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APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
BUILDING PROJECT IDENTIFICATION
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APPLICATION & PERMIT
PERMIT NUMBER
ADDRESS
ADDRESS
Son/ V
BUILDING — ELECTRICAL— PLUMBING — MECHANICAL
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OWNER'S
NPM
PHONE
►
OTY. ELECTRIC PERMIT F
PLAN CHECK VALIDATION
CUNTRAW
CTORS
NAME C'—f0
NAME
'Zii2 'Ic. rvo. gb
UTLETS-SWITCHES•RECEP 10.00/1.00
LIGHTING FIXTURES 10.00/1.00
CONTRACOR's G�CN�I IO ��
ADDRESS
APPLIANCES -RESIDENTIAL 4.00
.eJ�Or/
•
aO'� ilG S OS PHONE -Q
DATE OF APPLICATION
'PANELS 10.00
ARCHITECT
OR
ENGINEER
PANELS (OVER 20.00
PLAN CHECK FEE P.C. NO.
SIG NS TRAi986 3.00
uC. NO.
ADDRESS ENG
SPECIAL CI � 11.y 5.00
PERMIT VALIDATION
ZIP
EMP. METER 20.00
APPLICANT'SADDRESDOREss
MOTORS SEE FEE SCH.
SERVICE CHANGE 20.00
LICENSED 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
Professions Codc nd v_license is in full for and e 'eF
License Class ��• U Lic. Number
Date Contractor
v
OWNER -BUILDER DECLARATION.
I hereby affirm that I am exempt from the Contractor's License
Law for the following reason. (Sec, 7031.5, BuRnessand Professions
Code: Any city or county which structur a permit tons,ilea
improve, demolish, or repair any structure, prior too its issuance,
e, also
requires the applicant for such permit to file a signed statement that
he is licenced pursuant to the provisions of the Contractor's License
--�•
40 1 1-11
�_ I
MISC. Y6 ORD
ISSUANCE DATE
BLDG. ELECT, PLG. MECH.
❑ ❑
BUILDING PERMIT
"INFORMATION
pERMIT ISSUANCEVALUATION
10.00 O �
$/FT.
ELEC. CONTR. LIC. NO.
36'�
EL"/y dL
TOTAC. L Q
PERMIT TO
Law (Chapterand Profession, theref o of the
Business and Professions Code) or that he is exempt therefrom and
de) 0, Section is 00) exempt
the basis for the alleged exemption. Any violation of Section malty
by any applicant fora permit subjectstire $500).licem toacivil penalty
of not more than five hundred dollars (E500)J:
❑ 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 Cont ractoi s License Law does not apply to an owner of
E LL�G
DTV. PLUMBING PERMIT FEE
ALTER-DRAIN-WATER(EA.) 5.00
STORIES
TYPE CONSTR.
BACK FLOW PROTECT. DEVICE 4.00
OCC. GROUP
RES. UNITS
DRAINS -FLOOR, ROOF, AREA, COND. 5.00
FIXTURES - PER TRAP 5.00
IGAS - EA. SYSTEM - I INC. 4 OUTLETS 6.00
SO. FT. FLOOR AREA
TOTAL ACREAGE
property who builds or improves thereon, and who does such work
himself or through his own employees, provided that such improve.
mems are not intended or offered 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 im.
prove for purpose ofsale.).
❑ I, as owner of the property, am exclusively contracting with
GAS - EA. SYSTEM - OVER 4 (EA.) 2.00
BUILDING USE
RES IND CON PB Other
INDUSTRIAL WASTE INTER. 30.00
licensed Contractors to construct the project (Sec. 7044, BusinessLAWN
and Professions Code: The Contractor's License Law does not apply
to an owner of property who builds or improves thereon, and who
V.B. .
SPRINKLERS 1 INC 5 VB600
LAWN SPRINKLERS - OVER 5 (EA.) 1.00
ASSESSORS PARCEL NO.
contracts for such projects with a contractors) licensed pursuant to
the Contractors License Law.
❑ I am exempt under Sec. , B.&P.C. for this
reason
SEWER -SANITARY -STORM EA. 200ft/10.00
TRACT NO.
PARCEL NO.
WATER HEATER W/VENT 6.00
Owner _ Date
WATER SYSTEM 5.00
ACC. DATE
ACC. FILE NO.
WATER TREATING EQUIP. 5.00
WORK ERS'COMPENSATION DECLARATION
I hereby affirm that I have a certificate of consent to self -insure,
ZONING
ENG. SITE NO.
or a certificate Df Workers' Compensation Insurance, or a certified
copy thereof (Sec. 3800, Lab.C.) t/Q�'
-F
EE-"�'��// QS�
Policy No. Company f � �Q�
❑ C��[pfired copy is hereby famished.
mi of d is filed the inspemims divisio
FIRE SPRINK
ENERGY T44
cony with city .
Applicant u'T�'-���w/ gpL,t"Z.iYLL C�
MISC. - REFER TO ORD.
Y N [:]
Y ❑ NC:]
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(This section need not be completed if the permit is for one
PERMIT ISSUANCE 10.00
FLOOD ZONE
Y [. NO
A.L.II.C.
Y 0 NE]
PLG.CONTR. LIC. NO.
PLG,
TOTAL
hundred dollars (S 100) or less.)
I certify that in the performance of the work for which this per-
mit is issued, I shall not employ any person in any manner so as to
QTY: it MECHANICAL PERMIT FEE
FEE SUMMARY
BUILDING
become subject to the Workers' Compensation Laws of California.
Date Applicant
NOTICE TO APPLICANT: If, after making this Certificate of Ex-
'
ALTER OR ADD TO MECH. 500
.
APPLIANCE 5.00
AIR HANDLING UNIT (TO 10,000C.F.M.) 4.00
PLAN CHECK
FEE
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.
AIR HANDLING UNIT (OVER 10,000C.RM.) 6.00
SEISMIC FEE
CONSTRUCTION LENDING AGENCY
I hereby affirm that there is a construction lending agency for
EXHAUST HOOD (WITH DUCT) 5.00
the performance of the work for which this permit is issued (Sec.
3097, Civ.C.).
MICROFILM
HEATING UNIT (TO 100,000 B.T.U.) 8.00
Lender's Name
Lender's Address
HE UNIT (OVER 100,000 B.T.U.)9.50
ELECTRIC
d
I certify that I have read this application and stale 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) 4,00
BOILER-OOMP13 H,P. or 100,000 B.T.U.) 6.00
PLUMBING
hereby authorize represenlatives of this city to enter upon the
above-mentioned property for inspection purposes.
BOILER -COMP (Over 100,000 BTU) FEE SCH.
I MECHANICAL
(We) agree to Save. indemnify and keep harmless the City of
Cupertino against Babilities, judgments, costs and expenses which
may N any ey accrue at said City n consequence w the
granting of a Art cc .L1��Ljnce r
QY 1 J L T __
MISC. - REFER TO ORD.
PERMIT ISSUANCE 10.00
CONST. TAX
CH. CONT. LIQ NO.
MECH.
TOTAL
TOTAL
Signature of licant/ moor - Uate
OFFICE COPY '