10106APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
BUILDING PROJECT IDENTIFICATION
APPLICATION &PERMIT
BUILDING - ELECTRICAL- PLUMBING - MECHANICAL
PERMIT NUMBER
10106
DSc
A
ADDRESS
L f
OWNER'S
NAME
PHONE
CITY. ELECTRIC PERMIT FEE
PLAN CHECK VALIDATION
NA°TORSUTLETS-SWITCHES,
f 4 hlCqllA)6 LIC No. Q
RECEP 10.00/1.00
LIGHTING FIXTURES 10.00/1.00
nooaESSTORs
PPLIANCES- RESIDENTIAL 4.00
7'7D C I S T ONE o7$
DATE OF APPLICATION
PANELS 10.00
on
ENGINEER
LIC. NO
PANELS
PANELS(OVER 200 AMP) 20.00
PLAN CHECK FEE P.C. NO.
ISIGNS TRANS. 3.00
ARCH OR ADDRESS ENG.
SPECIALCIRCUIT 5,00
PERMIT VALIDATION
zIP
TEMP. METER OR POLE INS. 20.00
,f
K
noo ESSTS
MOTORS SEE FEE SCH.
SERVICE CHANGE 20.00
// p
LICENSED CONTRACTORS DECLARATION
TEMP. POLE 30.00
I hereby affirm! that 1 am licensed under provisions of Chapter 9
(Commencing with Section 7000) of Divisiorn�3' go fthe(��Bf}us�inursand
Professions Cod ICGn Li11 N full f0la
Number
ISSUANCE DATE
BLDG. ELECT. PLG. MECH.
0 0
Date Con
De[c Contractor t -LIJ�L
OWNER -BUILDER DECLARATION
I hereby affirm that I amm axe
exempt from the Contractor's License
BUILDING PERMIT
INFORMATION
MISC. - REFER TO ORD
PERMIT ISSUANCE 10.00
VALUATION
Law for the following reason, (Sec. 7031.5, Businessand Professions
Code: Any city or count ywhich requires OcDnittocowruct,
ELEC.CONTR. LIG NO.
ELEC.
TOTAL
boo
rmprOv0.ire applicant for su any structure, e fin, signed
ti, that
requires the applicant for such pemsit tool t a signed statement that
statement
pursuant to the provisions of the Contractor'sovist License
he is (Chapter
Law (Chapter 9 (commencing with Section of Division 3 of the
, PERMIT TO
Business and he alleged eCode) or that he is exempt therefrmn and
is exempt
the basis for the alleged exemption. Any applicant
of Section malty
by of moretha fora permit subjects th500).)cant toacivil penalty
of not more than floe hundred dollars (day
DTV. PLUMBING PERMIT FEE
STORIES
'TYPE CONSTR.
ALTER-DRAIN-WATER(EA.) 5.00
s with waits as
employees ❑ 1, as owner of the property, or my , and the
their sole compensation, will Jo the work, and the structure rs not
BACK FLOW PROTECT. DEVICE 4.00
OCC. GROUP
RES. UNITS
DRAINS -FLOOR, ROOF, AREA, COND. -5.00
intended or offered for sale (Sec. 7144, Business and Professions
Code: The Contractor's License Law docs not apply to an owner of
FIXTURES - PER TRAP 5.00
GAS - EA. SYSTEM -1 INC.4 OUTLETS 6.00
property who builds or improves thereon, and who does such work
himself or through his own employees, provided that such improve-
mentsare not intended or offcmd for sale. If. however, the building
S). FT, FLOOR AREA
TOTAL ACREAGE
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-
GAS - EA. SYSTEM - OVER 4 (EA.) 2.00
BUILDING USE
prove for purpose of sale.).
❑ I, as owner of the property, am exclusively contracting with
tr
RES IND CON PB Other
❑ ❑ ❑ ❑ ❑
. .
INDUSTRIAL WASTE INTER3000
licensed contractors to construct the project (Sec. 7044, Business
and Professions Code: The Contractor's License Law does not apply
to an owner of propsny who builds or improves themon. and who
LAWN SPRINKLERS- 1 INC 5 V.B. 6.00
LAWN SPRINKLERS - OVER 5 (EA.) 1.00
ASSESSORS PARCEL NO.
contracts for such projects with a contractors) licensed pursuant to
the Contractor's License Law,
❑ l am exempt under Sec.,B.&P.C. for this
reason
SEWER -SANITARY -STORM EA. 200tt/10.00
TRACT NO.
PARCEL NO.
WATER HEATER W/VENT 6.00
Owner Date
WATER SYSTEM 5.00
ACC.DATE
ACC. FILE NO,
WATER TREATING EQUIP. 5.00
W'ORRERS'COMPENSATION DECLARATION
1 hereby affirm that I have a certificate of consent m self-insurc,
ZONING
ENG. SITE NO.
or a certificate of Workers' Compensation Insurance, or a ecrtilrcd
copy the p f$r��I Lab C.)
Policy N oto pis n y.�1J%F
❑ Certified copy is herehy furnished.
`{O Cert;; �oPy iy_ Jd with t Ie city inspection division.
Abpli,Ce'-C_I7-LL
MISC.. REFER TO ORD.
FIRE SPRINK
y ❑ N❑
ENERGY T24
v ❑ N❑
CP-RTIFICATEOFEXEMPTION PROMWORRE-RS'
COMPENSATION INSURANCE.
(This section need not Ito completed if the permit is for one
PERMIT ISSUANCE 10.00
FLOOD ZONE
Y ❑ N❑
A.L.U.C.
.Y ❑' No
PLG. CONTR. LIC. NO,
PLG.
TOTAL
hundred dollars 151007 ar lis, J
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 m to
CITYMECHANICAL PERMIT FEE
FEE SUMMARY
become subject to the Worker' Compensation Laws of California.
Date Applicam
NOTICE TO APPLICANT: If, after making this Certificate of Ex-
ALTER OR ADD TO MECH. 5.00
BUILDING
APPLIANCE 5.00
PLAN CHECK
FEE
emption, you slsould become subject to the Workers' Compensution
provisions of the Lihor Code, you must forthwith comply with
such provisions or this permit shall he deemed revoked.
AIR HANDLING UNIT (TO 10,000C.F.M) 4.00
AIR HANDLING UNIT(OVER 10=C.F.M.) 6.00
SEISMIC FEE
CONSTRUCTION LENDING AGENCY
I hereby affirm that there is a construction lending agency for
the Performance of the work for which this permit is issued (Sec.MICROFILM
3097, Civ.C.)
Lender's Name
EXHAUST HOOD (WITH DUCT) 5.00
HEATING UNIT (TO 100,000 B.T.U.) B.00 g ^
Lender's Address
HEATING UNIT (OVER 100,000 B.T.U.) 9.50
ELECTRIC
1 certify that I have read this application andslate that the above
information is correct. I agree to comply with all City and county
ordinances and state laws relating to building construction, and
- VENTILATION FAN (SINGLE) 4.00
BOILER-COMP(3 H.P, or 100,000 B.T.U.1 6.00
PLUMBING
hereby mth.rve representatives of the city to enter upon the
above-mentioned property for inspection purposes.
BOILER -COMP 1 U)SEE FEE SCH.
MECHANICAL
MISC. - REFER TO ORD.
'
PERMIT ISSUANCE 10.00 Q ^'
(We) agree to Save, indemnify and keep InoCl. the City of
Cupertino against liabilities, ju ments, costs and cxpensea which
may i any way accrue agar t id City in Comequence of the
gylI0iof this permits
a6 k,
Slgnatore of APPBcant/Contract ate
CONST. TAX
MECH. CONT. LIC. NO.
[/�
f nUy
MECH.
TOTAL
r
TOTAL
OFFICE COPY