10280APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY .2_e'5'9
BUI LDI NG PROJECT 16ENTIFICATVMJ
APPLICATION & PERMIT
UILDING- ELECTRICAL- PLUMBING -MECHANICAL
PERMIT NUMBER
10280
a L«,NG
AobRss
OWNER'9
NAME
�.O.PHONE
QTY. ELECTRIC PERMIT FEE
PLAN CHECK VALIDATION
NAMERAcroes
CP;;VrWiP/ �aG+. io./7iSg
UTLETS-SWITCHES -RECEP 10.00/1.00
LIGHTING FIXTURES 10.00/1.00
CONTRACTORS
CONT
ACDFESs
PPLIANCES- RESIDENTIAL 4.00
Q
�.1� s 7;t. PHONE �.]'. a -Q S
DATE OF APPLICATION
PANELS 10.00
OgcMITECT
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
PE gTION
IN
EMP. METER OR POLE S. 20.00
ZIP
DEC ppEE
19UJ
APPLICANTS
AooREss
MOTORS SEE FEE SCH.
2 4�- • %S//
CEI}„E7 Of Cu .{,
�„'�
SERVICE CHANGE 20.00
LICENSED CONTRACTORS DECLA ATION
TEMP. POLE 30.00
1 hereby affirm that I am licensed under provisions of Chapter 9
(commencing with Section 7000) of Division 3 of the Business and
Professions fessns Code and my license is in full force and effect
Licemc Class_ - Lic.Number
ISSUANCE DATE
BLDG.
❑
ELECT.
❑
PLG
MECH.
❑
Date Contractor
OWNIi R -BUILDER DECLARATION
I hereby affirm that I am exempt from the Contractor's cense
Law or the following reason, (Sec. 7031.5, Bosluccsand Pr sslons
Code Any city or county whicbrequiresspermittoaonst cl,alter,
BUILDING PERMIT
INFORMATION
MISC.- REFER TO ORD
VALUATION
$/FT.
PERMIT ISSUANCE 10.00
ELEC. CONTR. LIC, NO.
ELEC.
TOTAL
inspro ', demolish, or repair any structure, prior to its ance, also
requires c applicant for such permit to file a Signe atement that
Ile is lice it pursuant to the provisions of the Cor,aclor', License
PERMIT TO
Law (Chap 9 (commencing with Section 70 of Division 3 of the
'
B.M. and ofasians Code) or that he i empt therefrom and
QTY.PLUMBING PERMIT - FEE
thebluesforth Ilegedesemption.Anyv' atkm.fSection703L5
byanyapplicant r a pemlit subjects It applicant toecivil penalty
ofnotmorethanfi hundoed(ollars 500).).
STORI
TV ECONSTR.
ALTER -DRAIN A.) 5.00
❑ 1, as owner o c property, my employees with wages a
their sole compennalio will do a work, and the structure is not
BACK F LOW PROTECT. DEV ICE 4.00
OCC. GROUP
RES. UNITS
DRAINS -FLOOR, ROOF, AREA, COND. 5.00
intended or offered for he IS . 7044, Business and Professions
Code The Contractor's LI n Law does not apply to an owner of
property who builds or imp es thereon, and who does such work
himself or through his ow m1 yees, provided that such improve-
Clem,senot intended offere r sale. If, however, the building
sa FT. FLOOR AREA
TOTALACREAGE
FIXTURES - PER TRAP 5.00 7,1"
GAS-EA.SYSTEM-11NC.40UTLETS 6.00 G.
or Impmverne, is so within one of completion, the owner -
builder will have th urden of provi o that he did not build or im-
prove for purpose fsaleJ.' -
❑ I, as uwn of [he property, am e Ivey contracting with
GAS - EA. SYSTEM - OVER 4 (EA.) 2.00
BUILDING USE
RES IND CON PB Ome
❑ ❑ ❑ ❑
INDUSTRIAL WASTE INTER. 30.00
licensed cant emrs to construct the projec Sec. 71,14, Business
and Profe ns Code. The Coatmetor's License w does not apply
to an ow er of property who builds or improves Teon, and who
LAWN SPRINKLERS - 1 INC 5 V.B. 6.00
ASSESSORS PARCEL NO.
LAWN SPRINKLERS - OVER 5 (EA.) 1.00
contra . for such projects with a contractor(O liven pursuant to
the Contractor's License Law.
❑ ImC exemptunder Sec. ,B.&P. I., this
rcpson
SEWER ANITARTORM EA. 200ft/10.00
TRACT no:
ACD. DATE
PARCEL No.
ACO. FILE NO.
WATER HE W/VENT ,6.00
Owner Date
WATER SYSTEM 5.00 4'0,
WATER TREATING EQUIP. 5.00
WORK E;RS'COMPENSATION DECLARATION
1 hereby affirm that 1 have a certificate of mment to s,IFmSCr,,
ZONING
ENG. SITE NO.
or a certificate of Workers' Compensalipn Insurance, or a certified
copy thereyf (Sec. 3800, Lab.0 1 a /�f�gH py
Policy N ��/`li%Q..mpany f/�
❑ Cerlifmd copy is hereby furnished-
Certified o s fityypp wth tpe city inspection divison.
Apicant •/IX.rs•to
FIRE SPRINK
Y ❑ N❑
ENERGY TQ4
Y ❑ N❑
MISC.- REFER TO ORD.
CERTIFICATE OF EXEMPTION FROM WORKERS'
PERMIT ISSUANCE 10,00%e
FLOOD ZONE
A.L.U.C.
COMPENSATION INSURANCE
ITh- section ed nut be completed if the Permit is for one
hundre s1$100)or less.))
Y E] NEI
Y ❑ N❑
PLG. CONTR. LIC. No.
.f/»QA/✓al. ,_ i7/
TAL /��'
I certify tha perm Bone of the work f hieh this per
mit is issued, 1 shatmploy any person i y manna w es to
_
CITY MECHANICAL PERMIT FEE
FEE SUMMARY
become wbjec[ to the Wor Compe - n Laws of California.
Date - Applicant
NOTICE TO APPLICANT. Iter m •this Cert ific3lc of Ex-
ALTER OR ADD TO MECH. - 5.00
BUILDING
APPLIANCE 5.00
AIR HANDLING UNIT (TO 10=C.F.M.) 4.00
PLAN CHECK
FEE
emption, you should a subject to the.Compensation
provisions of t abor Code, you most forthvo mply with
such provisi s or this permit shall be deemed revoked.
AIR HANDLING UNrNOVER 10=C.F.M.) 6.00
SEISMIC FEE
CONSTRUCTION LENDING AGENCY
I heEcpy afliml that there is a construction Icndxey for
the pada-Ilaf f the work for which t s issued ISec.
3097, Cl"E7
Lender's Name
EXHAUST HOOD (WITH DUCT) 5.00
MICROFILM
HEATING UNIT (TO 100,000 B.T.U.) 8.00
Lender's ress
HEATING UNIT (OVER 100,000 B.T.U.)9.50
ELECTRIC
VENTILATION FAN (SINGLE) 4.00
I vanity that 1 have read this applic.nou and at y the above
information is correct I agr c to comply with 311 city and county
ordinances and state laws relating to building construction, and
PLUMBING
801LER- COW (3 H.P. or 100,000 B.T.U.) 6.00
hereby au@orae representatives of this city to enter upon the
above-mentioned properly for inspection purposes.
BOILER -COMP 10ver 100,000 STUI SEE FEE SCH.
MECHANICAL
(We) agree to save, indemnify and keep harmless the City of
MISC. - REFER TO ORD.
Cupertino against liabilities, judgments, costs and expenses which
may in acru
tiny way ace against said City in cunrequence Of the
granting of/ is pc . I
/� 3/e
PERMIT ISSUANCE 10.00
CONST. TAX
MECH. CONT. LIG NO.
MECH.
TOTAL
TOTAL
Signature of Applicant/Contractor Ua[c
OFFICE COPY