this application and state that the above
information is correct. I agree to comply with all city and county
ordinances and slate laws relating to building construction, and
PLUMBING
BOILER- COMP(3 H.P. or 100,000 B.T.U.) 6.00
BOILER -COMP (Over 100,000 BTU) SEE FEE SCH.
MECHANICAL
hereby entlonell property for inspection purposes.
abuse. authored r.perLY for ec this city to enter upon the
MISC. - REFER TO ORD.
(We) agree to save, indemnify and keep I m ndess the City of
Cupertino against liabilities, judgments, costs and expenses which
may in a way accrue against said City in consequence of the
PERMIT ISSUANCE 10.00
CONST. TAX
g lis pcnnit.
�zilz. .0
MECH. CONT. LIC. NO.
MECH.
46Z44
gn re f p I t1C lr o
TOTAL
TOTAL
3
INSPECTOR COPY