10281APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLYaSS9
"BUILDING PROJECT IDENTI FIC
,
PERMITNUMBER
-
APPLICATION Sl PENI
BUILDING -ELECTRICAL- PLUMBING - MECHANICAL
10281
' BUILDING
ADDRESS
NAME
r NA
PHONE a/.� J
QTY. ELECTRIC PERMIT FEE
PLAN PLAN CHECK VALIDATION
N^(M ERAOTORS
UTLETS-SWITCHES-RECEP 10.00/1.00
LIGHTING FIXTURES 10.00/1.00
osTTORSADs
APPLIANCES- RESIDENTIAL 4.00
-
pj PHONE -2 e -e!
DATE OF APPLICATION
PANELS 10.00
ARCHITECT
OR
ENGINEER
LIC. NO.
PANELS (OVER 200 AMP) 20,00
PIAN CHECK FEE P.C. NO.
SIGNS TRANS. 3.00
nDDDRESS OR ENO'
SPECIAL CIRCUIT 6,00
PERI Yl .TION
r��ll
EMP. METER OR POLE INS. 20.00
ZIP
DEC 3 1W
��sa�
pW�' WrfInu
ISSUANCE DATE
BLDG. ELECT. PLG. MECH.
E:1 ❑ ❑
APPLICANTS
ADDRE$$ A
ss �-- .S 9 /.-
MOTORS SEE FEE SCH.
SERVICE CHANGE 20,00
LICENSED CONTRACTORS DECLARATION
I hereby affirm that 1 am licensed under provisions of Chaplet 9
(ecmmcncing with Section 7000) of Division 3 of the Business and
Professions Code J n iceree is in full force and effec .
License Clens_ Lic. Number_Z;U.Sj�
Date _���3 - Contra<lor�p7�jq
TEMP. POLE 30.00
BUILDING PERMIT
INFORMATION
OWthat I UI exem UECLA RA'T']ON
I hereby allirm that I am cxcnlpl Gam the Contractor's License
Law for the following reason. (See. 7031.5, Business and Professions
Code: ny city or county which structure permit to issuance,
MISC. - REFER TO ORD
PERMIT ISSUANC 10.00
VALUATION
S/FT.
ELEC-CONTH. LIG. NO.
C
TO L
improv tlenmlish, or repair any slrudum, prior to its issuance, also
is also
reruires - applicant for such permil to tilt a signed statement that
he is liters ursuanl to the provisions of the Cunlrnc is Licence
p MIT TO
Law (Chapter commencing with Sect inn 7000) of D' Ision3oflhe
Business and Pro ions Code) or that he is exenr therefrom and
QTY. MBING PERMIT FEE
the basis for the aIle exemption. Any violatiot fSection 7031.5
by any applicant for a it%objects the uppl'artl to a civil penalty
of not more than Eve lua ed dollars (5500
STO ES YPE CONSTR.
ALTER -DRAIN (EA.)
❑ I, as owner of the pr eRy, or my mployces with wages as
their sale compensation, will the w , 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 ( . 7 4, Business and Professions
Code: 'rhe Contractor's License L docs not apply to an owner of
FIXTURES- PER TRAP 5.00
GAS-EA.SVSTEM-11NC.40UTLETS 6.00
property who builds or improves I on, and who don such work
himself or through his own em yees, rovided that such improve-
mentsarenotintcndedorofl cJ for salt Lhoweveq the budding
SU, FT. FLOOR AREA
TOTALACREAGE
or hnprovement is soN wit none year of mpletion, the owner -
builder will have the bur n of proving that h id not build or Up-
GAS - EA. SYSTEM -OVER 4 (EA.) 2.00
BUILDING USE
Prove for purposeofsa.).
❑ I, as owner of le property, . tr ct ing with
RES IND CON PB Ome.
❑ ❑ ❑
INDUSTRIAL WASTE INTER. 30.00
LAWN SPRINKLERS- 1 INC 5 V.B. 6.00
licensed cont ratio to construct the project (See. 4, Business
he rojectiv Se
and Professions dc: The Contractor's License Law If of apply
ASSESSORS PARCEL NO.
LAWN SPRI S -OVER5 IEA.) 1.00
to an owner o property who builds or improves thereon, nd who
DO ntracts for uch projects with a contradorl sl licensed pursuant to
the Contractor's Li cense Law.
❑ lam exempt under Sec,-,B.&BC. for this
reason
SEW -SANITARY- ORM EA, 200ft/10.00 D-
TRACT NO.
PARCEL NO.
WATER HEATER W/VENT 6.00
•�
Owner Date
WATER SYSTEM 5.00
ACC. DATE
ACG FILE NO.
WATER TREATING EQUIP. 5.00
WORK ERS'COMPENSAIION DECLARATION
1 hereby affirm that I have a certificate ofemsenl to self -insure.
ZONING
ENG. SITE NO.
or a certificate of Workers' Compensation Insurance, or a certified
copy there pfJScc. 3800, LAI, .C.l.
Poo Cerci T/f„opyis hereby -/K
❑ Certified copy is hereby furnished.Certified co�py is li4ed the with the city inspection division.
Applicant;�_�lyV.�i_�
MISC.- REFER TO ORD.
FIRE BPRINK
Y[D N
ENERGY TTO
rE] NQ
CERTIFICATE 017 EXEMPTION FROM WORKERS'
COMPENSATION INSURANCI:
(This section need not be completed if the permit is for one
PERMIT ISSUANCE 10.00 le.
FLOOD ZONE
Y 1:1 NEI
A.L.U.C.
Y E] NEI
PLG. CONTR. LIC. NO.
aQ�
PLG.
TOTAL �.
hundred dollars 1$ 100) or IcssJ
1 mm in the perfommnce of the wark For which this per-
mit is issue all not employ any person in any manner so as to
QTY MECHANICAL PERMIT FEE
FEE SUMMARY
becomesuWscl to nrkeri Compensation Laws of California.
ALTER OR ADD TO MECH. 5.00
Date A
'rit
NOT' CE TO API'L Cn N'f: IL raking til' uniEcutc of pix-
BUILDING
APPLIANCE 5.00
PLAN CHECK
FEE
emption, you should become subject m rkers'Compunmtion
provisions of the Iatror C must for Inti I comply with
such provisions or this mit shall be d.cmcd revoked.
AIR HANDLING UNIT (TO 10A00C.F.M,) 4.00
AIR HANDLING UNIT(OVER 10MC.F.M.) 6.00
SEISMIC FEE
� CONSTRUCTION LENDING AGENCY
EXHAUST HOOD (WITH DUCT) 5.00
�that there is a construction lend�pg agency for
I hercby�T1'+;�Z
MICROFILM
the perfarmanc' k for whichthissued (Sec.
3097CivC.).
Lenderi Name
HEATING UNIT(TO 100,000 B.T.U.) 8.00
Addre_
HEATING UNIT (OVER 100,000 B.T.U.) 9.50Lender's
ELECTRIC
1 certify that 1 have read this application and state that [be above
VENTILATION FAN (SINGLE) 4.00
information is correct. I agree to comply with all city and county
ordinances and state laws relating m building convtmetion, and
BOILER COMP(3 H.P. or 100,000 B.T.U.) 6.00
PLUMBING
hereby authorize representatives of the city to enter upon the
above-mentioned property for inspection purposca.
BOILER -COMP (Over 100,000 BTU) SEE FEE SCH.
MECHANICAL
(we) agree to save, indemnify and keep hermlc s the City of
Cupertino against Babllilies, judgments, costs and ext'enses which
may in any way a e against said City in c'mati utnce of the
MISC. - REFER TO ORD.
PERMIT ISSUANCE 10.00
CONST. TAX
granfing of la perfiv
/, - A, --.es
MECH. CONT. LIC. NO.
MECH.
TOTAL
TOTAL
!�
Signature of Applicant/Contractor Date
OFFICE COPY