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APPLICANT TO FILL IN INF09MATION WITHIN RED LINES - USE,- ILL POINT PEN ONLY
BU LDINGgPROJECTIDENTI.., ION
APPLICATION&PERMIT5205
- ELECTRICAL- PLUMBING - MECHANICALOWNER'S
PERMIT NUMBER
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PLAN CHECK VALIDATION
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UTLETS• SWITCHES•R00.00NAMELIGnooaEss
DATE OF APPLICATION
PLAN CHECK FEE P.C. NO.
40D
SI I'vONE (7vEJ
AgovrtEC
OR
ENG."EEREs"5 2 UC.NOG_e`/SI1V1y1
PPLIANCES- RESIDENTIAL 4.00
PANELS 5.00
SIGNS 6.00
SIGNS TRANS. 3.00
ARCH. OR ENG.
AD ES$ /'
Yale / 0 `id' zip
SPECIAL CIRCUIT 5,OQ
PERMIT VALIDATION
�+
S
/�
S N E
EMP. METER OR POLE INS. 15.00
APPLICANT'S
ADDRESS
(_ ( 6.
MOTORS SEE FEE SCH.
SERVICE CHANGE 10.00
LICENSED CONTRACTORS DECLARATION
I hereby affirm that 1 am licensed under movisimm of Chapter 9
(commencing with Section 7000) of Division 3 of the Business and
Professions Code,.�fld my license is in full force n effect
License Clam!! � Lic. Number
Uatc =2:l� �j 1 Contmc
OWNER -BUILDER DECLARATION
1 herebyaffirm that I am exempt from the Contractor's License
P
Low: Any cityfollowing reason. hiche.uires Businessand toemeProfessions
Code: Any city or county which requiresa permit toconsuanc , also
improve, demolish, or repair any torci Prior to its Issuance, also
BLD
®
ECT. PLG. MECH.
R ❑
MISC. - REFER TO ORD
Ip` s4S I.i•UIN:�A�t�fJMIT
IN09111141 10N.I ,vv.
VALUATION WFT.
q
PERMIT ISSUANCE 6.00
ELEC. CONTR. LIC. NO. ELEC.
requires the applicant for such permit m file a signed statement that
permit
he is licensed pursuant to the provisions of the Contractor's License}
Law(Chapter 9(commencing with Section ]0001 of Division3of [he
Business and Professions Code) Or that he is exem [therefrom and
thebasisfor the alleged exemption. Any violation of5edi9n 70)15
TOTAL
e't'( ; §' `e PLUME �7+E �J>� pt ,i,:p,rn �+,•7•-^•
QTY .e PLUMBING PERMIT '_�r i+FEE-
..eSx>b ist.:.°'w'wd'AvK+EF4! YYsti'i'� �y3LL] 'd "•`+%�i1.
PERMIT TO
STORIES TYPE CO TR.
by any applicant for a permit subjects the applicant macivopenary
of not more than five hundred dollars (S500).):
'ALTER-DRAIN&VENT-WATER (EA.)4.00
3 V
113ACK FLOW PROTECT. DEVICE 2,00
DRAINS -FLOOR, ROOF, AREA, COND. 4.00
OCC. GROUP
a
REB. UNITS
❑ 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 Cun[mdor'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-
ments ire 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 of sale.).
❑ I, as owner of the property, am exclusively contracting with
licensed contractors to construct the project l5ec. 7044, Business
FIXTURES - PER TRAP 4.00
GAS-EA.SYSTEM-1 INC.40UTLETS 4.00
SO FT. FLOOR AREA
aff (000
O
TOTAL ACREAGE
avw,-OO
GAS- EA. SYSTEM - OVER 4 (EA.) 1.00
BUILDING USE
RES IND CON PB Other
❑ ❑ ❑ ❑ ❑
INDUSTRIAL WASTE INTER. 20.00
LAWN SPR INKLERS-1INC 5 V.B. 5.00
ASSESSORS PARCEL NO.
and Professions Code: The Contractor's License Law does not apply
to an owner of property who builds or improves thereon. and who
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s��p ..�3 -7-o
LAWN SPRINKLERS -OVER 5(EA.) 1.00
comm" is for such projects with a mmraclods) licensed pursuant to
the Contractor's License Law.
SEWER -SANITARY -STORM EA. 200ft/8.00
TRACT NO.
PARCEL NO.
WATER HEATER W/VENT 4.00
❑ l am exempt under Sec.-, BAP.C. for this
reason
Owner Date
WATER SYSTEM 4.00
ACC.DATE
ACC. FILE NO.
WORK ERS'COMPENSATION DECLARATION
WATER TREATING EQUIP. 4.00
1 hereby affirm that I have a cerrificatc of consent toself-insure,
or a certificate of Workers' Compensation Insurance, or a certified
ZONING
ENG. SITE NO.
a't{/A�, _
4 copy themml ( 0.1.ab�.I a
Policy N 5)ijsjl(gj
❑ Certlliedcopyls hereby lumishtd.
❑ Certified opy lite ith the city inspeaio d'
>< Applicant r?� j
FIRE SPRINK
Y ❑ N ❑
ENERGY TY4
y ❑ N❑
MISC. • REFER TO ORD.
PERMIT ISSUANCE 6.00
FLOOE
Y Cr N❑
A.L.O.c.
Y ❑ N❑
CERTIFICATE. OF EXEMPTION FROM ORKERS'
COMPENSATION INSURANCE
(This section need not be completed if the permit is for oneTOTAL
hundred dollars IS 100) or less.)
I certify that in the perlorm me. of the work for which this per
mit is issued, I shall not employ any Person in any manner so as to
hcwmcuibtcct tothe Workers'Compenmtion Laws of California.
Dote Applicant
PLG. CONTR. LIC. NO. M.G.
c� ev'tad Ci i:'a:t 4T.x' r +YEii
+y PS W-5
QTr MWic,f MECHANICAL PERMIT `''�' r FEE'
fats d d,.rf a. c_ }T ,,u iy z;a 'Ky�at t �,
t.'r,� `W'•''""'"
^"wR1RE SUMMARY'
,
ING
ALTER OR ADD TO MECH. 4.00
NOTICE TO APPLICANT: If. after making this Certificate of Lx-
empNon, you should become subject no the Workers' Compenmtlon
provisions of the Labor Code, you must forthwith comply with such provisions or this permit shall he deemed revoked.
APPLIANCE 4.00
CHECK
rKFEE
AIR HANDLING UNIT (TO 1QODOC.F.M.) 3.00CONSTRUCTION
AIRHANDLINGUNIT(OVER 10000C.F.M.) 5.00
IC FEEI
LENDING AGENCY
EXHAUSTHOOD (WITH DUCT) 2.00
hereby of irm that (here is a construction lending agency for
the performance of the work for which this permit is issued ISce.
3097. Civ.C.).
HEATING UNIT (TO 100,000 B.T.U.) 4.00ROFILM
HEATING UNIT (OVER 100,000 B.T.U.)7.50
ELECTRIC
Lender's Name
Lender's Address
II cemly that I have read this application and stale that the above
n fnrnalion 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 -CONK 13 H.P.or 100000 BTU.) 400
BOI LER-COMP (Over 10.000 BTU) SEE FEE SCH.
hereby authorize representatives of this city to enter upon the
above-mentioned property for inspection purposes.
(We) agree m save, indemnify and keep harmless the City of
Cupertino against liabilities, judgments, costs and expenses which
ma m nY way accrue a • 'nsl ' 'd City in consequence of the
gr Ing I'Ihia per ill.
MECHANICAL
MISC. - REFER TO ORD.
CONST. TAX
PERMIT ISSUANCE 3.00
MECH. CONT. LIC. NO. MECH.�tS
TOTAL
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