10018APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
BUILDING PROJECT IDENTIFICATION
APPLICATION &PERMIT
BUILDING -ELECTRICAL- PLUMBING -MECHANICAL
PERMITNUMBER
10018
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OW ER N A#PLAN
Nam /`(
QTY- ELECTRIC PERMIT FEE
CHECK VALIDATION
L!['� PRONE
CONTRACT R3
ry E
UTLETS-SWITCHES-RECEP 10.00/1.00
/�z LIc. ND.
LIGHTING FIXTURES 10.00/1.00
DATE OF APPLICATION
CONTRACTOR'S
/ /i7AODPE 7 �(f /E
lr`"PRONES/
PPLIANCES- RESIDENTIAL 4.00
PANELS 10,00
ORRLXITECT
ENGINEER
uc. NO. -
PANELS (OVER 200 AMP) 20,00
PLAN CHECK FEE P.C. NO.
SIGNS TRANS. 3.00
noo ESS ENG.
SPECIAL CIRCUIT 5.00
PERMIT VALIDATION
ZIP
EMP. METER OR POLE INS. 20.00
PaD
APPLICANT a
ADDRESSoREss
MOTORS SEE FEE SCH.
fE1 y g
NOV
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 Code and my, license is in full force a f c!.
License Class 7�.Lic. Number %
BLDG. E MECH.
❑ ❑ ❑
Date bContmctor l�.�tiYalJktT
OWNER -BUILDER DECLARATION
1 hereby affirm that I am exempt from the Contractor's License
Law for the following reason. (Sec. 7031.5, Business and Professions
Code: Any city or county which requires a permit to construct, alter,
_
BUILDING ERMIT
INFOR ATION
MISC. - REFER TO ORD
PERMIT ISSUANCE 10.00
VALUATION
S/FT.
ELEC. CONTE. LIC. NO. ELEC.
TOTAL
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
PERMIT TO
Law (Chapter 9 (commencing with Section 7000) of Division 3 of the
Business and Professions Code) or that he is exempt therefrom and
OTY. PLUMBING PERMIT FEE
1
el
STO ES
YPE CONSTR.
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).):
ALTER -DRAIN -WATER IEA.) 5.00
❑ 1, as owner of the property, or my employees with wages as
sole compensation, will do the work, and the stmetum is not
BACKFLOW PROTECT. DEVICE 4.00
Oce. DRouP
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
'
FIXTURES - PER TRAP 5.00 Q
GAS - EA. SYSTEM - I INC. 4 OUTLETS 6.00
50. Fr. FLOOR AREA
TOTALACREAGE
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
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.).
D 1, as owner of the property, am exclusively contracting with
GAS EASYSTEM -OVER 4 IEA) 200
• . ..
- BUIL SE
IND PB Other
❑ ❑ ❑
INDUSTRIAL WASTE INTER. 30.00
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 - OVER 5 (EA.) 1.00
ssEsco BP RGEL No.
contracts for such projects with a contmctos(s) licensed pursuant to
the Contractor's License Law.
SEWER -SANITARY -STORM EA. 200ft/10.00
TRACT NO.
PARCEL NO.
❑ I am exempt under Sec. ,B.&P.C. for this
reason
WATER HEATER W/VENT 6.00
Owner Date
WATER SYSTEM 5.00
ACC. DATE
ACC. FILE N0.
WATER TREATING EQUIP. 5.00
WORKERS'COMPENSATION DECLARATION
1 herehy affirm that 1 have a certificate of consent to self -insure,
or a certificate of Workers' Compensation Insurance, or a certified
ZONING
ENG. SITE NO.
copy thereof (Sec. 3800, Lab .C.I /
Policy No. Company Ft"09, krp
FIRE SPRINK
Y ❑ N❑
ENERGY T-24
Y.❑ N❑
❑ Certified copy,is he I furnished.
A)}�Q Certified s B wi v city inspection division.
p$i an[
MISC- REFER TO ORD.
CERT . TP F@%IiM N OM WORKERS'
PERMIT ISSUANCE 10.00 /0146
FLOODZONE
A.L.U.C.
COM ENSATION INSURANCE
This section need not be completed if the permit is for one
PLG. CONTR. LIC. NO.
PLD.
TOTAL
Y❑ IN C]
Y❑ N
hundred dollars ($100) or less.)
I certify that in the performance of lire work for which this per-
mit is issued, I shall not employ any person in any manner so as to
OTY. MECHANICAL PERMIT FEE
I
FEE SUM ARV
BUILDING -
become subject to the Workers' Compensation Laws of California.
Date Applicant
ALTER OR ADD TO MECH. 5.00
NOTICE TO APPLICANT: If, after making this Certificate of Ex-
emption, you should become subject to the Workers' Compensation
APPLIANCE 5.00
PLAN CHECK
provisions of the Labor Code, you most forthwith comply with
such provisions or this permit shall be deemed revoked
,
FEE
AIR HANDLING UNIT (TO 10=C.F.M.) 4.00
AIRHANDLING UNIT(OVER 10PMC.EM.) 6.00
SEISMIC FEE
CONSTRUCTION LENDING AGENCY
I hereby affirm that there is a construction lending agency for
EXHAUST HOOD (WITH DUCT) 5.00
per 3097, performance of the work for which this permit is issued (Sec.
the
MICROFILM
HEATING UNIT (TO 100,000 B.T.U.) 6.00
HEATING UNIT (OVER 100,000 B.T.U.)9.50
ELECTRIC
Lender's Name
Lender's Address
I certify tja l have read this application and stale that the above
information is correct. I agree to comply with all city and county
it ordinances and state laws relating to building comw Ilion, and
VENTILATION FAN (SINGLE) 4,00
PLUMBING
-
BOILER-COMP(3 H. P. or 100,000 B.T.U.) 6.00
BOILER -COMP (Over 100,000 BTU) SEE FEE SCH.
MECHANICAL
./hereby authorize rcpresenmtives of this city to enter upon the
above-mentioned property for inspection purposes.
MISC. - REFER TO ORD.
CONST. TAX
,
(We) agree to sxv , ndert ify and keep harmless the City of
Cupertino aga' I' i ties dgments, costs and expenses which
may in an wa ce artist said City in consequence of the
PERMIT ISSUANCE. 10.00
grantln lh'
/
MECH. CONT. LIC. NO.
MECH.
TOTAL
TOTAL
SignhalFJK licant/C Tactor Date
f1` I - OFFICE COPY