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APPLICANT TO FILL IN INFORMATION'WITHIN RED LINES -'USE BALL POINT PEN ONLY
BUILDING PROJECT I DENTIFICATI ON
APPLICATION & PERMIT
- ELECTRICAL- PLUMBING - MECHANICAL
PERMIT NUMBER
12 31 '6
BUILDING ,
ADDRESS
'BUILDING
NwN1ERrr'5 ' / C -t -6
JV
OTY. ELECTRIC PERMIT FEE
PLAN CHECK VALIDATION
T,eV ( tel �Yl�e dtid
r
NAME croRs "
NAME
LIC. No.
UTLETS-SWITCHES -RECEP 10.00 .00,
LIGHTING' FIXTURES 10.00/1.00
CONTRA
ADDRESS ons
PPLIANCES R SIDENTIAL .00
PANELS f0.00
PHONE
DATE OF APPLICATION
- -
OR
OR
ENGINEER
' LIC. No.
PANELS 200AMP) 20.00
PL AN CHECK FEE ,, P.C. No.
St STRANS. ' 3.00 -
ARCH.ORENG.- - -
ADDRESS
' '•eIP
$ LCIRCUI 5.00
-
PERMIT VALIDATION
,
E P. ETER OR PotrMS. 20.00
APPucnrvrs
ADDRESS "
MO .SEE FEE SCH.
'S S EFVkk CHAN 20.00
LICENSED CONTRACT S DECLARATION
I hereby affirm that I am lice it under provisions of Chapter 9
ISSUANCE DATE
(commencing with Section 700 of Division 3 of the Business and
Professions Code, and my llcen • Is In full force and effect.
License Class " C.Namber
BLDG.
- ❑
ELECT.
❑
PLG. MECH.
� I'{y
114YII
Urate .oltrictor
I I
'
BUILDING PERMITJ
OWNER -NUI ER DECLARATION
hereby affirm that I so xe from the Contra m's Litt
Law for the following rcaso (Sec.e. 7 7031.5, Bus ossa dl'ro
Code: Any city or county 1 fell requires a perm t o cc nsml... alter,
improve, demolish, or reps' ny structure, prio t Ys issuance, also
requires the applicant for s l.permit to file a si ne s element that
he is licensed pursuant to 1 provisions of the ntc for's License
Law (Chapter9 (commenc with Section 7000) fUi sion3oflhe
Business and Professions e) or that be is exe of th efrom and
the basis for the alleged axe prion. Any violatio of5ec n7031.5
INFORMATION
MSC. - REFE TO ORD r
VALUATION
�SIFT.
10.00
LEC. CONTR. LIC. NO. ELEC.
- TOTAL
PERMIT TO
A
OTY. PLUMBING XRMIT FEE i
STORIES
TYPE CONSTR.
by any applicant for It pemu III 'ca hoses penalty
of not more than five hundre I o ars ($500)J:
gLTER-DRAIN&VE-WATER(EA.) 5.00
❑ I, as owner of the pro arty, or my emplo ee with gas as
their sole compensation, will to the work, and t e ructus is not
intended or offered for sale Sec. 7044, Busin s u d Note signs
' BACK FLOW PROT CT. DEVICE 4.00 -
occ. GROUP
RES. UNITS
DRAINS -FLOOR OOF, AREA, COND. 5,00
Code: The Contractor's Licen. law does not a ly ) an owner of
property who builds or impro •s thereon, and to es such work
himself or through his own em oyces, provided ills such improve-
mems are nolimended or offers forsale. If, IV eq the building
`.
FIXTURES -P TRAP 5.00
SO. FT. FLOOR AREA
'
TOTAL ACREAGE
GAS-EA.S TEM-11NC.40UTLETS 6.00
or improvement is sold within o - year of co tion, tam owner-
builder will have the burden of pr ving that h d not build or im-
pr ve for purpose ofsale.I
Xc I, as owner of the properly, a exclu ely contracting with
GAS - E SYSTEM -OVER 4 (EA.) 2.00
BUILDING USE
RES IND CON PB Omer
0-0 ❑ ❑ ❑
INDU RIAL WASTE INTER. 30.00
L N SPRINKLERS- .B. 6.00
AWN SPRINKLERS - Mk 5 IEA 1 1.00
. ASSESSORS PARCEL NO.
licce d contractors to construct the ojec (Sec. 7044, Business
and Professions Code: The Contractor's ence Law does not apply
to an owner of property who builds or int vies the,eon. onJ who,
contracts for such projects with a contractors -enseA pursuant to
the COmra'tois License Law .
•
$EWERSANITAR V- 10.00
TRACT NO.
PARCELNO.
❑ I un pt Rude S c.R&P.C. I'.. this
WATER HEATER 6.00
rCesull'
Owner Dute U11a V 9
WATER SYSTEM .00
ACC. DATE
ACC. FILE N0.
WATER TREAT G I1
WORKERS'COMPENSATION DECLARATION
I hereby affirm that I have a certificate of consent to self -insure,
or a certificate of Workers' Compensation Insurance, or a certified
ZONING
ENG. SITE NO.
copy thereof (Sec. 3800, Lab.0 L
Policy No. Company
FIRESPRINK
Y ❑ N❑
ENERGY T-24
v ❑ N❑
❑ Certified copy is hereby furnished
❑ Certified copy, is: -filed with the city inspection division.;
Applicant
MISC. - R T D.
CERTIFICATE OFEXEM PTION FROM WORK ERS'
PERMIT ISSUANCE 10.00 .0
FLOOD ZONE
A.L.U.c.'
PLG. CONTR. LIC. NO.
_
PLG. '
'TOTAL 'O
COMPIiNSA'PION INSURANCE ';
(This section need not be completed if the permit Is for one
Y ❑ N ❑
Y ❑ • N❑
OTY MECHANICAL PERMIT FEE
-
FEE SUMMARY
hundred dollars IS 100) or less.) ".
I certify that in the performance of the work 'or which this per'
nail is issued. I shall not employ any person in any manner so as to
become subject to the Workers' Compensation Laws of California.
Date Applieant `
BUILDING
ALTER OR ADD TO MECH. 5.00
NOTICE TO APPLICANT: if, after making this Certificate of Ex-
emption, you should become subject tV the Workeri Campalsarlon
provisions of the Labor Code, you must forthwith comply with
such provisions or this permit shall be deemed revoked
APPLIANCE 5.00 -
PLAN CHECK
FEE
_IftAIR HANDLING UNI 10 ,000GF M.) 4.00
AIR HANDLINGUNI ,M.) 6.00
-SEISMIC FEE
CONSTRUCT' ION LENDING AGENCY
EXHAUST HOWff DUCT) 5.00
'
MICROFILM
^
1 hereby affirm that there Is a construction lending agency for
the performance mf the work for which this permit Is issued (Sec
3097, Civ.CJ. a -
HEATING UNIT ITO 1 8.00
ELECTRIC
Lender's Name
Lender's Address
',HEAT: NG UNIT( 00,000 B.T.U.19.50
I certify that I have read this application sad state that the above
information is correct. I agree to comply with all city and county
ordinances sad state laws relating to building construction, and
hereby authorize representatives of this city to enter upon the
above-mentioned property for inspection purposes.
VENTILATION FAN (SINGLE) 4.00
PLUMBING
iv
BOILER-COW(3H.P.or100,000B.T.U.1 6.00
BOILER-COMP .(Over 100,000 BTU: SEE FEE SCH.
MECHANICAL
MISC. - REFER TO ORD:
(We) agree to save, indemnify and keep harmless the City nl
Cupertino against liabilities, judgments, costs and expenses which
may ln1any way racer again said .ity iton"pence of the
gm his per,
r_9 6�
CONST. TAX
'
PERMIT ISSUANCE 10.00 �G --
MECH. CONT. LIC. NO. MECH,
TOTAL /T --
TOTAL
,
Signature of App cant/Contractor Date
01=1 -ICE COPY