8748APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
'. BUILDING PROJECT IDENTIFICATION
APPLICATION & PERMIT\
BUILDING — ELECTRICAL— PLUMBING — MECHANICAL
PERMIT NUMBER
BUILDING
aooRESS
T O C
OWNERS
'
NGLEN _rFJVA1,Ey PHONE ZS
CITYELECTRIC PERMIT FEE
P AN CHECK VALIDATION
CONTRACTORS
NAME
UTLETS- SWITCHES -RECEP 10.00/1.00
ILiGHTING FIXTURES 10.00/1.00
OU r.e0 C_uc No.q(,Z-Z 7(6
'
CONTRACTORS
CONTRAS
A
PPLIANCES- RESIDENTIAL 4.0011_
PANELS 10.00
r• y�('
71 — kI
�O MA PHONE q�O
DATE OF APPLICATION
ARCHITECTPANELS(OVER
OR
ENGINEER IVLA uc. No.
200 AMP) 20.00
PLAN CHECK FEE P.C. NO.
SIGNS TRANS. -3.00
ADDRESS ENG.
21P
CIRCUIT S,OO
PERMIT
PERMIT VALIDATION
G '
!YI 1985
EMP. METER OR POLE INS.
APPLICANT'S
ADDRESS
41
MOTORS E
SERVICE CHANGE 2
LICENSED CONTRACTORS DECLARATION
TEMP. POLE Q .
I),
1 hereby affirm that I am licensed under provisions of Chapter 9
"ISSUAN 6 DIATE
(commencing with Section 7000) of Division 3 of the Business and
Professions Co n r1U' license is in full for d feet.
LicenseC ss `r� Lic. Number 6
BLDG. ELECT. PLG. MECH.
(�,qB (1
Q "[J' -
Date Contract
BUILDING PERMIT
OWNER -BUILDER DECor N
I hereby affirm that 1 am exempt from the Contractor's License
Law forthe followingreason. (Sec. 7031.5, Business and Professions
Coda: Any city or county which requires a permit to construct, alter,
improve, demolish, or repair any structure, prior to its issuance, also
INFORMATION
MISC. — REFER TO ORD
VALUATION
PERMIT ISSUANCE 19'OQ
ELEC. CONTR. LIC. NO.
ELEC Q
requires the applicant for Such permit to file a signed statement that
he is licensed pursuant to the provisions of the Contractor's License
TOTAL /u
PERMIT TO
QTY. PLUMBING PERMIT FEE
Law (Chapter 9 (commencing with Section 7000) of Division 3 of the
Business and Professions Code) or that he is exempt therefrom and
the basis for the alleged exemption. Any violation of Section7031.5
11MI Al
STORIES
CONSTR.
by any applicant fora permitsubjects the applicant to a civil penalty
ofnot more than five hundred doliars($500)J:
ALTER -DRAIN -WATER (EA.) 5.00
❑ 1, as owner of the property, or my employees with wages as
their sole compensation, will do the work, and the structure is not
BACK F LOW PROTECT. DEVICE 4.00
1 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 an owner of
property who builds of improves (hereon, and who does such work
F IXTUR ES - PER TRAP 5.00
SO, FT. FLOOR AREA
TOTAL ACREAGE
himself or through his own employees, provided that such improve-
ments are not intended or offered for sale. If, however, the building
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 im.
prove for purpose of sale.).
❑ I, as owner of the property, am exclusively contracting with
GAS - EA. SYSTEM - OVER 4 (EA.) 2.00
BUILDING USE
RES IND CON PB Omer
❑ ❑ ❑ ❑ ❑
INDUSTRIAL WASTE INTER. 30.00
LAWN SPRINKLERS- 1 INC 5 V.B. 6.00
LAWN SPRINKLERS -OVER bkW 1.00
ASSESSORS PARCEL NO.
licensed contractors to construct the project (Sec. 7044, Business
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 contractors) licensed pursuant to
the Contractor's License Law.
SEWER -SANITARY -STORM EA. 200ft/1
TRACT NO.
PARCEL N0.
❑ Iamexemplineler SeB.&P.C. for this
reason
WATER HEATER W/VENT
Owner Dale
WATER SYSTEM 5.0
ACC. GATE
ACG FILE NO.
WATER TREATING EQUIP.
WORKERS'COMPENSATION DECLARATION
1 hereby affirm that I have a certificate of consent to self -insure,
or a certificate of Workers' Compensation Insurance, or a certified
ZONING
ENG. SITE NO.
copy thereof (See. 3800, Lab.C.).
Policy N-02 552itl'ompany GFp,1,52A L ALC .
=c fled co is llere mtshed.
❑ Certh is tiler with the city inspection division.
Applicant r, ', L—IQLr �
FIRE SPRINK
Y ❑ N❑
ENERGY T 24
Y ❑ N❑
MISC. - REFER TO ORD.
-
CER I 1 ATE OF EXEMPTION FROM WORKERS'
PERMIT ISSUANCE .i0:A0 & CN
FLOOD ZONE
A.L.U.G.
COMPENSATION INSURANCE
(This section need not be completed if the permit is for one
PLG. CONTR. - LIC. NO.PLG.
TOTAL 0 rA,
v ❑ N ❑
Y ❑ N❑
QTY. MECHANICAL PERMIT FEE
FEE SUMMARY
hundred dollars ($100) or less)
I certify that in the performance of the work for which this per-
mit is issugd, I s all not employ any person in any manner so as to
BUILDING'
become so 'el eWorkers'Compensution Laws of California.
Date Applicant
NOTICE (CANT: If, after making this Certificate of Ex-
ALTER OR ADD TO MECH. 5.00
APPLIANCE 5.00
PLAN CHECK
emption, yo hould 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.
FEE
AIR HANDLING UNIT (TO 10000C.F.M.) 4.00
AIRHANDLING UNIT(OVER 10=C.F.M.) 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 wgrk for which ibis permit is issued (Sec.
3097, Cni C.I /
MICROFILM
HEATING UNIT (TO 100,000 B.T.U.) 8.00
HEATING UNIT (OVER 100,000 B.T.U.)9.50
ELECTRIC
�.'.��
Lender's Name n� -
Lender's Addre
I 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 state laws relating to building construction, and
VENTILATION FAN (SINGLE) 4,00
PLUMBING
C 4
Q
BOILER- COMPI3H.P, Gr100,000 B.T.U.) 6.00
BOI LER-COMP (Over 100,000 BTU) SEE FEE SCH.
MECHANICAL
hereby authorize representatives of this city to enter upon the
above-mentioned property for inspection purposes.
MISC. - REFER TO ORD.
CONST. TAX
(We) agree to save, indemnify and keep harmless the City of
Cupertino against liabilities, judgments, costs and expenses which
may in any I accrue against said City in consequence of the
granting t p rmit
c
PERMIT ISSUANCE 10.00
MECH. CONT. LIC. NO.
MECH.
TOTAL
TOTAL
7tiz L�
Signa r Applicant/Contractor Date
.t
OFFICE COPY