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APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
13U I LDI NG PROJECT I DENTIFICATI ON
APPLICATION & PERMIT
BUILDING - ELECTRICAL- PLUMBING _MECHANICAL
PERMIT NUMBER
6258
BUILDING
DDRESS
OWNER '$ IPLAN
CHECK VALIDATION
NAME /
OTY. ELECTRIC PERMIT FEE
D r49W12E
NAME AcroRsx
�f _
UTLETS-SWITCHES-RECEP 5.00/1.00
LI TING FIXTURES 5.00/1.00
49 toVi ,,Vij
OLidYso
CONTRACTOR' `. /
ADDRESS a INb
APPLI NCES -RESIDENTIAL 4.00
PANELS 5.00
p i
7
V R NEL y
DATE OF APPLICATION
ARCHITECT i
OR
ENGINEER
uc. No.
SIGNS 6.00
PLAN CHECK FEE P.C. NO.
SIGNS TRAN 3.00
ARCH,OR ENG.
ADDRESS
SPECIAL CIRCLIX 5,00
PERMIT VALIDATION
TEMP. METER OR LE INS. 15.00
ZIP
Are.. CAS ES4
A00
MOTORS SEE FEE SCH.
SERVICE CHANGE 10.00
�(
LICENSIE1) CONTRACTORS DIECLARA'I'ION
I
I hereby affirm that 1 am licensed under provisions of Chapter 9
ISSUANCE DATE
(commencing with Section 7000) of Division 3 of the Busi •ss and
Professions aZj sl license is in full tore 4 f , f
License Cla Lie Number
BLDG. ELECT.
❑ ❑
PLG. MECH.
❑
Date onlractor
BUILDING PERMIT
OWNER -BUILDER DECLARnnoN
hereby collo, that I am exempt from the Contractor',dPo License
U. ti A nycitlloriounty T.(See703 quires S,Businessund Professions
permit IOconstant,al ter,
Cody. Any city or county which structure,
or repair any anti toff prior n its issuance. also
requires, he applicant for such permit file a signet actor's i that
requires tired Pursuant
heir CImple 9(com to the provisions of clic )ofDnixion License
Law (Ch and Professions Codeng ) or Section is exemftItierchomfthe
Business and Code) or that he is exempt Ice and
INFORMATION
MISC. - REFER TO ORD
VALUATION
SIFT.
PERMIT ISSUANCE 6.00
ELEC. CONTR. UC. N0.
ELEC.
TOTAL
PERMITTO
a
T%L (fM V/N�
t
DTV. PLUMBING PERMIT FEE
STORIES
TYPE CONSTR.
ion 70
the basis for the alleged exemption. Any violation I(Seclion 7031.$
he alleged
ALTER -DRAIN & VENT -WATER (EA.) 4.00
by any applicant for a permit subjects the applicant toa civil penalty
If not more than Ove hundred dollars (S5000.):
❑ 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 F LOW PROTECT. DEVICE 2.00
OCCGROUP
RES. UNITS
DRAINS -FLOOR, ROOF, AREA, COND. 4.00
intended or offered for sale (Sec. 7044, Business and Professions
Code: The Contractor's License Law does not apply to an owner of
property whit builds or improves thereon, and who does such work
SO. FT. FLOOR AREA
TOTAL ACREAGE
FIXTURES - PER TRAP 4.00
himself or through his own employees, provided that such improve-
ments ore not intended or offered for sale. If, however, the building
GAS-EA.SYSTEM-11NC.40UTLETS 4,00
or unprovement.is sold within one year of completion, the owner-
builder will have the burden of proving that he did not build or im-
prove lot purpose of sale.).
O I, as Owner Of the Property, am exclusively c nt,.mctlllg with
GAS - EA. SYSTEM -OVER 4 IEA.) 1.00
BUILDING USE
RES IND CON PB Other
INDUSTRIAL WASTE INTER. 20.00
LAWN SPRINKLERS - 1 INC 5 V.B. 5.00
LAWN SPRINKLERS - OVER 5 (EA.) 1.00
ASSESSORS PARCEL NO.
Ilccnscd cunlmctu[1't0 construct the Project (Sec 7044, Business
and Professions Code The Contractor's License Law docs not apply
m ml ownet of properly who builds Or improves thereon, and who
contracts for such projects with a contract Orfs) licensed pUstert lu
the Contractors License Law.
SEWER -SANITARY -STORM EA. 200ft/8.00
TRACT No.
PARCEL NO.
❑ I am exempt under Sec. .B;&P.C. for this
reason
WATER HEATER W/VENT 4.00
Owocr Dale
WATER SYSTEM 4.00
ACC. DATE
ACC. FILE NO,
WATER TREATING EQUIP. On
WORKIERS'COMPENSATION DECLARATION
I hereby afro... that I have a certificate ofconsenl to self-insmc,
or a el'ltlflCaleOr W'Or ffa�nSallOnOmpeIn 1 a [ a cl it'd
copy thereof' (Scc. 3800. Lab.C.).
cill
ZONING
ENG. SITE NO.
Policy No. COmpeny
Cl Cenilied'opyjshe .�u�l)yd /1
QiCfrti He ca Y Is 1 d I1✓/ 1' y INpeclion Division.
nl j /
FIRE SPRINK
Y ❑ IN
ENERGY T24
Y ❑ N❑
MISC. - REFER TO ORD.
'I 11,1 ` 6 ON WORKERS'
PERMIT ISSUANCE 6.00
FLOOD ZONE
A.LUC.
ai
TITS INSURANCE,
1'I'hls seelidn reed net be completed if the pent it la for of s
PLG.CONTR. LIC. NO.
PLO
1,AL
V N
❑ ❑
V N
❑ ❑
'
OTY. MECHANICAL PERMIT FEE
FEE SUMMARY
hundred dolor, IS 100) or less.)
I eerlify that ei the performance of the work for which this per-
mit is issued, I shall not employ any person in any manner so as to
BUILDING
)[calms subjeCI IO the Workers' Compensation Laws Of California.
Dale App union
ALTER OR ADD TO MECH. 4,00
NOTICE 10 APPLICANT: 11, after making this Certificate of Ex.
emption, you should beconlcsubjfut lO the Workers' COmpensatiml
APPLIANCE 4.00
PLAN CHECK
provisions of the Labor Code, you must forthwith comply withFEE
such provisions or this permit shall be deemed revoked.
AIR DLING UNIT (TO 10=C.F.M.) 3.00
AIRH LINGUNIT(OVER 10p00C.F.M.) 5.00
SEISMIC FEE
CONST RUCTION LENDING AGENCY
EXHAUST OOD WITH DUCT) 2.00
I hereby affirm that there is a construction lending agency for
lire performance Of the work for which this permit is issued (Sec.MICROFILM
3097, Civ.CJ.
HEATING U T (TO 100,000 B.T.U.) 4.00
HEATING UNIT V ER 100,000 B.T.U.)7.50
ELECTRIC
Lender's Name
Lender's Address
I certify that l have read this application and state that the above
intornmlion is correct. 1 agree to comply with all city and county
ordinances and state laws relating to building construction, and
VENTILATION FA (SINGLE) 3.00
PLUMBING
BOILER - COW (3 H.P.O 00,000 B.T.U. 4.00
BOILER -COMP IOver 100. BTUI SEE FEE SCH.
MECHANICAL
hereby authorize representatives of this city to enter upon the
above ... cption,d property Ibr inspection purposes.
MISC. - FER TO ORD.
(We) agree to save: indemnify and keep Imnnless the City of
Cupertino against liahllities, judgments, costs and expenses which
may in any w_ny, a 11G� against aid City in consequence OIthe
CONST. TAX
PERMIT ISSUANCE 3.00
CH. CONT. LIC. NO.
MECH.
lingo(•
�
AL
TOTAL
S' alar• Date
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