C8204APPLICANT TO FILL IN INFORMATION WITHIN RED LINES -USE BALL POINT PEN ONLY
BUILDING PROJECT IDENTIFICATION
APPLICATION & PERMIT
PERMIT NUMBER
i"�/OWNER
not LDING
ADDRESS
Z
BUILDING - ELECTRICAL-PLUMBING-.MECHANICA8204
-
'5
NAME /aJ 0
)411-6
QTY. ELECTRIC PERMIT FEE
,UTLETSeSWITCHES-RECEP
PLAN CHECK VALIDATION
NAME AcrDR's
10.00/1.00
44 LIc. NO.;!971zl
LIGH,T.ING FIXTURES 10.00/1.00
ADDEssiDRsa6R
PPLIANCES- RESIDENTIAL 4.00
PANELS 10,00
' PRONE 94fl-,7Z77
DATE OF APPLICATION
ARCHITECT
OR
O
ENGINEER
• LIC. No.
PANELS (OVER 200 AMP) 20,00
PLAN CHECK FEE P.C. NO.
SIGNS TRANS. 3.00
ADDDRESS ENG'
SPECIAL CIRCUIT 5.00
PERMIT VALIDATION
ZIP
EMP. METER OR POLE INS, 20.00
/�
, Ips
0
APPLICANTS
Z/Ja�
AooREss fp
- '- 514 SS
MOTORS SEE FEE SCH.
SERVICE CHANGE 20.00
LICENSED CONTRACTORS DECLARATION
TEMP. POLE 30.00
I 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 in full force and effect.
LicenMse Class / • / �- Lic. Nunlher 98;7/ Z
_GT. Contract...
ISSUANCE DATE
BLDG.
El
ELECT.
1:1
PLG. MECH.
11Date
BUILDING PERMIT
INFORMATION
'O_WNNER-BUILDER DECLARATION
I hereby collo that I so exempt frp.5 the Contractors License
Code:Law Any citylowingreywhichrequire a perm5. it errand Professions
Code: Any cur os coo my it any structure permit toconstruct.
improve, demolish. Dr repair any structure, prior to its issuance, also
uance, also
lie is les elle applicant for such permit to file a signed actor's i that
he is licensed pursuant to the provisions of the Contractor's License
Law (Chapter 9kowith atio7on3of the
Business and Professions Code) or that he , exemptthercltom and
MISC.- REFER TO ORD
VALUATION
$/FT.
PERMIT ISSUANCE 1000
ELEC. CONTR. T. LIQ N0.
ELEC.
TOTAL
PERMIT TO
/
QTY. PLUMBING PERMIT FEE
STORIES
TYPE CONSTR.
thenyapor Any violation of Section 703L5
by any applicant l'orupevnerl dollars the epplicant toacivil penalty
applicantI.,a permitPbjc
of not more than five hundred dollars 15500).1:
ALTER-DRAIN-WATER(EA.) 5.00
❑ h as owner of the property, or my employees with wages as
their sole compensation, will do the work, and Llie Structure is not
intended or offered for sale (Sec. 7044, Business and Professions
BACK FLOW PROTECT. DEVICE •4.00
OCC. GROUP
RES. UNITS
DRAINS -FLOOR, ROOF, AR EA, COND. '5.00
Code: The Contractor's License Law docs not apply to an owner of
property who builds or improves thereon, and who does such work
himself or through his own employees, provided that such improve-
mentsarenetintehdedorofferedforsale. If. however, the building
_
FIXTURES - PER TRAP 5.00
SO. FT, FLOOR AREA
TOTALACREAGE
GAS - EA. SYSTEM -9,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 int-
prove for purpose of sale.).(. r I -'•
❑ I, as owner of the property, um exclusively contracting with
GAS - EA. SYSTEM -OVER 4 IEA.( 2:00
BUILDING USE
RES IND CON Pe Omer
❑ ❑, ❑ ❑ ❑
INDUSTRIAL WASTE INTER. 3.0.00
licensed contractors to construct the project (Sec. 7044, Business
and Professions Code: I he Contractor's License Law does not apply
LAWN SPRINKLERS - 1 INC 5 V.B. 6.00
ASSESSORS PARCEL NOV
to an owner of property who builds or improves thereon, and who
LAWN SPRINKLERS - OVER 5 (EA.) 1.00
contracts for such projects with a contrneun(s) licensed pursuant to
the Connector License Law.
❑ lam exempt under Se ,B.&P.C. for this
reason
SEWER -SANITARY -STORM EA. 200ft/10.00
TRACT NO.
PARCEL No.
WATER HEATER W/VENT 6.00
Owner Date
WATER SYSTEM 5.00
ACC. DATE
ACC. FILE NO.
WATER TREATING EQUIP. 5.00
WORK ERS'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 there ro*3001 Lab. .1.
Policy No 'may/ q
FIRE SpRINK
Y ❑ N ❑
ENERGY T24
V ❑ N❑
❑ Cerllfi�a treby lumished.
Q/Cerci(((IIId �upy is f� th the y inspection division.
Apel....fE &k021 4C_-
MISC.- REFER TO ORD.
CE ICATE OP EXEMPTION FROM WORKERS'
PERMIT ISSUANCE 10.00
FL000 zoNE
A. L.u.c.
COAIPENSATION INSURANCE
(This section neer) not be completed if the permit is for one
PLG. CONTR. LIC. NO.
PLG.
TOTAL
V ❑ N❑
Y ❑ N❑
hundred dollar, IS100) or less.)
1 ecril'y that in the performance W tire work•for which thin per-
mit is issued, I shall not employ any person in any manner I, as to
QTY. MECHANICAL PERMIT FEE
FEE SUMMARY
BUILDING
ajJ
become subject to the Workers' Compensation Laws of California.
Dau.' Applicant
ALTER OR ADD TO MECH. 5.00
NOTICE TO APPLICANT: If, atter ..laking this Cer iflcale of Ex-
a
emption, you should become subject to the Workers' Compensation
provisions of D, Labor Code, you must forthwith comply with
such provisions or this permit shall be deemed revoked.
APPLIANCE 5.00
AIR HANDLING UNIT (TO IO,CODC.F.M.) 4.00
PLAN CHECK
FEE
t0j
AIR HANDLING UNIT(OVER 10=C.F.M.) 6.00
SEISMIC FEE
CONSTRUCTION LENDING AGENCY
1 hereby art...I that Deere is a construction lending agency lot
EXHAUST HOOD (WITH DUCT) 5.00
the performance of the work for 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
H EATI NG LIN IT (OVER 100,000 B.T.U.) 9.50
ELECTRIC
1 certify that I have read this application and state that the above
VENTILATION FAN (SINGLE) 4.00
information is correct. I agree to comply with all city and county
ordinances and state laws ,rating to building construction, and
PLUMBING
BOILER-COMP(3 H.P. or 100,000 B.T.U.) 6.00
BOILER -COMP (Over 100,000BTUISEEFEESCH.
MECHANICAL
henay aWhorizt represenimives of this city to enter upon the
above-mentioned property for inspection purposes.
(We) agree to save, indemnify send keep harmless the City of
Cupertino against liabilities, judgments, Cosa and expenses which
may_ n any way xecme against said City in consequence of the
ranti Sof thi per it.
MISC. - REFER TO ORD.
CONST. TAX
PERMIT ISSUANCE 10.00
MECH. CONT. LIC. NO.
MECH.
_ - 5
TOTAL
TOTAL
-7
atere of Applicml/Contractor Date
INSPECTOR COPY _\