C9240APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
BUILDING PROJECT IDENTIFICATION
& PERMIT
BUILDING -ELECTRICAL- PLUMBING -MECHANICAL
PE IT NUMBER
8240
BUILOINGAPPLICATION
ADDRESS ^M'••-
OWNER'5
NAME al LL_
d 3.7�
/) GHON
QTY. ELECTRIC PERMIT FEE
PLAN CHECK VALIDATION
CONTERACTORS /
UTLETS-SWITCHES -RECEP 10.00/1.00
LIGHTING FIXTURES 10.00/1.00
L_._S LIC. NO.
COD NTRA RRAcrOR's
ADDRESS
APPLIANCES,- RESIDENTIAL 4,00
PHON99p'- ZZ2.PANELS
DATE OF APPLICATION
10.00
ARCHITECT
OR
ENGINEER
LIC.NO.
PANELS (OVER 200 AMP) 20.00
PIAN CHECK FE7 P.C. NO,
SIGNS TRANS. 3.00
DURESS ENG.
A
SPECIAL CIRCUIT 5.00
PERMIT VALIDATION
TEMP. METER OR POLE INS. 20.00
ZIP
.
,. '//
I 4 S
8/L
APPLICANT s
ADDDRESSDRESSMOTORS
1-725 TT
S; 7.
SEE FEE SCH.
SERVICE CHANGE 20.00
LICENSED CONTRACTORS DECLARATION
TEMP. POLE r 30.00
I hereby affirm that I am licensed under provisions of Chapter
I of Division 3 oftireof Business and
(commencing with Section frets,
P net v WS Code, and my li[¢115e 15111 fill] (Otte and e(fL'CL
' I-iccnse Class Lie Number
1
ISSUANCE GATE
BLDG. ELECT. PLG. MECH.
❑ ❑ ❑ ❑
G /T
Dutc_�� Contraau
BUILDING PERMIT
INFORMATION
OWNER -BUILDER DECLA RAS,Z011. f
�T' 6
I herby collo that I um exempt from the Contractor's Lssions
Law for tleity orc000lywhichrecuiresc penut essund Professions
ng reason. (See
Codi An ycityor coo nlywhiny Structureperms to its isamucalter.
improve, demolish, or repair any itructive, prior to its issuance, also
requires the applicant for Such perent to file a signed statement that
he is licensed pursuant to the provisions of the Contractor's License
Law (Chapter 9 (commencing with Section 70001 of Division 3 of the
Business and Professions Code) or that he is exempt therefrom and
MISC.- REFER TO ORD
PERMIT ISSUANCE 10,00 6,5.
VALUATION
cz0/ V0 �
g/FT.
ELEC. CONTR. LIC. NO.
ELEC.
TOTAL d.� UL
PERMIT TO
GTY. PLUMBING PERMIT FEE
the basis for the alleged uemption. Any violation ol'$eaion 703 L$
STORIES
TYPE CONSTR.
by any applicant for a permit subjects the applicant toe civil penalty
of not more than five hundred dollars (5500).):
ALTER -DRAIN (EA.) 5.00
• ❑ 1, as owner of the property, or Illy 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 (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 wlln does suCll work
hinlscH or through his own employees, provided that such improve-
mentsare let intend,,] proffered for sale. If, however, the building
FIXTURES - PER TRAP 5.00
SQ FT. FLOOR AREA
TOTAL ACREAGE
GAS-EA.SYSTEM-l1NC.4OUTLETS 6.00
or improvement is sold within one year of completion, the owner
builder will Have the burden o(proving that he did not build or int -GAS
-
prove for purpose ofsalc.).INDUSTRIAL
❑ I, as owner of the Property, v exclusively contracting with
GAS EASYSTEM OVER 4 (EA) 200
. -..
BUILDING USE
RES IND CON PB Omer
❑ ❑ ❑ ❑ ❑
. .
WASTE INTER3000 I
licensed contract.,., to construct the project (See 7044, Business
and Profusions Code: l'he Contractor's License Law docs not apply
to an owner of property who builds or improves thereon, and who
LAWN SPRINKLERS -I INC 5 V.B. 6.00
LAWN SPRINKLERS - OVER 5 (EA.) 1.00
ASSESSORS PARCEL NO.
_
contracts for such projects with a corrosions) licensed pursuant to
the Corrector's License Law.
SEWER -SANITARY -STORM EA. 200ft/10.00
TRACT NO.
PARCEL NO.
❑ I am exempt under Sec. ,B.&P.C. for this
reason
WATER HEATER W/VENT 6.00
OWllet Date
WATER SYSTEM 5.00
ACC.DATE
ACC. FILE NO,
WATER TREATING EQUIP. 5.00
WORK ERS'COMPENSATCN DECLARATION
1 hereby affirm that I have a certificate of consent to self -insure,
or a certificate of Workers' Compensation Insurance, or a certified
ENG. SITE NO.
^
copy thmcof IScc. 3800, Lab.C.).
Policy No.�•��fw. tfi{,any �I-ryp-H
❑ Ccrtl icdf coloyif'ah,mby (urnishcd
Certilie 'd pr w I the city inspeceti�on: �division.
❑ �
nlmlicanl.;SC'
'tp�ZONING
x
FIRE SPR INK
v ❑ N ❑
ENERGY T 24
Y ❑ N❑
MISC. - _REFER TO ORD.
CERI'IPICATE OF EXEMPTION PROM WORKLRS'
PERMIT ISSUANCE - 1-100., 41 K
FLOOD ZONE
A.L.uL.
COMPENSATION INSURANC17
(This section need not be completed if the permit is lot one
V N
❑ ❑
V N
❑ ❑
PLG. CONTR. LIC. NO.
PLG. / µ
TOTALa sp
lwndred dollars IS 100) or less.)
I certify that in lire performance of the work for which INS per-
mit is issued, I shall not employ any person in any manner sn as to
QTY. MECHANICAL PERMIT --FEE
FEE SUMMARY
BUILDING
�Q SZ
become subject to the Workers' Compensation Laws of California.
Date Applicant
'10
ALTER OR ADD O MECH. 5.00
NOTICE APPLICANT: If, after making this Certificate of 1>x-
emption, you should become subject to rte Workers' Compensation
provisions of the Labor Code, you must forthwith comply with
such provisions or this permit shall be deemed Smoked.
APPLIANCE J5.00 U U
AIR HANDLING UNIT (TO 10=CF.M.) 4.00
PLAN CHECK
FEE
AIR HANDLING UNIT(OVER 10MC.EM.)6.00
SEISMIC FEE,
�V
CONSTRUCTION LENDING AGENCY
EXHAUST HOOD (WITH DUCT) 5.00
I hereby affirm that there is a construction lending agency for
(lieImrforc'anee of the work for which this permit is i.,sued (Sec.
3097.
MICROFILM
HEATING UNIT (TO 100,000 B.T.U.) 8.00
Lender's Name
LcnJcr's Andress
HEATING UNIT (OVER 100,000 B.T.U.)9.50
'ELECTRIC
I certify that I have read this application and state that the above
VENTILATION FAN (SINGLE) 4.00
1-
infornlation is correct 1 agree to comply with all city and county
ordinances and state laws relating to building construction, and
•PLUMBING
C{%
BOILER -COMP 13 H. P. Or 100,000 B.T.U.1 6.00
BOILER -COMP IOver 100,000 BTU) SEE FEE SCH.
MECHANICAL_-
hereby authorize representatives of this city to enter upon the
above-memianed property for inspection purposes.
(We) agree to save, indemnify and keep harmless the City of
Cupertino against liabilities, judgments, costs and expenses which
may in any way accrue ins( Said City in consequence of the
MISC. - REFER TO ORD.
CONST. TAX
PERMIT ISSUANCE dA"rBB ,I
gfantln h�-mi
MECH. CONT. LIC. NO.
MECH.
'
TOTAL S'7rt�
TOTAL
qq
gnature A p I ac or Lrid
INSPECTOR COPY