10830APPLICANT TO FILL IN INFORMATION WITHIN REDLINES — USE BALL POINT PEN ONLY
BU I LDING PROJECT IDENTIFICATIONPERMIT
APPLICATION & PERMIT -
BUILDING — ELECTRICAL— PLUMBING — MECHANICAL
NUMBER
O O
BUILDING
ADDRESS
I C�LaCoop
OWNER'S -
""ME
OTY. ELECTRIC PERMIT FEE
PLAN CHECK VALIDATION
-
CONTRACTORS -
NAME•
UTLETS-,SWITCHES -RECEP 10.00/1.00
LIGHTING FIXTURES '10.00/1.00
z uc. No.
,
CONTRACTOR'SPPLIANCES-RESIDENTIAL
ADDRESS x� s C'1�•
.4.00
PANELS .. .10.00
-7
C❑L -�, PHONE ql• 81
DATE OF APPLICATION
ARCHITECT
OR
ENGINEER
LIC. NO. _ -
PANELS (OVER 200 AMP) 20.00
PLAN CHECK FEE P.C. NO.
SIGNS TRANS.' 3.00 -
ARCH.OR ENG.
ADDRESS � �
SPECIAL CIRCUIT 5,00
PERMIT VALIDATION
-
EMP. METER OR POLE INS. 20.00
-, iIP
/
/
APPLICANTS
ADDRESS
MOTORS . ' SEE FEE SCH.
SERVICE CHANGE 20.00y1//
LICENSED CONTRACTORS DECLARATION
I hereby affirm that I am licensed under provisions of Chapter 9
(commencing with Section 7000) of Division 3 of the Business and
Professions Code and license is in full for a e �1,' `
Licens Class Lie. Nnobe��
DSIe Contractor kte
ISSUArJCE'DATE
BLDG.
❑
ELECT. I
❑
PLG. MECH.
❑
BUILDING PERMIT
ppo�
OWNER -BUILDER DFiCLARATIONTMb•\�
I hereby affirm that I am exempt from the Contractor's License
P
Law for
the nycit followingreason.on.ch c. requires a permit tocndtruct, mons
alter,
to its issuance,
Cade: Any mulish coo my whiny structure, prior
improve, demolish, or repair any structure, prior to its usuance, also
requires lite 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(commencing with Section 7000)of Division 3 of the
Business and Professions Code) or that he is exempt therefrom and
INFORMATION
'MISC. — '' REFER, TO ORD
A
I VALUATION
• . -
• $/FT.
PERMIT ISSUANCE - 10.00
ELEC. CONTR: LIC. NO. ELEC. ,
TOTAL
-
PERMIT TO '
p7
OTY. PLUMBING PERMIT FEE
STORIES
TYPE CONSTR.
the basis for the alleged exemption. Any violation of Section 7031.5
. 5. 0.0
ALTER -DRAIN -WATER (EA) 500
by any applicant for a permit subjects the applicant to a civil penally
of not more than five hundred dollars ($500)):
1, as owner of 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
BACK FLOW PROTECT. DEVICE 4.00
OCC. GROUP
RES. UNITS
DRAINS -FLOOR, ROOF, AREA, COND. 5.00
Code: The Contractor's License Law does not apply to an owner DI'
property who builds or improveadhereon, and who does such work
himself or through his own employees, provided that such improve-
ments are. not intended or offered for sale. If, however the building
...
-"
FIXTURES - PER TRAP 5.00
SD, FT. FLOOR AREA
TOTAL ACREAGE
-
GAS-EA.SYSTEM-11NC.40UTLETS 6.00
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 purpose of sale.).
❑ 1, 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
GAS - EA. SYSTEM - OVER 4 (EA.) 2.00
BUILDING USE
RES IND CON PB oma,
❑ ❑ ❑ ❑
INDUSTRIAL WASTE INTER. 30.00
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 Licensc Law.
❑ I am exempt under Sc,'..;B.&P:C. I'n, lhls
SEWER -SANITARY -STORM EA. 200ft/10.00
TRACT NO.
-' -
PARCEL NO.
WATER HEATER W/VENT 6.00 t,OO
reason
Owner Date
WATER SYSTEM - 5.00
ACC.DATE
ACC. FILE NO.
WATER TREATING EQUIP. 5.00
WORKERS'COMPENSA'I'ION D17CI-ARATION
I hereby affirm that I have a certificate of consent to self -insure,
or a certificate of Workers''C pensation Insurance. or a certified
ZONING
ENG. SITE NO.
copythereoff5e .IMA[ F [i•Z
Policy No. ma CoOS , i.L1R •
p
❑ Certified Ishemb r Rhed.
.q Cert p is f h tcDsp+'ision'
Appheant !/A/f
FIRESPRINK
Y ❑ N ❑
ENERGY T 24
'
Y ❑ ' N❑'
MISC.- REFER TO ORD.
CERTIFICATEOF EXEMPTION FROM WORKERS'
PERMIT ISSUANCE
FLOOD ZONE
A.W.O.
PCG. CONTR. NO,
1�CnQ 3J
PLG. `u OO
TOTAL
COMPENSAON INSURANCE ,
TI
section need not be completed if the permit is for one
Y❑ N❑
Y❑ N[:](This
OTY. MECHANICAL PFj�LA IT FEE
Ph v
FEE SUMMARY
hundred dollars ($100) or less)
I certify that in the performance of the work for which this Per.
mil is issued, I shall not employ any person in any manner so as to
become subject to the Worken' Compensation Laws of California.
Date Applicant
NOTICE TO APPLICANT: If, Her making this Certificate of Ex-
emption, you should become subject to the Workers' Compensation
BUILDING
go
ALTER OR ADD TO H.' rO 5.00
APPLIANCE, ' U 5.00
PLAN CHECK
provisions of the Labor Code, you must forthwith comply with
such provisions or this permit shall be deemed revoked.
-
'AIR HANDLING UNI OpODGF.\ .00
FEE '
AIR HANDLING UNIT(OVER1 ..M.)6.00
.SEISMIC FEE
CONSTRUCTIONLENDING AGENCY
I' 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.).
EXHAUST HOOD (WI CT) - 5.00
MICROFILM
HEATING UNIT (TO 100,000 B.T.U.) 8.00
HEATING UNIT(OV ER 100,000 B.T.U.) 9.50
ELECTRIC
Leader's Name
Lender Is Address
I certify that I have read this application and state that the above
1 Information is correct.,[ agree to comply with all city an0.counly
,ordinances and state laws relating to building construction, and
VENTILATION FAN (SINGLE) 4.00
PLUMBING
gQILER-COMPI3 H.P. Dr 100,000 B.T.U.) 6.00
,BOILER -COMP (Over 700,000 BTU) SEE FEE $CH.
MECHANICAL
'
mheby authorize representatives of this city to enter upon the
ve-mentioned property for inspection purposes.
.MISC. - 'REFER TO ORD.
CONST,.TAX
-
(We) agree m save, indemnify and keep harmless the City of
Cupertino . aIran Ku
es, judgments, costs and expenses which
may m way gainst said City in consequence of the
it I this pe
r�Lu�GTJ e2 I1 PG
PERMIT ISSUANCE' 10.00
TOTAL
MECH. CONT. IIC. N0. MECH./!
TOTAL
Signature of Applicant/Contractor Date
'OFFICE COPY