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APPLICANT TO FILL IN INFORMATION WITHIN RED LINES- USE BALL POINT PEN ONLY j
BUILDING PROJECT[ DENTIFICATION-
'APPLICATION &PERMIT
BUILDING -ELECTRICAL- PLUMBING -MECHANICAL
PRM BER
364- � /� .
'T
aDILDINO
AOOREss
O�6 � �✓� / Rd� P
!�
OWNER'S
NAME
OTY. ELECTRIC PERMIT FEE
-PLAN CHECK VALIDATION
j`�s/•y PHONE
`RACTORS
DATE OF APPLICATION
CO
rvnmE]]�� p T
LIC. NO. J; O 7L
UTLETS - SWITCHES -RECEP 5.00/1.00
LIGHTING FIXTURES 5.00/1.00
CONTRACTORS
ADDRESS OR
ADDRESS / A
7// CAe..7.4. 'L PH0NE 9 Y6 Ei,l DI)
PPLIANCES- RESIDENTIAL 4.00
PANELS 5.00
ARCHITECT
OR /
ENGINEER
uc. No.
SIGNS 6.00
PLAN CHECK FEE P.C. NO.
SIGNS TRANS. 3.00
AARCH 08 DDRESS ENG.
SPECIAL CIRCUIT 5.00
PERMIT VALIDATION
TEMP. METER OR POLE INS. 15.00
ZIP
ADDRESS -
ADDRESS ./, A
7// CA.(xe/ /,,, t
MOTORS SEE FEE SCH.
SERVICE CHANGE 10.00
LICENSED CONTRACTORS DECLARATION
I hereby affirm that I am licensed under provisions of Chapter 9
(commencing with Section 7000) of Division 3 of the Business and
Li is in full (or a in;,'/
License G ase Lic. Number 06
Professions Cod/� of
ISSUANCE DATE
BLDG. ELECT.
� ❑
PLG. MECH.
❑ ❑
/7
Uatx Contractor
BUILDING PERMIT
OWNER -BUILDER DECLARATION
I hereby affirm that 1 am exempt from the Contractor's License
Law for the followingmason.(Sec. 7031.5, Business and Professions
Code: Any cryor county which requires a permit toconslruct,alter,
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
Law (Chapter 9(commencing with Section 7000) of Division'3 oftbeG.IJa
Business and Professions Code) or that he is exempt therefrom and
the basis for the alleged exemption. Any violation o(Section 7031.5
INFORMATION
MISC. - REFER TO ORD
VALUATION
S/FT.
PERMIT ISSUANCE 6.00
ELEC. CONTR. LI NO.
.
ELEC.
TOTAL
PERMIT TO
_
CITY. PLUMBING PERMIT FEE
STORIES
TYPE CONSTR.
by any applicant for a permit subjects the applicant ton civil penalty.
of not more than five hundred dollars (5500).):
ALTER -DRAIN -WATER (EA.) 4.00
❑ I, as owner of the property, or my employees with wages as
their sole compensation, will do the work, and (lie structure is not
. BACK FLOW PROTECT. DEVICE 2.00
OCC. GROUP
RES. UNITS
DRAINS -FLOOR, ROOF, AREA, COND. 4.00
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 dues such work
himself or through his own employees, provided that such improve.
ments are not intended or ffered for sale. If, however, the building
'
FIXTURES - PER TRAP 4.00
SC. FT. FLOOR AREA
TOTAL ACREAGE
GAS - EA. SYSTEM - 1 INC.4 OUTLETS 4.00
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 ofsale.).
❑ I, as owner of the property, am exclusively contracting with
GAS - EA. SYSTEM - E .) 1.00
BUILDING USE
RES IND CON PB Ocher
❑ ❑ ❑ ❑ ❑
INDUSTRIAL WASTE INTER.
LAWN SPRINKLER C 5 V.B. 5.0
LAWN SPRINKLERS - OVER 5. E .00
ASSESSORS PARCEL NO.
licensed contractors to construct the project (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
contracts forsuch projects with a co omgor(sl licensed pursuant to
the Contractor's License Law.
SEWER -SANITARY -ST EA. 200ft/5.00
TRACT NO.
PARCEL NO.
❑ lam exempt under Sec. ,B.&P.C. (ar this
reason
WATER HEATER WNE 4.00
Dale Owner
WATER SYSTEM 4.00
ACC. DATE
ACC. FILE NO.
WORK ERS'COMPFNSATION DECLARATION
WATER TREATING EQUIP, 4.00
1 hereby affom that I have a certificate of consent to self -insure,
or a certificate of Workers' Compensation Insurance, or a certified
-
ZONING
ENG. SITE NO.
copy there NS e. 3800, LAC.).
Policy No.[LIl c Co an prey
FIRE SPRINK
Y ❑ N ❑'
ENERGY T-24
Y ❑ No
❑ Certified copy is hereby famished.
)' Certified II_opy jp Nled 'wiOlJhety Jp^ction division.
Applicant C
MISC.- REFER TO ORD.
CERTIFICATF.OF EXEMPTION FROM WORKERS'
PERMIT ISSUANCE 6.00
FLOOD ZONE
A.L.U.C.
PLG.CONTR. LIC. NO.
PLGTAL
TO❑
COMPENSATION INSURANCE
(This section need not be completed if the permit is for one
Y [:] N
Y [:] N ❑
MECHANICAL PERMIT FEE
FEE SUMMARY
hundred dollars (S 100) or II
. I certify that in the performance of the work for which this per -DTV.
mit is issued, I shall not employ any person in any manner so Its to
BUILDING
a
become subject to the Workers'Compensation Laws oPCalifornia.
Date Applicant
NOTICE TO APPLICANT: If, after making this Certificate of Ex-
ALTER OR ADD TO MECH. 4.00
APPLIANCE 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.
CONSTRUCTION LENDING AGENCY
AIR HANDLING UNIT (TO 10)=C.F.M.) 3,00
AIR HANDLING UNIT (OVER 10=C.F.M.)5.00
SEISMIC FEE
-26
'1 hereby affirm that there is a construction lending agency for
the performance of the work for which this permit is issued (Sec.
3097, Civ C.). vw�"
Lender's Name
EXHAUST HOOD (WITH DUCT) 2.00
'MICROFILM
HEATING UNIT (TO 100,000 B.T.U.) 4.00
H EATING UNIT (OVER 100,000 B.T.U.)7.50
ELECTRIC
Lender's Address
1 certify that I have read this application and state that the above
information is correct. I agree to comply with all city and county
ordinances and state laws relating to building construction, and
VENTILATION FAN (SINGLE) 3.00
PLUMBING
BOILER- COMP 13 H.P. or 100,000 B.T.U.) 4.00
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.
MISC. - REFER TO ORD.
CONST. TAX
(We) agree to Save, 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
granting of this permit.
6z�e !SP Sys'
PERMIT ISSUANCE 3.00
MECH. CONT: LIC. N0.
'
MECH.
DTAL
TOTAL
/3
Signalurc (Applicant/Contractor Uate
OFFICE COPY