C8858APPLICANT TO FILL IN INFORMATION WITHIN RED LINES -USE BALL POINT PEN ONLY
BU LDI NG PROJECT 1 DENTI FICATI ON
APPLICATION & PERMIT
PERMIT NUMBER
BUILDING
ADDRESS
It��U
BUILDING - ELECTRICAL -PLUMBING -MECHANICAL
����
OWN 5
PLAN CHE VALI� N
N4mE
QTY. ELECTRIC PERMIT FEE
S�T�•
J�ry 1�0'
K PHONE 2
,T��'�nj1
fir' of CIU e&o
CONTRACTORS
HAVE _
OUTLETS-SWITCHES-RECEP 10.00/1.00
LIGHTING FIXTURES 10.00/1.00
uc. NO.Q-
CONTRACTOR
ADDRESS '.
PPUANCES- RESIDENTIAL 4.00
PANELS 10.00
tor vvffA BONE a ^
DATE OF APPLICATION
CHI
OR
ENGINEER
LIc.NO,
PANELS (OVER 200 AMP) 20.00
PLAN CHECK FEE P.C. NO.
L'
SIGNS TRANS. 3.00 U
ARCH.OR ENG.
SS
SPECIAL CIRCUIT 5.00
PERMIT VALIDATION
EMP. METER OR POLE INS. 20.00
ZIP
p
AS
ADDRESS
MOTORS SEE FEE SCH.
SERVICE CHANGE 20.00
LICENSED CONTRACTORS DECLARATION
TEMP. POLE 30.00
I hereby uffirnt that I am licensed under provisionsof Clmpter 9
(eonlmencing with Section 7000) of Division 3 of the Business and
Proferslnlls t.'Ode, and Iny license Is in lull I ..no and effect.
License Class �-/� Lic. Number�rl�.gg�
ISSUANCE DATE
BLDG.
ELECT.1
❑El
PLG. MECH.
❑
Date Contractor__
.BUILDING PERMIT
INFORMATION
OWNER -BUILDER DECLARATION
I hereby affrn tett 1 mm exempt flan, the Contractor's License
Law for the followingo,"on. (See. 7031.5. B minessand Professions
Code: Any city or county which requires a permit to construct, alter,
onpmve, demolish, or repair any structure, prior to its issuance, also
requires the applicant for such permit to file a signed statement that
he is licensed pursuant to the provisions of the Contractor's License
MISC. - REFER TO ORD
PERMIT ISSUANCE 10.00
EE
VALUATION
f % voO
$/FT.
ELEC. CONTR. LIC. NO.
ELEG.
TOTAL
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
STORIES
TYPE CONSTR.
the basis for the alleged exemption. Any violation of Section 7031.5
by any applicant for a permit subjects the applicant to a civil penalty
of not more than five hundred dollars ($500).)
ALTER -DRAIN -WATER (EA.) 5.00
t❑ 1, as owner of the property, or my employees with wages as
heir sole compensation, will do the work, and the structure is not
BACK FLOW PROTECT. DEVICE 4.00
OCC. GROUP
RES. UNITS
DRAINS -FLOOR, ROOF, AR EA, COND. 5.00
intended Or offered for sale (Sec. 7044, Business and Professions
Code: The Contractor's License Law docs not apply to an owner of
property who builds or improves thereon, and who docs such work
himself or through his own employees, provided that such improve-
mentsarenotintendedorofferedforsale. If. however, the building
or Improvement is sold within one year of completion, the owner-
builder will have the burden of proving that he did not build or int-
prove for purpose of sale.LiINDUSTRIAL
❑ 1, as owner of the property, am exclusively contacting with
FIXTURES - PER TRAP -� 5.00
SO, FT. FLOOR AREA
TOTAL ACREAGE
GAS-EA.SYSTEM-11NC.40UTLETSN6.00
GAS - EA. SYSTEM -OVER 4 (EA.) 2.00
BUILDING USE
RES IND CON RR Omer
E]F] ❑ ❑
WASTE INTER. �._,-30.00
licensed contactors m construct the project (Sec. 7044, Business
and Professions Cade: The Contractor's License Law does not apply
to an owner of property who builds or improves thereon, and who
contact for such projects with a cortractons) licensed pursuant to
the Contractor's License Law.
LAWN SPRINKLERS - 1 INC 5 V.B. 6.00
LAWN SPRINKLERS - OVER 5 (EA.) 1.00 k
ASSESSOR RCEL NO.
SEWER -SANITARY -STORM EA. 200ft/10.00 1
TRACT NO.
PARCELING.
❑ lumexcmplunder Sec. .BAP.C. for this
reason
WATER HEATER W/VENT 6,00
Owner Date
WATER SYSTEM _ �• X 5.00
ACC. DATE
ACF FILE N0.
WATER TREATING EQUIP. 5.00
WORKERS'COMPI"NSA TION DECLA RA'I'[ON
I hereby affirm that I hove a ccrtiticmu of onecnl to self -insure,
or It certificale of Workers' Compensation Insurance, or a certified
copy therent(Scc 3800, Lah.C.). ''..
ZONING
ENG. SITE NO.
Policy Nn. Con.punyr
FIRE SPRINK
ENERGY T 24
NE]
❑ Certifiedtt,ppy is hurEhyl lr, i11,1 .
ElCerI itc Iy Is I., with 11 y ns Choi division.
Applicant `}'i .E
--��{
MISC.-YE]NE]Y❑
C u /
f '
CYRTIFICA'IF OF EXEMPH NPROM WORKERS'
PERMIT ISSUANCE 10.00
FLOOD ZONE
A.L.U. C.
PLG. CONTE. LIC. NO.
PLG.
TOTAL
COMPFNSA7'ION INSURANCE
(This section need nal be completed if the permit is for one
Y ❑ N ❑
Y ❑ N ❑
hundred dollars IS 1001 or less.) '
I certify that in lire performance of the work for which this per-
mil 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.
Dam Ah Iicant
NOTICE TO APPLICANT': If, after making this Certificate of Ex -
eruption, 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.
APPLIANCE "` 5.00
PLAN CHECK
FEE
3 j
-
AIR HANDLING UNIT (TO JOSMC F.M.) 4.00
AIR HANDLING UNIT(OVER 10=C.F.M.) 6.00
SEISMIC FEE
yGU
CONSTRUCT ION LENDING AGENCY
1 hereby affirm that there is a construction lending agency for
EXHAUST HOOD (WITH DUCT) 5.00
the performance of the work lir which this permit is issued (Sec.
3097, Civ.C.).
MICROFILM
H EATING UN IT (TO 100,000 B.T.U.) 8.00
Lender's Name
Lender's Address
HEATI NG UN IT (OVER 100,000 B.T.U.)9.50
ELECTRIC
I certify that 1 have read this application and state that the above
VENTILATION FAN (SINGLE) 4.00
information is ....reel. I alone to comply with all city and county
ordinances and state laws relating to building construction, and
PLUMBING
BOILER-COMP(3 H.P. or 100,0008.T.U.) 6.00
BOILER -COMP (Over 100.000 BTU) SEE FEE SCH.
MECHANICAL
hereby aulhorite representatives of this city to enter 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, jud •mems, ,s IS and expenses which
may in any wa ecme alp.aid City in consequence of the
granting of it P.
P• nlit.
�? h n„ 0 -�
CONST. TAX
PERMIT ISSUANCE 10.00
MECH. CONT. LIF NO.
MECH.
TOTAL
TOTAL
3 3 �t 3
"-99
SFmAmu c Of Applhcnnt CootmeorC [)are
INSPECTOR COPY