8695APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
BUILDING PROJECT IDENTIFICATION
APPLICATION & PERMIT
BUILDING -ELECTRICAL -PLUMBING -MECHANICAL
;PERMIT NUMBER
r
o "9
`/� 111 V5
HOLDING
ADDRESS Cl
30� _µ��{Z
OWNER'S
NAME
QTY. ELECTRIC PERMIT FEE
PLAN CHECK VALIDATION
45 PHONE
NAME acroRs -
pFi'Tr�3o��
UTLETS-SWITCHES -RECEP 10.00/1.00
uc. No.
LIGHTING FIXTURES 10.00/1.00
ADDRESSTOR's
APPLIANCES -RESIDENTIAL 4.00
PANELS 10.00
(� �J PHONE �O
DATE OF APPLICATION
ARCHIT,
OR
ENGINEER
LIC. No.
PANELS 200 AMP) 20.00
PLAN CHECK FEE P.C. NO.
SIGNS TRANS. 3.00
ADDRESS EN
ZIP
SPECIAL SPECIAL CIRCUIT 5.00
PERMIT VALIDATION
�./
/'�
TEMP. METER OR POLE INS. 20.00
ADDRESS
aoR Ess
MOTORS SEE FEE SCH.
SERVICE CHANGE 20.00
V (i
�(,�P'�([]
LICENSED CONTRACTORS DECLARATION
TEMP, POLE 30.00
I hereby affirm that 1 ons licensed under provisions of Chapter 9
(commencing with Section 7000) of Division 3 of the Business and
Professions Cade, and my license is in full force and effect.
License Class /2 .. Gl r- Lic. Number
VSSVANCE DATE
BLDG.
❑
ELECT.
❑
PLG. MECH.
❑ ❑
Dale �Conlruclor
BUILDING PERMIT
INFORMATION
OWNER-Bm1.DER DECLARATIOi
7 from the Con Vac, ors License
I hereby aollo that I nm ex (See
Law for theity following Pei (Sea 7031.5.ermit I.codlruct.aer.
Coda: Any city or county which requiresa permit toconslrucL alter,
imprnve, demolish. nr repair any structure, prior to its issuance, also
the applicant for such revisit to fila a signed statement that
requires ilicensed
he is licensed 9 (comm en the ng with
provisions of Ore Contractors 3 of the
Law (Cha and the of o of the
Business and Professionsxempt or that he is exempt therefrom and
Professions Code) or Section is 00) exempt
MISC.- REFER TO ORD
PERMIT ISSUANCE 10.00
VALUATION
^l
$/FT.
ELEC. CONTR. LIG. NO.
ELEC.
TOTAL
PERMIT TO
S /�,,, /
_ v
QTY. PLUMBING PERMIT FEE
STORIES
TYPE CONSTR.
Ole basis for the alleged exemption. Any violation of Section 703L5
by any applicant Cora permit subjects theS500h.limmtOacivil lxnalty
of not more than five hundred dollars (5500)J :
.-
ALTER-DRAIN&VENT-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 FLOW PROTECT. DEVICE 4.00
OCC. GROUP
RES. UNITS
DRAINS -FLOOR, ROOF, AREA, COND. 5.00
intended or offered for sale (Sea 7044, Business and Professions
Codu The Contractor'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 elnployees. provided that such imprnve
mems are not intended or offered for sale, If. however, the building
-
FIXTURES - PER TRAP 5.00
SO. Fr. FLOOR AREA
TOTAL ACREAGE
GAS - EA. SYSTEM - I INC. 4 OUTLETS 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 ofsale.).
❑ I, as owner of Oar property, am exclusively contracting with
GAS - EA. SYSTEM - OVER 4 IEA.) 2.00
BUILDING USE
RES IND CON PB Other
❑ ❑ ❑ ❑ ❑ (�
. .
INDUSTRIAL WASTE INTER3000
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 will) a eontmetorls) licensed pursuant m
the Contractor's License Luw,
LAWN SPRINKLERS - 1 INC 5 V.B. 6.00
LAWN SPRINKLERS - OVER 5 (EA.) 1.00
ASSESSORS PARCEL NO.
SEWER -SANITARY -STORM EA. 200tt/10.00
TRACT NO.
PARCEL NO.
❑ lamexemPltlllder Sea - ,B.&I',C.Ibrlhls
reason
T WATER HEATER W/VEN6.00
Owner '� Date
WATER SYSTEM 5.00
ACC.DATE
ACC. FILE NO.
WATER TREATING EQUIP. 5.00
WLRKERS' COMPENSA'I ION DECLARATION
I 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 thmebf (Sec. 3800, Lab.C.).
Policy No. Company
I
FIRE SPRINK
v❑ N
ENERGY T-24 t
v❑ N❑
❑ Ce ed copy' is hereby Iumiehed.
eortificd copy�q filed with lm ity� inspection division.
A Icant� /� ,
MISC.- REFER TO ORD.
�g
CF.R'I'IFIIICCAATTEE OF EXI MPFION FROM WORKERS'
PERMIT ISSUANCE 10.00
FLOOD ZONE
A_L.U, C.
COMPP.NSA'1'ION INSURANCE
('Phis section need not he conmlelM if the permit N lar one
PLG. CONTR. ❑C. NO.
PLO,
TOTAL
Y ❑ N❑
Y ❑ N❑
hundred dollars ($100) or less I
I certify that in the performance of the work for which this per-
(nit is issued, I shall not employ ally person in any manner so as to
QTY. MECHANICAL PERMIT FEE
FEE SUMMARY
BUILDING
Q ..5�
become subject to the Workers' Compensation Laws of California.
Date Applicant
ALTER OR ADD TO MECH: 5.00
NOTICE TO APPLICANT': if. after making this Certificate of Ex-
emption, you should become subject to the WorkersCompensation
provisions of the Labor Code, you must forthwith comply with
such provisions or this permit shall be deemed revoked.
APPLIANCE 5.00
AIR HANDLING UNIT (TO 10=C.F.M.) 4.00
PLAN CHECK
FEE
.?
AIR HANDLING UNIT (OVER 10=C.F.M.) 6.00
SEISMIC FEE
�C)
CONSTRUCTION LENDING AGENCY
I busby affirm that there is a construction lending agency I'nr
EXHAUST HOOD (WITH DUCT) 5.00
tire30 7aCiv,I.rCtance of the work for which this permit is isvued fSec.
MICROFILM
'
HEATING UNIT (TO 100,000 B.T.U.) 8.00
Lender's Node
Lender's NamAddrew
HEATI NG UNIT (OVER 100,000 B.T.U.) 9.50
ELECTRIC
V
I I haul read (his application and state that the above
VENTILATION FAN (SINGLE) 4.00
information is
Ordina ccs n correct. I agree ti comply with all city and county
ordinances and state 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 SCM.
MECHANICAL
hereby authorize representatives this City to ewer upon the
above-mentioned property for inspection purposes.
MISC. - REFER TO ORD.
(We) agree to save, indemnify and keep harmless the City of
Cupertino against liabilities, judgments, costs and expenses which
,tiny in any way area a against said City in consequence of the
PERMIT ISSUANCE 1000
.
CONST. TAX
grunt lig of p miL I
:d
MECH. CONT. LIC. NO.
MECH.
TOTAL
TOTAL
3
S na r of Applicant/ ontractor Date
INSPECTOR COPY