10260 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALLPOINT PEN ONLY
_BUI LDI NG PROJEC IDENTIFI A'� i:-Dl t� y PERMIT NUMBER
I-„LDI, APPLICATION & PEI iT
u101,: 60
ADO_, / UILDING - ELECTRICAL-PLUMBING-MECHANICAL �� 1
N,NNNAL 's L vV }'Sy ` PLAN CHECK VALIDATION
NAA ',: „'"�.�.- �.....-:a`-:::�..ti�:»,.'.y.; ice.
QTY. ELECTRIC PERMIT'-�Y N C- FEES
PHarvE n m. ...,ELECTRIC
..:.: ., .. . r ".. .• ,i.. -
• C%TEO Rs /J OUTLETS-SWITCHES-RECEP 10.00/1.00
/z��LIC.No. LIGHTING FIXTURES 10.00/1.00
no R o-s APPLIANCES-RESIDENTIAL 4.00
�ln i
vrsON W PANELS 10,00 DATE OF APPLICATION
ARCHnECT PLAN CHECK FEE P.C.No.
on PANELS(OVER 200 AMP) 20.00
ENGINEER
IRC.No. ISIGNSTRANS. 3.00
ARCH.OR
ADDRESS ENO SPECIAL CIRCUIT 5.00 PERMIT VALIDATION
ZIP EMP.METER OR POLE INS. 20.00 4 ,
APPLICANT'S
ADDRESS MOTORS - SEE FEE SCH.
SERVICE CHANGE 20.00 1 I Si/p
Woo LICENSED CONTRACTORS DECLARATION TEMP.POLE 30.00 I 0
c I hereby affirm that I am licensed under provisions of Chapmr 9
2 w ISSUANCE DATE
vii 4 AA, (comi�ARUER
0)of Division 3 of the Business and BLDG. ELECT. PLG. MECH.
m z ProfeCode, MYe is in full force an ❑ ❑ ❑
O w LiceLic.Number
? m r DateContractor
c m or DECLARATIO ;;]t.:BUILDING PERMIT,�t'cylTil
E a o"j -'.t:'frINFORMATION #2; w I hereby affirm that I am exempt from the Contractor's License MISC.- REFER TO ORD
u o 4 Law for the following mason.(Sec.7031,$,Business and Professions , VALUATION $/FT.
- - PERMIT ISSUANCE 70.00
Code:Any city or county which requiresa permit to construct,alter,
4 0 improve,demolish.or repair any structure,prior to its issuance,also ELEC.CONTR. LIC.NO, ELEC.
C u requires the applicant for such permit to file a signed statement that TOTAL PER TO
w m he is licensed pursuant to the provisions of the Contractor's Licenu ` 3
r Z a
Law(Chapter 9(commencing with Section 7000)of Division 3 oflhe .ry,:�>;%1.,,q' t`• ""'-'+- - �',i^ I�1 -/yy
E F p Business and Professions Code)or that he is exempt therefrom and CITY.itr.[ "' PLUMBING PERMIT .,p Z
FEEa
o the basis for the alleged exemption.Any violation of Section7031 5 le STORIES TYPE CONSTR.
n ;m by any applicant fora permit subjects the :ant toocivil penalty ALTER-DRAIN of not mothan five hundred dollars(55 o).)emp
❑ I,as owner at the property,or my employees with re is not
BACK F LOW PROTECT. DEVICE 4.00 OCC.GROUP RES.UNITS
their sole compensation,will(S the work,and the structure rs not
intended or offered for sale(Sec. ]does Business and Professions 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.FLOOR AREA TOTAL ACREAGE
himself or through his own employees,provided that such Improve-
mentsarenotintendedorofferedforsale.If,however,the building GAS-EA.SYSTEM-11NC.40UTLETS 6.00
or'vn -provemeni is sold within one year of completion,the owner- GAS EA.SYSTEM-OVER 4 IEA.) 2.00
builder will have the burden of proving that he did not build or im- BUILDING USE
prove for Purpose of sale.). INDUSTRIAL WASTE INTER. 30.00 RES IND CON PB Omer
❑ I,as owner of the Property,am exclusively contracting with
licensed contractors to construct the project(Sec.7000,BusinessLAWN SPRINKLERS- 1 INC 5 V.B. 6.00
and Professions Code:The Contractor's License Law does not apply ASSESSORSPARCEL NO.
to antr owner of property who builds tr improves thereon.and who LAWN SPRINKLERS-OVER 5(EA.) 7.00
contracts Ict such Projects with a contracted sl licensed pursuant to
the Contractor's License law. SEWER-SANITARY-STORM EA.200ft/70.00 TRACT NO. PARCEL NO.
❑ 1 am exempt under Sec...B,&.p.C.for this WATER HEATER W/VENT 6.00
n'/ Datc WATER SYSTEM 5.00
�/ ACC.GATE ACG FILE NO.
O K ENSATION DECLARATION WATER TREATING EQUIP, 5.00
1 hereby affirm that 1 have a certificate of consent to self-insure,
or a certificate of Workers'Compensali n InsurgP e,or a cprtific ZONING ENG.SITE NO.
copy thereof(Sec.3800 pim, 1. WJ A-JI
Policy No. Company
❑ err ified copy' reby Is d. FIRE$PRINK ENERGYT
Z Z Certified y is filed t city nspection ravisio 24
FO A li,ant MISC- REFER TO ORD, v0 N� vE] N�
EC CERT( A OF EXEMPT( FR MWORK PERMIT ISSUANCE 10.00 FLOODZONE A.LU c.
.
LLC MPENSATION INSURANCE PLGCONTR. u1,.NO. PLG.
O (This section need not be completed if the permit is for one TOTAL v N� Y ry�
Z hundred dollars(S 100)or less.)
00 I certify that in the performance of the work for which this per QTY MECHANICA ~'FEE SUMMARY
1,.L I- mit is issued,1 shall not employ any person in any manner so as ro FEE
O L) become subject to the Worker Compensation Laws of California.
C. Date Applicant ALTER OR ADD TOM BUILDING
} 0NOTICE TO APPLICANT: If,after making this Certificate of Ex- 5.00
Z emption,you should become subject to the Workeri Compensation APPLIANCEPLAN CHECK
provisions of the Labor Code, you must forthwith comply with awl
U such provisions or this permit shall be doomed revoked AIR HANDLING UNIT(TO 4FEE.00
CONSTRUCTION LENDING AGENCY AIR HANDLING UNIT(OV AOOGEM.I 6.DO SEISMIC FEE
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 ISec ICROFILM
3097.Civ.CJ. HEATING UNIT(TO 100,000 B.T.U.) 8.00
Lender's Name
HEATING UN IT 100,000 B.T.U.)9.50 x
Lender's Address ELEC RIC
I certify that I have read this application and state that the above VENTILATION FAN (SINGLE) 4.00
Information is correct. I agree TO comply with all city and county' PLUMBING
ordinances and state laws relating to building construction, and BOILER-COMP(3 H.P.or 100,000 B.T.U.) 6.00
hereby authorize Top....native, of this city to enter upon the
above-mentioned propy for' ection purposes. BOILER-COMP (Over 100.000 BTUI SEE FEE SCH. MECHANICAL -?vt
(We) agree to save i nify and keep harmless the City of MISC.- REFER TO ORD. Ste/
Cupertino against i s,mjud toms, costs and expenses which ONST.TAX
may in a asci saitl City in c
gran oft onsequence of the PERMIT ISSUANCE 10.00
- MECH ONT. LIC NO. MECH.
OTAL
signal o PPlica /Contractor Date
OFFICE COPY