8502APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
BU LD1 NG PROJECT I DENTI FICATI ON
APPLICATION & PERMIT
BUILDING - ELECTRICAL- PLUMBING - MECHANICAL
PERMIT NUMBER
8502
3WLDING
ADDRESS
o2O/ -;;'_04ER 45
OWNER'S•
NAME
�J�
DTV. ELECTRIC PERMIT FEE
PLAN CHECK VALIDATION
NOMTRAcroR-���/
OUTLETS-SWITCHES-RECEP 10.00/1.00
LIGHTING FIXTURES 10.00/1.00
DATE OF APPLICATION
ADDRESS ORE55 G t '
.
�J.1 PHONE
PPLIANCES- RESIDENTIAL 4.00
PANELS 10.00
AR HITECi
OR
ENGINEER
LIC. No.
PANELS (OVER 200 AMPI - 20.00
PLAN CHECK FEE P.C. NO.
SI GNS TRANS. 3.00
neo Ess ENG,
SPECIAL CIRCUIT 5.00
PERMIT VALIDATION
TEMP. METER OR POLE INS. 20.00
ZIP
ADDRESS ES
ADDS
MOTORS SEE FEE SCH.
S
SERVICE CHANGE 20.00/�.4o/d
LICENSED CONI RACTORS DECLARATION
TEMP. POLE 30.00
1 Imreby affirm that 1 am licensed under provisions of Chapter 9
(commencing with Section 7000) of Division 3 of the Busing andBLDG.
Professions Co an t license is in full force ant ec .
Class Lic. Number
ISSUANCE DATE
❑
ELECT.
❑
PLG. MECH.
❑ El
Date Conlracmr
BUILDING PERMIT
INFORMATION
dOwN : -BUILDER Ia:ct.n AT ��
I hcrchy affirm that 1 Din exempt from the Contractors License
Low lin the following reason. (Sec. 7031.5, Businessand Professions
Code: Any city en county which requires a permit m construct, alteq
improve, 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
VALUATION
,
$/FT.
ELEC. CONTR. LIC. NO.
ELEC.
TOTAL
PERMIT TO
QTY. PLUMBING PERMIT FEE
' Law (Chapter 9 (coal ..nein, with Section 7000) cd Division 3 of tm
Business and Professions Code) or that he is exempt therefrom and
STORIES
TYPE CONSTR.
the basis for the alleged cxcmption. Any violation m(Seetion 7031.5
by any applicant fora permit subjects the applicant W a civil penalty
of not more than five hundred dollars (5500)):
ALTER -DRAIN -WATER IEA.) 5.00
❑ 1, 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. DEV ICE 4.00
OCC. GROUP
RES. UNITS
DRAINS -FLOOR, ROOF, AREA,COND. 5.00
intended or offered I'or ,sale (Sec. 7044, Business and Professions
Code: 'I lie Contractors License Law does not apply to an owner of
FIXTURES - PER TRAP X00
GAS-EA.SYSTEM-11NC.40UTLETS 6.00
S0, FT. FLOOR AREA
TOTAL ACREAGE
property who builds or improves thereon, and who does such work
hlmsdfor through his own employees. provided that such improve-
mentsarenotintendedorofferedforsxle. If, however, the budding
or improvement is sold within one year of completion. the owner-
builder will have the burden of proving that be did not build or im-
prove ]or purpose of"sale.).INDUSTRIAL
❑ I, as owner of the property, DID exclusively contracting with
GAS - EA. SYSTEM - OVER 4 (EA.) 2.00
BUILDING USE
RES IND CON Pe Door
❑ ❑ ❑ ❑ ❑
. .
WASTE INTER3000
licensed contractors to construct the project (Sec. 7044, Business
and Professions Code: I Ile CORInDCIO! f License Law does 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.
enorels for,mB projectswith a contractors) licensed pursuant to
the COOtraetOrs License Law. ,.
SEWER -SANITARY -STORM EA. 200ft/10.00
TRACT NO.
PARCEL NO.
❑ lam exempt tinder Src. ,N.&P.C. for this
reason
WATER HEATER W/VENT 6.00
Owner Date
WATER SYSTEM 5.00
ACC.DATE
ACG FILE NO.
WATER TREATING EQUIP. 5.00
WORK ERS'COMPENSATION DECLARATION
I hcrchy affirm that 1 have a certificate of consent to self -insure.
Far a certificate of Workers' Compensation Insurance or a certified
ZONING
ENG. SITE NO.
copy Ihcmof (Sec. 3800, Lah.C).
policy N�yyr�np:yfyL�(p,CC
C py h r y arnishct. -"`''
Cr11f •d copy Ais will 1L"t�-pREion division.
App leant
.
FIRE SPRINK
y❑ N❑
ENERGY T24
v❑ N❑
MISC.- REFER TO ORD.
CERTIFICA'1'E0Ie fix EMP.fION FROM WORKERS'
PERMIT ISSUANCE
FLOOD ZONE
A.L.U.C.
COMPENSATION INSURANCE
('Phis section nee8 not be completed it the permit is (or one
hundred dollars (5100) or no,
PLG. CONTR. IJC. N0.
PLG.
TOTAL
Y ❑ N ❑
Y ❑ N ❑
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
OTY. MECHANICAL PERMIT FEE
FEE SUMMARY
BUILDING
.
become subject to the Workers' Compensat ion Laws of California.
Dale Applicant
ALTER OR ADD TO MECH. 5.00
NOTICE 'I'O'APPLICAN'1': IL 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 nmst forthwith comply with
such provisions or this permit shall be deemed revoked.
AIR HANDLING UNIT (TO 10MC.F.NL) 4.00
FEE
'
CONSTRUCT ION LENDING AGENCY
AIR HANDLING UNIT (OVER 10)"C.F.M.) 6.00
SEISMIC FEEj O
1 hereby affirm that there is u construction lending agency for
the performance of the work for which this permit is issued (Sec.
3097, Civ.C.),
EXHAUST HOOD (WITH DUCT) 5.00
MICROFILM
HEATING UNIT (TO 100,000 B.T.U.) 8.00
Lender's Name
Lender's Address
HEATING UNIT (OVER 100,000 B.T.U.)9.50
ELECTRIC
VENTILATION FAN (SINGLE) 4.00
I certify that I have read this application and state than the above
information is correct. I agree to comply with all city and county
ordinances and state laws relating to building construction, and
PLUMBING
U
BOILER -COMPO 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-mentioned property for inspection purposes.
(we) agree to save, indemnify and keep harmless the City of
MISC. - REFER TO ORD.
Cupertino against liabili " •tits, costs and expenses w r....
may in any way ac' U u•ainst su d City in consequence of the
CONST. TAX
PERMIT ISSUANCE 10.00
gra 'n • oft s er iL
'A
ECM. CONT. LIC. NO.
MECH.
TOTAL
TOTAL
Loolibel i1sly
F I INSPECTOR COPY