6602(' APPLICANT. -TO FILL IN INFORMATION WITHIN RED LINES- USE BALL POINT PEN ONLY
= BUILDING PROJECT IDENTIFICATION'
h
APPLICATION & PERMIT • '.
BUILDING _ •ELECTRICAL- PLUMBING - MECHANICAL
PERMIT NUMBER
/6 {/��
66OZ
BUILDING / �
ADOness C� _
NwNR s
°mE /(� � (�1/ �
/ �r • • 1 PHONE (/Q
OTV.
ELECTRIC PERMIT
FEE
PLAN CHECK VALIDATION
,
"
.
DATE OF APPLICATION
CONTRACTOR 's -
NAM _ _
c.NO°
UTLETS - SWITCHES - RECEP 5.00/1.00
:'
LIGHTING FIXTURES 5.00/1.00
•P.
eo T A ORs
.AO nE55 _
O�jr PHONE
PPLIANCES- RESIDENTIAL; 4.00
'PANEL$.
.:5.00
OIRiCI Tter r -
ENGINEEfl
' sec. NO.'
J "SIGNS
16.00
PLAN CHECK FEE P.C. NO.
'SIGNS
TRANS. 3.00
_
ARCH FOR ENG. - '
';
SPECIAL CIRCUIT 5.00
PERMIT VALIDATION ,
•�////�//71�`
ISSUANCE DATE
BLDG. LE PLG. MECH.'
❑ ❑
TEMP. METER OR POLE :INS. r 15.00.
ADDRESS
ADDRESS
-
MOTORS4e 6 = SEE FEE SCH.
SERVICE CHANGE 10.00
LICENSED CONTRACTORS DECLARATION
I hereby affirm that 1 am licensed under Provisions of Chapter 9
(commencing with Section 7000) of Division .3 of the Business and
Professions Cod n- Y bense is in full f t d Z •
License Class �'- Lie. Nut"
Dnt4 Contractor
-
'_ -
-
' ..
OWNER- BUILDER DECLARATION,
I hereby affirm that 1 am exempt from the Contractor's P's License•
,Law for the following reason ( Sec. 7031.5, Business and Professions
Code: Any city or county which reyuiresa permit to construct , alter,
improve, demolish, or repair any structure, prior to its issuance, also
returner the applicant for shelf permit to file a signed statement that
Ile is- licensed pursuant to the provisions of the Contractor's License
Law (Chapter 9 (commencing with Section 7000) of Division 3 of the
Business and Professions Code) or that he is exempt therefrom and
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 (8500).):. -
❑ I, as owner of the property, Or my employees with wages as,
their sole compensation, will do the work, and the structure Is not
intended or offered for sale (Sec. 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-
mentsarenotint ended or offered for sale. If, however, the building
or improvement is sold within mie year of completion, 0m owner-
builder will have the burden of proving that he. did not build or am-
Prove forpruposeofale.). ,,- s .' • -
Cl 1, as owner of the property, am exclusively contracting with
licensed, contractors to construct the project (Sec. 7044, Business
and Professions Code: 'fhe Contractor's License Law does not apply
to an owner of property who builds or improves thereon, and who
contracts for such projects with a contractor(s) licensed Pursuant to
the Contractor's License Law,
❑ lam exempt under Sec. ,B` &P.C. for this
rcuson
BUILDING PERMIT
INFORMATION
MISC.- .REFER TO ORD
PERMIT ISSUANCE 6.00
•�
VALUATION -
$ /FT.
EL .FON
R. �� LIC. NO, -
!/
ELEC.
TOTAL
���
T
OTY.
PLUMBING PERMIT
FEE
STORIES
TYPE CONSTR.
-
ALTER-DRAIN (EA.)4.00
BACK FLOW PROTECT. DEVICE 2.00
OCC. GRO P
,
RES. UNITS
DRAINS- FLOOR, ROOF, AREA; COND." 4.00
FIXTURES - PER TRAP, _ 4.00
GAS- EA.SYSTEM- 1.INC.4 OUTLETS 4.00
S0. FT..FLOOR AREA
TOTAL ACREAGE
'GAS
- EA: SYSTEM -OVER 4 (EA.1' 1.00
BUILDING USE
IND CON Pfl . Other
❑'. ❑ ❑ ❑
INDUSTRIAL WASTE INTER. 20.00
'
LAWN SPRINKLERS- 1 INC 5 V.B. 5.00
LAWN SPRINKLERS - OVER 5 (EA.)' 1.00
ASSESSORS PARCEL NO.
_
I •
-
SEWER - SANITARY -STORM EA. 200ft /8.00
TRACT NO,
PARCEL NO.
WATER HEATER W /VENT 4.00
Owner - 'Date
WATER SYSTEM 4.00
WORKL'RS'COMPFNSATION DECLARATION
I hereby .affirm that I have acertiffcateofchnsent toself- insure;
or a certificate of Workefi Compensal inn Insurance, or a certified
cop, there o ( 00, I.aI1 C.).'
1'olicY No.�Company-
❑ Gem (, copy is hereby furnished,
f,'fe'.Certifi• c W11X -F itti the city inspection division.
n,p mum - -- I /i7
ACC. DATE
ACC, FILE NO.
„
WATER TREATING EQUIP. 4.00
-
ZONING
ENG. SITE NO.
MISC.- REFER TO ORD.
FIRESPRINK
Y❑ N❑
ENERGY T -24
Y IN
CE R' I FICA 11: OF Ii XFM PTION FROM WORKERS'
COMPFNSATION INSURANCE
(This section need not be completed if fire permit is for one
hundred dollars ($ I00) b, less.)'
I•certify that in the perlormance of the work,for which this per-
mit is issued, I shall not employ any person in any manner so as to
become subject to t u, Workers Compensation Laws of California.
Date � Applicant
PERMIT ISSUANCE 6.00
FLOOD ZONE
Y ❑ IN
A.LOF.� •"
Y ❑' .N❑
PLG. CONTH. LIC. NO.
PLO. '
TOTAL
OTY.
MECHANICAL PERMIT •
FEE
FEE SUMMARY
BUILDING
-
ALTER OR ADD TO MECH. 4.00
-
NOTICE TO APPLICANT: If, after making this Certificate of F.-
emption, you should become subject to the Workers' Compensation
Provisions of the Labor Code, you must forthwith comply with
such provisions or this permit shall be deemed revoked.
CONSTRUCTION LENDING AGENCY
I hereby affirm thi l there is a construction leading agency for
the performance of the work for which this permit is issued (Sec
3097, Cie.C.).
APPLIANCE' 4.00
AIR HANDLING UNIT (TO 10=C.F.lM 3.00
.PLAN CHECK,
FEE'
AIR HANDLING UNIT (OVER 1000011F.M.). 5.00
SEISMIC FEE
'EXHAUST HOOD (WITH DUCT( 2.00
MICROFILM
HEATING UNIT (70,100,000 B.T.U.) 4.00
Lender's Name
Lcnderi Address -
I certify that l have read this application and stale that (4c above
information is correct. I agree to comply'with all city and'cohnty
ordinances and state laws relating to,bbildn' cnnstmaion, and
hereby ahtheri4e representatives of this. city to enter. Pon the
above - mentioned property for inspection purposes.
(We) agree to cove, indemnify and keep harmless the City of
Cupertino against liabilities, judgments, costs and expenses which
may in any way accrue against said City In consequence of the
gmnf of this permi
HEATING UNIT 100,000 B.T.U.)7.50
,
ELECTRIC
3.50
VENTILATION FAN (SINGLE) 3.00
PLUMBING.
BOILER- COMP(3 H.P. Or 100,000 B.T.U.) 4.00
'gOILERr MP verl ,00 BTUI SEE FEE $CH.
MECHANICAL
-7
MISC. I
PERMb ISSUANCE
E. O ORD.
f 3.00
-
-
CON ST. TAX
MECH. ONT. LIC. NO. MECH.
/,? TOTAL
/� Y
TOTALS
Signature of APP ma n/Comrac r Uute
r OFFICECOPV