8379APPLICANT TO FILL IN INFORMATION WITHIN RED LINES- USE BALL POINT PEN ONLY
BUILDING PROJECT IDENTIFICATION
APPLICATION & PERMIT
BUILDING - ELECTRICAL- PLUMBING - MECHANICALTOR
PERMIT NUMBER
8379
B.ILDIN ��08�
I "e �1 _ 16, �-
OWNERS
-
PLAN CHECK VALIDATION
NAME
QTY. ELECTRIC PERMIT FEE
NAME crag's
NAM[
OUTLETS -SWITCHES-RECEP 10.00/1.00
LIGHTING FIXTURES 10.00/1.00
••�•• Lic. 3.3�� i
ADcrons
ADDRES
ORESS
PPLIANCES- RESIDENTIAL 4.00
PANELS 10.00
wyT PHONE ,g
DATE OF APPLICATION
ARCHITECT I
OR
ENGINEER
LIC. No. 2 Z
PANELS (OVER 200 AMP) 20,00
PLAN CHECK FEE P.C. NO.
SIGNS TRANS. 3.00
ADDRESS sea -
SPECIAL CIRCUIT 5,00
PERMIT VALIDATION
TEMP. METER OR POLE INS.
37 •_ ZIP
/
AooRess Ts
9
MOTORS p SEE FEE SCH.
SERVICE CHANGE 20.00
LICENSED CONTRACTORS DECLARATION
TEMP. POLE 30.00
1 hereby affirm that I am licensed under provisions of Chapter 9
(commencing with Section 7000) of Division 3 of the Business and
Professions code and my license is iu toll Iitr -and fl7ect. ��
License Class_._ Lie . Nwnhcr- 7.-2.L `�
Datc_a1�C_a� Con[raclor
OWNER-BUILDER DECLARATION
1 hereby collo that J an exempt from the Contractor's License
Law Code: Any city or conyw hicSec.70]1. 5, tlusit to ants Professions
tru tune Penni[ toconstruct, renatleq
Code: Any city or county which structure,
improve, demolish, or repair any strut turf, 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
ISSUANCE DATE
BLDG. E�LEGT
PLG. MECH.
B I D NG PERMIT
INFORMATION
MISC.- REFER TO ORD
PERMIT ISSUANCE 10.0 r
VALUATION
$/FT.
ELEC. CONTR. LIC. N0.
TOTAL
TOTAL
PERMIT TO
OTV. PLUMBING PERMIT FEE
Law (Chapter 9 (emnmencing with Section 7000) of Division 3 of the
Business and Professions Code) or that he is exempt therefrom and
Q
ORIES
TYPE CONSTR.
the basis for the alleged exemption. Any violation of Section 7031.5
by any applicant for a permit subjects the applicant to it civil penally
of not Inure than five hundred dollars (S500).):
ALTER -DRAIN -WATER IEA.) 5.00
❑ I, as owner of Ore 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
REB. UNITS
DRAWS -FLOOR, ROOF, AREA, COND. 5.00
intended or offered for sale (Sec. 7044, Business and Professions
Code: The Contractor's License Law does nos apply to an owner of
properly who builds or improves thereon, and who docs such work
himself or through his own employees, provided that such fntprove-
ments are not intended or offered for sale. IL however, the building
FIXTURES - PER TRAP 5.00
SO, FT FLOOR AREA
TOTAL ACREAGE
GAS - EA. SYSTEM -11INC. 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 int
prove for purpose ofsale.).
❑ I, as owner of lire property, am exclusively contracting with
GAS - EA. SYSTEM - OVER 4 IEA.) 2.00
BUILDING USE
'RS IND CON PB Omer
❑ El 13 11
INDUSTRIAL WASTE INTER. 30.00
LAWN SPRINKLERS - 1 INC 5 V.B. 6.00
LAWN SPRINKLERS - OVER 5 (EA.) 1.00
licensed contractors to construct the project (Sec 7044, Business
and Professions Code: I lie Contractor's License Low docs not apply
to an owner of property who builds or improves thereon. and who
1 ASSESSORS PARCEL NO.
contracts for such projects with a contractors) licensed pennant to
tire Contractor's License Law.
SEWER -SANITARY -STORM EA. 200ft/10.00
TRACT No.
PARCEL NO.
❑ lain exempt under Sec. ,B.&P.C. for this
WATER HEATER W/VENT 6.00
reason
Owner Date
WATER SYSTEM 5.00
ACC. DATE
ACC. FILE NO.
WATER TREATING EQUIP. 5.00
WORKERS'COMPENSATION 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 thereoflSec. 3800, Lab.C.).'
Policy No. Company
FIRE SPRINK
YE] NE]
ENERGY T 24
Y❑ NE]
❑ Certified copy is hereby furnished.
❑ Certil'ict copy is filed with 0 c cit' inspection division.
Applic
CIiRTIFICA'Tf>OI' l\EMPTI(N PROM WORKERS'
MISC.- REFER TO ORD.
PERMIT ISSUANCE 10.00
FLOOD ZONE
A.L.u.c.
PLG. CONTR_ LIC. NO.PLG.
TOTAL
• COMPENSATION INSURANCE
]'his section need not he completed if the permit is for one
y� N�
V� N❑
hundred dollars IS 100) or Iessr
I certify that in the performance of the work for which this per
mit is issued. I shall not employ any person in any manner so as to
OTV MECHANICAL PERMIT FEE
FEE SUMMARY
BUILDING
become subject to the Workers' Compensation Laws of California.
Date Applicant
ALTER OR ADD TO MECH. 5.00
NOTICE '10 APPLICANT: If, after making this Certificate of Ex-
APPLIANCE 5.00
PLAN CHECK
emption, 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.
FEE
AIR HANDLING UNIT (TO 10=C.F.M.) 4.00
AIR HANDLING UNIT(OVER 10=C.F.M.) 6.00
SEISMIC FEE
CONSTRUCT ION LENDING AGENCY
I hereby affirm that there is a construction lending agency for
EXHAUST HOOD (WITH DUCT) 5.00
rniance of tire work for which this permit is issued (Sec.
the ere3097.
MICROFILM
HEATING UNIT (TO 100,000 B.T.U.) 8.00
Lenndeedr's Name
r's Addle Less
HEATI NG UN IT (OVER 100,000 B.T.U.) 9.50.
ELECTRIC
� �U
1 certify that I have read this application andstate the above
VENTILATION FAN (SINGLE) 4.00
Information is co uccl. I agree to comply with all citythat and county
ordinances and stat, luws relating to building construe lion, and
PLUMBING
BOILER-COMP13 H.P. or 100,000 B.T.U.) 6.00
BOILER -COMP (Over 100,000 BTU) SEE FEE SCH.
MECHANICAL
hereby authorize representatives of this city to enter upon the
above-Inentioned property for inspection purposes.
MISC. - REFER TO ORD.
(We) agree to save, indemnify and keep harmless the City of
Cupertino against liabilities, judgments, costs andexpenses which
may in any way accrue against said City in conseyucnce of the
CONST. TAX
PERMIT ISSUANCE 10.00
granting of this permit.MECH.
CONT. LIC. NO.
MECH.
_
TOTAL
TOTAL
IBI ur tfApplican ac D'Ic
INSPECTOR COPY