10873APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
BUILDING PROJECT IDENTIFICATION
APPLICATION &PERMIT
UILDING - ELECTRICAL- PLUMBING - MECHANICAL
PERMIT NUMBER
10873
ADDRESS
BUILDING lr �T
Qt L'
c7
OWNERS
w An 2
QTY, ELECTRIC PERMIT FEE
PLAN CHECK VALIDATION
e PHONE
�-
NOME CTORs
UTLETS-SWITCHES-RECEP 10.00/1.00
G ek t UC. NO.4p
LIGHTING FIXTURES 10.00/1.00
DATE OF APPLICATION
CONTRACTORS
. ADDRESS /%/F
(,y r S Jr PHONE �131
PPLIANCES- RESIDENTIAL 4.00
PANELS 10.00
RcwrecT
OR
O
ENGINEER -
LIC. No.
PANELS (OVER 200 AMP) 20.00
PLAN CHECK FEE P.C. NO,
- '
SIGNS TRANS. 3.00
ADDRESS ENG'
SPECIAL CIRCUIT 5,00
PERMIT VALIDATION
EMP. METER OR POLE INS. 20.00
ZIP
CJ ehfJ"�'`✓
APPLICANTS
ADDRESS
MOTORS SEE FEE'SCH.
SERVICE CHANGE 20.00
LICENSED CONTRACTORS DECLARATION
I hereby affirm that I am licensed under Provisions of Chapter 9
ISSUANCE DATE
(commencing with Section 7000) of Division 3 of the Business and
Professions Code d v license is in full force ff t
License Clss D Lie. Number
BLDG.
❑
I ELECT.
❑
PLG. I MECH.
❑
-
Date �Conlractar
BUILDING PERMIT
OWNER -BUILDER DECLARATION
I hereby cthe ollo that 1 am exempt from the Contractor's License
e. Professions
Law forAny
INFORMATION
MISC.- REFER TO ORD
VALUATION
$/FT.
PERMIT ISSUANCE 10.00
Code: Any city or county which requirese permit to construct, alter,
which requires a permit to
improve, demolish, or repair any rmit toff priors its issuance, also
requites the applicant for such permit to file a signed statement that
pursuant is licensed pursuato the provisions of the Contractor's License
ELEC.CONTP. LIC. N0.
ELEC.
TOTAL
IT TO
-PERMIT
QTY. PLUMBING PERMIT FEE
Law (Chapter 9 (commencing with Section 7000) of Division 3 of the
Business and Professions Code) Or 111.1 he is exempt therefrom and
the hasis for the alleged exemption. Any violation of$ection 7031.5
/11&:S7*
STORIES
TYPE CONSTR. .
by any applicant for a permit subjects the applicanllo a civil penally
of not more than five hundred dollars (5500).):
ALTER -DRAIN &VENT -WATER (EA.) 5.00
❑ I, as owner of the properly, 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
BACK FLOW PROTECT. DEVICE 4.00
OCC. GROUP
RES. UNITS
DRAINS -FLOOR, ROOF, AR EA, COND. 5.00
Code: The Contractor's License Law does not apply to an owner of
property who builds or improves thereon, and who does such work
FIXTURES - PER TRAP 5.00
SO.FT.FLOORAREA
TOTALACREAGE
himself or through his own employees, provided that such improve-
mentsare not intended or offered for sale. If, however, the building
GAS - EA. SYSTEM -1 INCA OUTLETS 6.00
or improvement is sold within one year Of completion, Ore owner.
builder will have the burden of proving that he did not build or am-
prove for purpose of sale.).
❑ 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
LAWN SPRINKLERS -I INC 5 V.B. 6.00
LAWN SPRINKLERS - OVER 5 (EA.) 1.00
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 for such projects with a contractor(s) licensed pursuant to
the Contractors License Law.
SEWEJI-SANITARY-STORM EA. 200ft/10.00
TRACT NO.
PARCEL NO.
❑ lam exempt under Sec. , BAP.C. for this
reason
WATER HEATER W/VENT 6.00
Owner Date
WATER SYSTEM 5.00
ACC. DATE
ACC. FILE NO.
WORKERS'COMPENSATION DECLARATION
WATER TREATING EQUIP. 5.00
I hereby affirm that 1 have a certificate ofcousent to self -insure,
ix k
or a certificate of Workers' Ccame anon In umnee ora reified
ZONING
ENG. SITE NO.
copytheific.t of Lab.0
Policy No. COmpany �/
FIRESPRINK
ENERGY T-24
❑ Certifiedcopy is herebyfurni ed.
❑ Cetlifse cop Med wjt the y Ins lios n division.
Applicant -F7E Vni
Y ❑ N❑
Y ❑ rv❑
MISC. - - REFER TO ORD.
CERTIFICATE OF EXEMPTION F M WORKERS'
PERMIT ISSUANCE 10.00
FLOOD ZONE
A.L.U.C.
PLG. CONTR. LIC. NO:
PLC.
TOTAL
COMPENSATION INSURANCE
(This section need not he completed if the permit is for one
Y❑ NE]
V❑ N❑
MECHANICAL PERMIT FEE
FEE SUMMARY
hundred dollars IS 100) or Ices.)
I certify that in the performance of the work for which this per-
mit is issued, 1 shall not employ any person in any manner so as to
BUILDING
become subject to the Workers' Compensation Laws of California
Date Applicant
ALTER OR ADD TO MECH. 5.00 Q
NOTICE TO APPLICANT: If, after making this Certi l'icate of Ex
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.
APPLIANCE 5.00
PLAN CHECK
FEE
AIR HANDLING UNIT (TO 10 C.F.M.) 4.00
AIR HANDLING UNIT PWC.F.M.) 6.00
SEISMIC FEE
CONSTRUCTION LENDING AGENCY
EXHAUST HOOD (WITH DUCT, ' 5.00
MICROFILM
I hereby affirm that there is a construction lending agency for
the performance of the work for which this permit is issued (Sec.t
3097, Civ.C.).
HEATING UNIT ( 0,000 B.T.U.) 8.00
HEATINGUNITi ER 100,00 .9.50
ELECTRIC
Lender's Name
Lender's Address
I certify that I have read this application and state that the above
information is correct. 1 agree to comply withall city and county
ordinances and stale laws relating to building conslruclion, and
VENTILATION FAN 4.00
PLUMBING
BOILER- COMP (3 H.P.O 1 0,000 B.T.U.) 6.00 -
g61LER-COMP (over 100,000 BTU) SEE FEE SCH.
MECHANICAL
3 O'a
hereby authorize representatives of this city to enter upon the
above mentioned property for inspection purposes.
(We) agree to save, indemnify and keep harmless the City of
Cupertino against liabilities, judgments, costs and expenses which
may in any y accrue against said C' in quence of the
grand f BQprmR
MISC. - REFER TO ORD.
CONST. TAX
PERMIT ISSUANCE 10.00 6
MECH. CONT. LIC. NO. TOTAL
3 (,
TOTAL
Sign OTApplicriTITIC.IHISCIVDe
OFFICE COPY .