8670APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
BU LDI NG PROJECT I DENTI FICATI ON
APPLICATION &PERMIT
BUILDING - ELECTRICAL- PLUMBING - MECHANICAL8670
PERMIT NUMBER
UILRININ
AODG
ESS
l�
O R
NAME
PHONE
CITY . ELECTRIC PERMIT FEE
PLAN CHECK VALIDATION
DATE OF APPLICATION
NAMERAcrons -
IZ<le1. Cr T uc, NO I `,4C
741 OUTLETS - SWITCHES -RECEP 10.00/1.00
/y, LIGHTING FIXTURES 10.00/1.00
CONTRACTORS
ADDRESS yir „�^ y
7 d/0- V1 g.� YVHONE •) S41.�i
;P
PPLIANCES- RESIDENTIAL 4.00
PANELS 10.00
;HI
DR
ENGINEER
uc. No.
PANELS (OVER 200 AMP) 20.00
PLAN CHECK FEE P.C. NO.
SIGNS TRANS. 3.00
ARCH
Ess true -
' ZIP
SPECIAL CIRCUIT 5.00
PERMIT VALIDATION
I ^
ISSUANCE DATE
BLDG. E ECT PLG. MECH.
❑ E] [-]License
rrEMP. METER OR POLE INS. 20.00
APPLICANT'S
aooREss
MOTORS SEE FEE
SERVICE CHANGE 20.000.00
LICENSED CON'T'RACTORS DECLARATION
/ hereby affirm Ilial I am licensed under provi,iu e, 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.
lass 4 - 1 O Lic. Number � .�'� ! )j
Date Contractor„„/j,�ti.-, E
TEMP. POLE 30.00
OWNER -BUILDER DECLARATION
1 hereby .]firm that I .m exempt from the Cmdraetor's License
Law for the ]'ollowing reason. (Sec. 7031.5, Businessand Professions
Code: Any city or county rep which structure permit o its issuance,
alalter,
prior no its issuance, also
improve, he applicant
or repair any structure, file
requires the applicant for such permit to file .signed statement that
he IS lic(Chapter
9Or6llm en Ili{: with provisions Of 700 Contractor's 1•of the
of Division 3 of the
Busi (Chapter 9 (commencing with Section is exempt
Business and Professions crept or that he is exempt therefrom and
the basis plc the alleged exert prion. Any violation tto action malty
by any applicant fora permit subjects SSOO).he licant toacivil penalty
of not more than five hundred dollars (my em :
❑ I, as ..net at the property, or my employees with wages as
their sole compensation, will Jo the work, and the stn¢mre Is not
intended or offered for sale (See. 7044, Business and Professions
Code: The Contractor's License Law does 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-
mentsarenotintendedoroffered for sale. 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-
sale.).
prove ors owner
❑ L as owner of the property, he exclusively contracting with
find Pro contnrdors to cCmnton,Tnet the project (sco. 7044, Business
and Professions Code: The Contractor's License s Unction. Joos non apply
to tr owner of property who builds tr improves hand who
contracts for such projects with a contracWrts)licensed pursuant to
the 1....dor-s License Sc,,
❑ lam txempt under Sec. ,B.&P.C. for his
reason
BUIf DING PERMIT
INFORMATION
MISC. - REFER TO ORD
PERMIT ISSUANCE 10.00
VALUATION
$/FT.
ELEC. CONTR. LIC. NO.
ELEC. N
TOTAL N�
PERMIT TO
CITY. PLUMBING PERMIT FEE
5 IES
TYPE CONSTR.
ALTER -DRAIN VENT -WATER (EA.) 5.00
BACK FLOW PROTECT. DEVICE 4.00
OCC. GROUP
RES. UNITS
DRAINS -FLOOR, ROOF, AREA, COND. 5.00
FIXTURES - PER TRAP 5.00
GAS-EA.SYSTEM-11NC.40UTLETS 6.00
sD. Fr. aooR AREA
TOTAL ACREAGE
GAS - EA. SYSTEM - OVER 4 (EA.) 2.00
BUILDING USE
RES IND CON PB Other
0 ❑ 0 0 ❑
INDUSTRIAL WASTE INTER. 30.00
LAWN SPRINKLERS- 1 INC 5 V.B. - 6.00
ASSESSORS PARCEL NO.
,-
LAWN SPRINKLERS -OVER 5 (EA.) 1.00
SEWER -SAN ITAR V -STORM EA. 200ft/10.00
TRACT NO.
PARCEL NO.
.WATER HEATER W/VENT 6.00
Owner Date
WORKERS'COMPENSA'PION DECLARATION
I hereby affirm that I have a certificate of consent to self -insure.
or a certificate of Workers' Compensation Insurance, or a certified
copy thereof (See. 3800, Lab.C.).�t i../e J . J •?' , .-+ f
Policy N'o. Company
WATER SYSTEM 5.00
ACC. DATE
ACG FILE NO,
WATER TREATING EQUIP. 5.00
ZONING
ENG. SITE NO.
'
I,q f
❑ Certified copy is •Tcby I-AshcT,
❑ CIC H f eU , 'th he ,ily it �p,etion division.
Applicant vo Is II
FIRE SPRINK
y❑ N❑
ENERGY T44
Y❑ NE]
MISC.- REFER TO ORD.
ER1'IFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(This aclim, need not be completed if the permit is for OTIC
hundred dollars IS 100) or less,)
I certify that in the perl'urnwnce of the work for which this per-
unt is issued, I shall not employ any person in any manner so as to
become subject to the Workers' Compensation Laws of California.
Date Applicant
'PERMIT ISSUANCE 10.00
FLOOD ZONE
Y El NEI
A.L.U.C.
Y E] NEI
PLG. CONTR. LIC. NO.
PLG.
TOTAL
CITY. MECHANICAL PERMIT FEE
FEE SUMMARY
BUILDING
ALTER OR ADD TO MECH. 5.00
NOTICE TO APPLICANT: If, after making this Certificate of Ex-
emption, you should become subject to the Wmkv,, Compensation
provisions of the Labor Code, you must forthwith comply with
such provisions oT this permit shall be deemed revoked.
CONSTRUCTION LENDING AGENCY
I hereby .ffinn that there is a construction lending agency for
the performance of the work for which this permit is issued (Sec.
3097. Civ.C.).
APPLIANCE 5.00
PLAN CHECK
FEE
AIR HANDLING UNIT (TO 1OJ100GF.M.) 4.00
AIR HANDLING UNIT (OVER 10000GEM.) 6.00
SEISMIC FEE
EXHAUST HOOD (WITH DUCT) 5:00
MICROFILM
HEATING UNIT (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 l have read this application and slate that the above
information is correct. I agree to comply with all tiny and county
ordinances and state laws relating to building construction, and
representatives forms of this city to enter upon the
hereby above-mentioned
above-mentioned property forinsp of this
purports.
(We) agree to save, indemnify and keep harndess the City of
Cupertino against liabilities, judgments, costs and expenses which
may% in any ways accrue Against said City in consequence of the
grunting of P,nnit �•
�h� (o.N ��s�00allZ 'r
VENTILATION FAN (SINGLE) 4.00
BOILER H.P. or 100,000 B.T.U.) 6.00
PLUMBING
BOILER -COMP (Over 100,000 BTU) SEE FEESCH.
MECHANICAL
MISC. - REFER TO ORD.
PERMIT ISSUANCE 10.00
CONST. TAX
MECH. CONT. LIC. NO.
MECH.
TOTAL
TOTAL
.
Ig atom of Appbca t/ onmactor Tate'
INSPECTOR COPY