9126APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
- 'BIALDING PROJECT I DENTIFI N
APPLICATION'& P*IIT
BUILDING - ELECTRICAL - PLUMBING -- MECHANICAL
PERMITNUMBER
Z
aDILDINC
ao DRESS
A-VL'
WNGR'S
NAME
j VHONE
v 6 psi. E
OTY'
�
ELECTRIC PERMIT
FEE '
,. PLAN CHECK VALIDATION
DATE OF APPLICATION
CONTRACTORS
NAME
�-f( '3
160 sold[ me%�IC.NO, 23'f�l�
OUTLETS - SWITCHES -RECEP 10.00/1.00
LIGHTING FIXTURES 10.00/1.00
CON TRACTOR'S
ADDRESS
�SToJr y4 PHONEz899i9
PPLIANCES - RESIDENTIAL 4.00
PANELS 10.00
ARCHITECT
0. ENGINEER
" LIC. NO
PANELS (OVER 200 AMP) 20.00
-
PLAN CHECK FEE P.C. No.
SIGNS TRANS. 3.00
ARCH. OR ADDRESS ENG.
ZIP
SPECIAL.CIRCUIT 5.00
PERMIT VALIDATION
p
ISSUANCE DATE
,EMP. METER OR POLE INS. 20.00
_
APPLICANT'S
AGGRESS
'
MOTORS SEE FEE SCH..
SERVICE CHANGE 20.00
LICENSED CONTRACT ORS DECLARATION
1 hereby affirm that 1 am licensed under provisions of Chapter 9
(commencing with Section 7000) of Division 3 of the Business and
Prnfusslons CoA and m cn Li is in full f�r�� u cry
Lmle Class �(1}_ Lie. Number </
'' )a1L• s� /�„�S Coot raclnr GY• %(y_� -(
OWNER-BUILDER DECLARATION �
I hereby affirm that I am exempt from the Contractor's License
Law for the following mason. (Sec, 7031.5, Business and Professions
Code: Any city or county which requires a permit to construct, alter,
improve, demolish, or repair any structure, prior In its issumlxe, also
requires the applicant for such permit to file a signed statement That
lie is licensed pursuant to the provisions of the Contractor's License
Law (Chapter 'I (commencing with Section 7000)of Division Sol the
Business and Professions Code) or that he is exempt therefrom uiid
the basis for the alleged exemption. Any violation of Section 7031.5
by any applicant for a permit subjects the applicant to a civil penalty
of not more than five hundred dollars (5500).):
O 1, as owner of the property, a my employees with wages as
their sole r offered compensation, will (S the work, and the structure is not
intended or offered for sale (Sec. a doe Business and Professions
Code: The Contractor'., License Law does nut 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.
`•me6ts are not intended or offered for sale. If, however, the building
or improvement is sold within one-year of completion, the owner-
i builder will have the burden of proving that he did not build or im-
prove for purpose ofsaleJ.
O 1, as owner of the property, am exclusively contracting with
licensed contractors to construct the project (Sec. 7044, Business
and Professions Code: The Contractor's License Law dues not apply
to an owner of property who builds or improves thereon, and who
contracts for such projects with a contractoGs) licensed Portland to
theContractor'sLicenseLaw.
❑ 1 am exempt under Sec. ,BARC. for this
reason
TEMP. POLE 30.00'
-
SLOG. ELECT.
❑ ❑
PLC. MECH.
❑
BUILDING PERMIT
INFORMATION
MISC. - REFER TO ORD
PERMIT ISSUANCE 10.00
VALUATION
$ /FT.
ELEC. CONTR. LIC. NO.
ELEC.•
TOTAL
PERMIT TO
GTY.
PLUMBING PERMIT
ALTER- DRAIN, &VENT -WATER (EA.) 5.00.
FEE
STORIES
TYPE CONSTR.
BACK FLOW PROTECT. DEVICE 4.00
OCC. GROUP
RES. UNITS
•TOTAL
DRAINS- FLOOR, ROOF, AREA, COND. 5.00
F IXTUR ES - PER TRAP 5.00
GAS- EA.SYSTEM- 11 6.00
SO. FT. FLOOR AREA
ACREAGE
GAS - EA. SYSTEM -OVER 4 (EA.) 2.00
- BUILDING USE
RES IND CON PS Omer
El 0 C] 13
INDUSTRIAL WASTE INTER 3000
. .
LAWN SPRINKLERS- 1 INC 5 V.B. 6.00
ILAWN SPRINKLERS - OVER 5 (EA.) 1.00
-
ASSESSORS PARCEL NO.
SEWER - SANITARY -STORM EA. 200t1 /10.00
TRACT NO.
PARCEL NO.
WATER HEATER W /VENT 6.00
Owner Dlde
WATER SYSTEM 5.00
WOR KERS'COM PENSATION DECLA RAT ION
I hereby affirm that 1 have a certificate ofconsent to si lTinsum,
or a certificate of Workers' Cc mpenerlion Insurance, or a certified
copy thereof (Sec. 3800, pang L 1(O MELgi✓�
copy er Company _
ACC.DATE
ACC. FILE NO.
WATER TREATING EQUIP. 5.00
ZONING
ENG. SITE NO.
❑ Ifie 1 opy is hereby furoi had.
�Cer 'I'i copy s -file wit the CIY inspection Aivisiun.
. Applir t
FIRE SPRINK
Y E] NE]
ENERGY T14
Y E] NC]
MISC. -. � � REFER TO ORD.
CI:RTIPICA'1'E OF EXEMPTION F M WORKERS'
COMPENSATION INSURANCE
(This section need not be completed it the permit is for one
hunt red dollars ( $100) or less )
1 certify that in the performance of the work for which this per-
out is issued, 1 shall not employ any person in any manner so as to
become subject to the Workers' Compensu l ion Laws of Carl'oin in.
Date-Applicant
PERMIT ISSUANCE 10:00
FLOOD ZONE
Y, 0' N ❑
A. L.U.C.
Y O NC
PLG. CONTR. LIC. NO.
- -
PLG.
TOTAL
MECHANICAL PERMIT
FEE
FEE SUMMARY
BUILDING
ALTER OR ADD TO ME �p 5.00
NOTICE CF; TO API ICAN : 1
II, after making this Certificate of Ex-
emption, you should become subject In the Workers' Compensation
provisions of the Labor Code, you must forthwith comply with
such provisions or this permit shall be deemed revoked.
CONSTRUCTION,LENDING AG17NCY.
I hereby Sidon that there is a construction lending agency for
the performance of the work for which this permit is issued (Sec.
3097, is Name Lender's Name
APPLIANCE 5.00
AIR HANDLING UNI 1 Q 4.00
PLAN CHECK
FEE
AIRHANDLINGUNITIOVER IO,000C.F•M.) 6.00
SEISMIC FEE
-
�.
EXHAUST HOOD IQ a0 ' 5.0 C)
HEATING UNIT (TO 100,000 B.T.U.) 8.00
MICROFILM
o
Lenders Address
I certify that l have read this application and state that the above
information is correct. I agree to comply'with all city and county
dinances and state laws relating to building construction, and
:oby authorize representatives of this putty to enter 'upon the
above-mentioned property for v inspection f thi purposes.
(We) agree Love, indemnify and keep harmless the City of
Cupertino against liabilities, judgments, costs and expenses which
may i any way ace a against said City in consequence of the
gra t' 'of, hisp ml[ /
�h
Ign turcofApplicant 'o ir' for r ale «-
L
HEATING UNIT (OVER 100,000 B.T.U.) 9.50
ELECTRIC
VENTILATION FAN (SINGLE) 4.00
00
PLUMBING
BOILER -COMP (3 H.P. or 100,000 B.T.U.) 6.00
,
Ll 0,0,9
BOILER -COMP Iowa, 100,000 BTU) SEE FEE SCH.
MECHANICAL
y�
O
MISC. - REFER TO ORD.
PERMIT ISSUANCE 10,00
0 J
CONST. TAX
MECH. CONT. - LIC. NO.
MECH.
TOTAL
Qrr
TOTAL
OFFICE COPY.