10215APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
BUILDING PROJECT I DENT[ F I CATION
APPLICATION & PERMIT
-
BUILDING.- ELECTRICAL- � PLUMBING - MECHANICAL
PERMIT NUMBER
10215
BUILDING
AooREss
wNE S
NAME •
ONE
-
OTY. ELECTRIC PERMIT FEE
PLAN CHECK VALIDATION
cTORs
NON4
UTLETS- SWITCHES -RECEP 10.00/1.00
uc.%.,
ea (Aft
LIGHTING FIXTURES 10.00/1.00
noE
AONRE55 TOR'$
APPLIANCES 1RESIDENTIAL 4.00
HONE
':� PANELS 10.00
DATE OF APPLICATION
on -
ENGINEER
- LIC. No.
PANELS (OVER 200 AMP) 20.00
PLAN CHECK FEE P.C. NO.
SIGNSTRANS. 3.00
ADD 'Ess Ervc. /
SPECIAL CIRCUIT 5.00 "
PE ATION
ZIP
TEMP. METER OR POLE INS. 20.00
DEC 121986
ADDRESSTS �.
MOTORS SEE FEE SCH.
' ..
SERVICE CHANGE 20.00
-'
City of Cupertino -
LICENSE D 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
I'mfesswns Iv,�yfh y{.i- - in full for'c
License Cla 6ti�(2}t Number
ISSUANCE DATE
BLDG.. ELECT. LG MECH.
❑ ❑ ❑
Dam Ctmuntem�
!rFMRI
Re
BUILDINGP RMIT
ContION
I hereby affirm that 1 um exensp[ from the Contractor's Li ase
an, exempt
t from
Law for the following reason.(Sec. 7031.5. Business.. d]Tofu Bions
Code: Any city or county which requirese permit to construct, L alter,
INFORM TION
MISC. - - � REFER TO ORD
PERMITISSUANCE 10.00
VALUATION
$/FT.
ELEQ CONTR. i LIC. NO.
TOTAL
nnprnes delapplic Or repair any permit
tore, pa signed
n statement thatIs.
requires the applicant for [he prormit to file a signed isLithat
he is licensed to the provisions of Contractor's License
PE IT TO
9 (commencing 700 of the
Law (Chapterand Professions
Business and he alleged Code) or that hu is exempt ectio'mm and
Code) or Section is exempt
the basis for the allegedexemption. Any violation of Section 7031.5
by any applicant for a permit subjects the applicant toacivil penalty
of not more than five hundred dollar ($500).):
_
OTV. PLUMBING PERMIT FEE
'
STORIES
TVP CONSTR.
ALTER -DRAIN & VENT -WATER (EA.) 5.00'
❑ 1, as owner of the property, or my employees with wages as
their sole compensation, will do the work, and the StInchuc is not
BACK F LOW PROTECT. DEV ICE 4.00
DCC. GROUP
REB. UNITS
' intended or offered for sale (Sec. 7044, Business and Professions
Code: The Contractor's License Law does not apply to an owner of
DRAINS -FLOOR, ROOF, AREA, COND. 5,00
FIXTURES - PER TRAP 6.00
GAS-EA.SYSTEM-11NC.40UTLETS 6.00
property who builds or innproves Oiercon, and who does such work
himself or through his own employees, provided that such improve-
mentsarenotintendedoroffered for sale. If, however, the building
SO. FT, FLOOR AREA
TOTAL ACREAGE
or improvement is Sold within one year of completion, the owner -
builder. will have the burden of proving that he did not build or im.
prove for purpose of sole. p
❑ 1; as owner of the property, am exclusively contracting with
licensed contractors to construct the project (Sec. 7044, Bmines,
and Professions Code: The Contractor's License Law does not apply
GAS - EA. SYSTEM - OVER 4 (EA.) 2.00
BUILDING USE
S IND CON Pe Other
INDUSTRIALWASTE.INTER. 30.00
LAWN SPRINKLERS- 1 INC 5 V.B. 6.00
gSSES50flS PARCEL NO.
to anowner of property who builds or improves thereon. and who
LAWN SPRINKLERS - OVER 5 (EA.) 1.00
contracts for such projects with a contractopta licensed pursuant to
the Contractor's License Law.
❑ I am exempt under Sec. ,B.&RC. for this
.son
SEWER -SANITARY -STORM EA. 200ft/10.00
TRACT NO.
PARCEL NO.
7
WATER HEATER W/VENT 6.00
Owner Dote
WATER SYSTEM 5,00
ACC.DATE :
ACC. FILE NO.
WORKERS'COMPENSAT10N DECLARATION
WATER TREATING EQUIP. 5.00
I hereby aftion that I have . cartificate of consent to Sel6intme,
- ZONING
ENG. SITE N0.
a certificate of Workers' Compensation' Insurance,' or a certified
- - -
)or
<op (Sec. 3800, Lab.CJ.
P cy No.- Company -
by
❑ Certif d cop is hereby form e
❑ Certi a is Ii led ve ci ction Division.
pplican _
'
FIRE SPRINK
v❑ It
ENERGY TQ9
Y❑ N❑
MISC.- REFER TO ORD. ..
PERMIT ISSUANCE 10.00
iRTIFICATEOF FROM WORKERS'
COMPENSATION INSURANCE
(This Section need not be completed if the permit is for one
FLOOD ZONE
Y'❑ N ❑
A.L.U.c.
Y ❑ N ❑
PLG. CONTR. LIC. No.
PLG.
TOTAL
hundred dollars (S 100) or less)
-
I certify that in Om performance of One 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
become subject todhe Workers' Compensation Laws of California..
ALTER OR ADD TO MECH. 5.00 -
Date Applicant
BUILDING
NOTICE TO APPLICANT: If, after making this Certificate of Ex-
APPLIANCE' 5.00
AIR HANDLING UNIT (TO 10=CF.M.) 4.00
PLAN CHECK
FEE
'
emption, you should become subject to the Workers' Compensation
provisions of the labor Code, you most forthwith comply with
such provisions or this permit shall be deemed revoked.
AIR HANDLING UNIT(OVER 10=1C.EM.) 6.00
SEISMIC FEE
CONSTRUCTION LENDING AGENCY,
I hereby affirm that there is a construction lending agency for
One performmme of the work for which this permit is issued (Sec.
3097, Civ.C.). - -
Lender's Nance
EXHAUST HOOD (WITH DUCT) 5.00
HEATING UNIT (TO 100,000 B.T.U.) 8.00
MICROFILM'
Lenders Address
HEATI NGUNIT(OVER 100,000 B.T.U.)9.50,
ELECTRIC
VENTILATION FAN (SINGLE) 4,00
H.P.'or 100,000 B.T.U.) 6.00
I certify that I have read this application and state that the above
information is c'orrec[.,I agree In comply with all city and countyBOILER-COMP(3
ordinances and state laws relating to building construction,'and
PLUMBING -
hereby enthorite representatives ec this city to enter upon the
.-m authored Property for Inspection purposes. -
BOILER -C (Over 0,000 BTU) SEE FEE SCH.
MECHANICAL
( ) agree to save, indemnify and keep harmless the City o!
Caper no against liabilities, juments costs and expenses which
may any way .ecru agai t s ' ty in consequence the
grant- of this permit:
L
n u c of pP c ora clot Ualc70
MISC. - REFER TO ORD..
PERMIT IS UANC 10.00
CONST. TAX
MICH. CONT. LIC. NO.
111111617
MECH.
TOT �j
/ 4
OTAL
TOTAL-
18192514161