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APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
' ,BUILDING PROJECT 1 DENTI F�ION
APPLICATION & WIT
BUILDING - ELECTRICAL- PLUMBING - MECHANICAL
PERMIT NUMBER -- -
11560
rBWLE1ING' Frm- s
ADDRESS r
OwNER'a
OTY. ELECTRIC PERMIT FEE
PLAN CHECK VALIDATION
DATE OF APPLICATION
NANTRAcr �(
wNAME U%/YL��"�✓
-F � tic, N.JZ,.962.3
OUTLETS-SWITCHES-RECEP 10.00/1.00
LIGHTING FIXTURES 10.00/1.00
CONTRACTORS DDRESS
/4)V1 2- `/fj �C'(r� PHONE/J"03�
PPLIANCES-RESIDENTIAL 4.00
PANELS 10.00
ARCHITECTPANELS
OR
ENGINEER
LIC. NO.
(OVER 200 AMP) 20.00
PLAN CHECK FEE P.C. NO.
SIGNS TRANS. 3.00
EOR Esc.
ZIP
SPECIAL CIRCUIT 5,00
PERMIT VALIDATION
ISSUANCE DATE
TEMP. METER OR POLE INS. 20.00
APPLICANTS
ADDRESS
MOTORS SEE FEE SCH.
SERVICE CHANGE 20.00
LICENSED CONTRACTORS DECLARATION
1 hereby affirm that,) am licensed under provisions of Chapter 9
(commencing with Section 7000) of Division 3 of the Business and
Professions Co,y, and; y 'cense is in full force nd Cf e L p
License C'sg + Lie.is Number
BLDG.
❑
ELECT.
❑
PLG. MECH,
ryl O
Date Contractor
OWNER -BUILDER DECLARATION
I hereby affirm that I um exempt from the Contractor's License
Law ferrite following reason. (See. 7031.5, Business and Professions
Code: Any city or county which requires a permit to construct, alter,
Improve, demolish, or repair any structure, prior In 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
Law (Chapter 9 (commencingwith Section 7000) of Division 3 of the
Business and Professions Code) or that he is exempt therefromnd
the basis for the alleged exemption. Any violation of Section 7031a .5
byanyapplicantforapermitsubjectstheapplicant to a civil penalty
of not more than five ... dred dollars (5500).):
❑ I, as owner ol'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 Contractor's License Law docs not apply to an owner of
property who builds or improves thereon, and who docs such work
himself or through his own employees, provided that such improve-
mentsarenotintendedorofferedforsale. 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 as owner of sale.).
❑ I, as owner of the property, am exclusively contracting with
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 contractorts) licensed pursuant to
the Contractor's License Law.
❑ lam exempt under Sec. ,B.&P.C. fUr111i9
reason
BUILDING PERMIT
INFORMATION
MISC.- REFER TO ORD
VALUATION
$/FT.
PERMIT ISSUANCE 10.00
ELEC. CONTE. LIC. NO.
ELEC.
TOTAL
PERMIT TO
rSL yD
Y V
OTY. PLUMBING PERMIT FEE
STORIES
TYPE CONSTR. -
gLTER-DRAIN-WATER (EA.) 5.00
BACK FLOW PROTECT. DEVICE 4.00
OCC. GROUP
RES. UNITS
DRAINS -FLOOR, ROOF, AREA,COND. 5.00 30-
FIXTURES - PER TRAP S.OD
SD. FT. FLOOR AREA
TOTAL ACREAGE
GAS - EA. SYSTEM - I INC. 4 OUTLETS 6.00
GAS - EA. SYSTEM -OVER 4 (EA.) 2.00
BUILDING USE
RES IND CON PB Omer
0 ❑ ❑ O 0
INDUSTRIALWASTE INTER. 30.00
LAWN SPRINKLERS - 1 INC 5 V.B. 6.00
ASSESSORS PARCEL NO.
LAWN SPRINKLERS - OVER 5 IEA.) 1,00
SEWER -SANITARY -ST 200ft/10.00
TRACT NO.
PARCEL NO.
ER HEATER W/VCNT 6.00 -�
WATEA C)
Owner Date
WORKE:RS'COMPENSA'IION DECLARATION
1 hereby affirm that I have a certificate ofconsent to self -insure,
or a certificate of Workers' Compensation Insurance, or a certified
copy thereof (Sec. 3800, Lab.C.).
Policy No. Company
❑ Certified copy is hereby furnished.
❑ Certifie y is 01,•d- wit a Il s e on division.
Applicant ja- 4, ;& f§��_
WATER SYSTEM I 5.00
ACC. GATE
ACC FILE NO.
WATER TREATIN QUIP.. 5.00
I l�B�
ZONING
ENG. SITE NO.'
_
FIRE SPRINK
v 1 n �
ENERGY T 24
v ❑ N❑
MISC. - REFER TO ORD.
CBRTIFICATEOFI OXO PROM WORKERS'
COMPS ATION INSURANCE
(This section need not be completed if the permit is for one
Im odred dollars IS 100) or [Co.)
I certify that in the performance of the work for which this per -DTV.
mit is issued, I shall not employ any person in any manner so as to
become subject to the Workers' Compensation Laws of California.
Date Applicant
PERMIT ISSUANCE 10.00 O �
FLOOD ZONE
Y� N�
A.L.U.C.
V� N�
PLG. CONTE. LIC. NO.
-
PLG. 3s-
TOTAL
MECHANICAL PERMIT FEE
FEE SUMMARY
BUILDING
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
provisions of the Labor Code, you must forthwith comply with
such provisions or this permit shall be deemed revoked.
CONSTRUCTIONLENDINGAGE.NCY
1 hereby affirm that there is a construction lending agency for
the performance of the work for which this permit Is issued (Sec.
3097, Civ.C.).
Lender's Name
APPLIANCE 5.00
PLAN CHECK
FEE -
AIR HANDLING UNIT (TO 10=CF.M.) 4.00
AIR HANDLING UNIT(OVER 10=C.F.M.) 6.00
SEISMIC FEE
EXHAUST HOOD (WITH DUCT) 5.00
MICROFILM
HEATING UNIT (TO 100,000 B.T.U.) 8.00
HEATI NG UN IT (OV E R 100,000 B.T.U.) 9.50
ELECTRIC
Lender's Address
I certify that I have read this application and slate that the above
information is correct. I agree to comply with all city and county
ordinances and state laws relating to building construction, and
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 way accrue against said City in consequence of the
gra retia p rmi .MECH.
�y (
VENTILATION FAN (SINGLE) 4.00
PLUMBING
/ AS
BOILER-COMPl3 H.P. or 100,000 B.T.U.) 6.00
BOILER -COMP (Over 100,000 BTU) SEE FEE SCH.
MECHANICAL
MISC. - REFER TO ORD.
CONST. TAX
PERMIT ISSUANCE 10.00
CONT. LIC. NO. MECH.
TOTAL
TOTAL
Signature of Ap cant/Contractor [
OFFICE COPY