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,"NT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
LD1 NG PROJECT I DENTI FICATION
-
APPLICATION & PERMIT
PERMIT NUMBER
BUILDING - ELECTRICAL -PLUMBING -MECHANICAL
09890
OWNER'S 1
NAME
i
QTY. ELECTRIC PERMIT FEE
PLAN CHECK VALIDATION
NE
CO TRACTORS
SME
Co OUTLETS - SWITCHES -RECEP 10.00/1.00 Q
sec. No.
DATE OF APPLICATION
.3 LIGHTING FIXTURES 10.00/1.00 (3
ADDRESSTofls
49(da L -ONE r'•+ r�C�+,
PPLIANCES- RESIDENTIAL 4.00
PANELS 10.00
on TCT
ENGINEER
LIC. No.
PANELS (OVER 200 AMP) 20,00
PLAN CHECK FEE P.C. NO.
ISIGNS TRANS. 3.00
ADDREss'ENG'
SPECIAL CIRCUIT 5.00
PERMIT VALIDATION
EMP. METER OR POLE INS. 20.00
ZIP
/
ADDRESSTs
MOTORS SEE F
SERVICE CHANGE 20.00
/ 1!D��
LICENSED CONTRACTORS DECLARATION
TEMP. POLEOCT nos0 QO
1 hereby affirm that I am licensed under provisions of Chapler 9
(commencing with Section 7000) of Division 3 of the Business and
Professions Ccr e,,��qy�Id my license is in full lore nd effartino
License Class -n L/ Cic. Numbe _
Date" �Con[mdo
fn Orsakl
BLD LE PUT MECH.
�'
-
OWNER -BUILDER DECLARATION
I hereby affirm that I am exempt from the Contractor's License
Law Code: Any
Code: Any city or county
city countyng whichrequires
sa Bmit reconstruct,
oconsuanc alter,
any
.BTOOLDIN PERMIT
INFORMATION
MISC.- REFER TO ORD
PERMIT ISSUANCE 10.00
VALUATION
S/FT.
ELEC. CONTR. LIC. NO. ELEC.
TOTAL J V
improve, d¢m0I15I1,Ul repair anyflNetllre, print LO its Issuance, a50
it structure, prior t
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 wit Or Sec than 7000) of Division 3 of the
PERMIT
Business and Professions Code) or that he is exempt therefrom and
QTY. PLUMBING PERMIT FEE
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 (5500).):
STORIES
TYPE CONSTR.
gLTER-DRAIN-WATER (EA.) 5.00
❑ 1, as owner of theproperty, or my employees with wages as
their Sole compensation, will do the work, and the structure is not
BACK FLOW PROTECT. DEVICE 4.00
OCC. GROUP
RES. UNITS
DRAINS -FLOOR, ROOF, AREA, COND. 5.00
intended or offered for sale (Sec. 7044, Business and Professions
Code: The Contractor's License Law does not apply to an owner of
F IXTUR ES - PER TRAP 5.0
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-
ments are not intended or offered for sale. If, however, the building
GAS-EA.SYSTEM-11NC.40UTLETS 6.00
or improvement is Sold within one year of completion, Ole owner-
builder will have the burden of proving that he did not build or im-
prove for purpose of sale.).
❑ 1, as owner of the property, am exclusively contracting with
GAS - EA. SYSTEM - OVER 4 (EA.) 2.00
RES IND CON PB Omar
❑ ❑ ❑ ❑ ❑
INDUSTRIAL WASTE INTER3000
. .
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
LAWN SPRINKLERS- 1 INC 5 V.B. 6.00
LAWN SPRINKLERS - OV -5 (EA.) 1.00
ASSESSORS PARCEL NO.
contracts for such projects with a conlmdor/5) licensed pursuant to
the Contractors License Law.
SEWER -SANITARY- A. 200ft/10.00
TRACT NO.
PARCEL NO.
❑ Iemexemptbnder Sec., B.&P.C. for this
reason
WATER HEATER W/VENT.�956.00
Owner Data
WATER SYSTE 5.00
ACC. GATE
ALC. FILE NO.
WATER TREATING EQUIP..,jina 5.00
WORKERS'COMPENSATION DECLARATION
1 hereby .1fnm that 1 have a certificate of consent to self -insure,
or a certificate of Workers' Compensation Insurance, or a certified
-
Clry01 QlAso--
ZONING
ENG. SITE NO.
copy thereof(See, 3800, Lase,�,y
Policy No. Compan' fFf�/zFL/T'%t-IA�-
FIRE SWINK
Y ❑ N ❑
ENERGY 24
Y ❑ No
❑ Certified copy is hereby furnished.
❑ Cer'Ie 'o i. d 't city inspection division.
Applies
MISC.- REFER TO ORO.
PERMIT ISSUANCE 10.00 d
CERTIFICATE. OF EXEMPTION PROM WORKERS'
FLOOD ZONE
A.L.U.C.
PLG. CONTR. LIC. NO.
PLG.
TOTAL.1
COMPENSATION INSURANCE
(This Section need not be completed if the permit is for one
Y ❑ N ❑
I Y ❑ N ❑
hundred dollars (S 100) or less.)
I certify that in the performance of the work for which this per
mil is issued, I shall not employ any person in any manner so as to
DTV. MECHANICAL PERMIT FEE
FEE SUMMARY
BUILDING
become subject to the Workers' Compensation Laws of California.
Dmc ApplicantALTER
OR ADD TO MECH. 5.00
NOTICE TO APPLICANT: If, after making this Certificate of Ex-
APPLIANCE 5.00
PLAN CHECK
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
FEE
AIR HANDLING UNIT (TO 10p000.F.M.) 4.00
AIR HANDLING UNIT (OVER 10=1C.RM.) 6.00
SEISMIC FEE
O
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 (70 100,000 B.T.U.) 8.00
HEATING UNIT 100,000 B.T.U.)9.50�/
ELECTRIC
Lender's Name �I Y'bl.:k��
Lender's Addre< _..
_
I certify that l have read fills application and state that the above
formation is correct. I agree to comply with all city and county
d 'nonce, and slide lows relating to building construction, and
-hereby authorize re resentative5 of this city to enter upon the
above-mentioned pr city for inspection purposes.
VENTILATION FAN (SINGLE) 4.00
PLUMBING
/ CC �✓
lV
BOILER- CONP(3 H. P. or 100,000 B.T. U.) 6.00
- BE10var 100,000 BTU) SEE FEE SCH.
MECHANICAL
MISC. - REFER TO ORD.
CONST. TAX
(We) agree to s e, indemnify and keep harmless the City of
Cupertino against abilities, judgments, costs and expenses which
m way ccrue against said City in consequence of the
PERMIT ISSUANCE 10,00
a i t "s iL
MECH. CONT. LIC. NO.
'
MECH.
TOTAL
TOTAL
i lure ol'A Iicanl/C tractor Date
'OFFICE COPY