10726APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
BUILDING PROJECT IDENTIFICATION,
APPLICATION & PERMIT
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BUILDING -ELECTRICAL- PLUMBING - MECHANICAL
PERMIT NUMBER
10726
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OWNER'S -
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ELECTRIC PERMIT FEE
PLAN CHECK VALIDATION
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OUTLETS•SWITCHES-RECEP 10.00/1.00
LIGHTING FIXTURES - 10.00/1.00
LIC. NO.
ADDRESS ofl's
ADDRESS
PPLIANCES- RESIDENTIAL 4.00
PANELS 10.00
PHONE
DATE OF APPLICATION
ARCHITECT -
OR
ENGINEER
LIC. No.
PANELS (OVER 200 AMPI 20.00
I
PLAN CHECK FEE P.C. NO. '
'
SIGNS TRANS. 3.00
AARCH, OR DDRESS ENG.
ZIP
SPECIAL CIRCUIT 5.00
PERMIT VALIDATION f
EMP. METER OR POLE INS. 20.00
APPLICANTS
aooREss
MOTORS SEE FEE SCH.-
SERVICE CHANGE 20.00
/
LICENSED CONTRACTORS DECLARATION
I hereby affirm that I am licensed under provisions of Chapter 9
ISSUANCE DATE
(commencing with Section 7000) of Division 3 of the Business and
Professions Code, and my license is in full force and effect.
License Class Lie. Number
BLDG.
❑
ELECT.
❑
PLG. MECH.
❑
Date Contractor
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BUILDING PERMIT
On that I am exemptthe C at -
1 hereby affirm that I am exempt from'the Contractor's License
from
Law for the following reason. (Sec. 7031.5, Businessand Professions
Code: Any city or county which requiresapermit to construct, alter,
improve, demolish, or repair any structure, prior to its issuance, also
INFORMATION
MISC. - REFER TO ORD
VALUATION
SIFT.
PERMIT ISSUANCE 10.00
-
ELEC. CONTR. LIC. N0.
ELEC.
requires the applicant for such permit to file a signed statement that
he is licensed pursuant to the provisions of the Contractor's License
TOTAL
PERMIT TO
OTV. PLUMBING PERMIT FEE
Law (Chapter 9(commencing with Section 7000) of Division 3 ofthe
Business and Professions Code) or that he is exempt therefrom and
the basis for the alleged exemption. Any violation of Section 7031.5
STORIES
TYPE CONSTR.
ALTER-DRAIN-WATER(EA.) 5.00
by any applicant for a permit subjects the applicant toa 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 F LOW PROTECT. DEVICE 4.00
OCG. GROUP
RES. UNITS
DRAINS -FLOOR, ROOF, AREA, COND. 5.00
Code: The Contractor's License Law does not apply to an owner of
property who builds or.improves thereon, and who does such work
F IXTUR ES - PER TRAP 5.00
SO, FT. FLOOR AREA
TOTAL ACREAGE
himself or through his ownemployees; provided tlmt such improve-
mentsamnotintendedorofferedforsale. If, however, the building
GAS EA. SYSTEM -1INC. 4OUTLETS 6.00
OF improvement is sold within one year of completion, the owner-
buil •r will have the burden of proving (hat he did not build orm-
P for purpose ofsale.). -
' 1, as owner of the property, am exclusively contracting with
GAS - EA. SYSTEM - OVER 4 (EA.) 2.00
BUILDING USE
RES IND CON PB oche,
❑ ❑ ❑ - ❑ ❑
INDUSTRIAL WASTE INTER. 30.00
LAWN SPRINKLERS - 1 INC 5 V.B. 6.00
LAWN SPRINKLERS - OVER 5 MA.) 1.00
ASSESSORS PARCEL NO.
,
lic sed contractors to construct the project (Sec. 7044, Business
an Professions Code: The Contractor's License Law does not apply
to an owner of property who builds or improves thereon, and who
co tracts for such projects with a contractords) licensed pursuant to
the Contractors License Law.
SEWER-SANITARYST 2001t/10.00
TRACT NO,
PARCEL NO.
I a eNe pt u er , BAP.C, for this
WATER HEATER W/V 6.00
`Ram'
wner Date
WATER SYSTEM 00 5.00-
ACC. DATE
ACC. FILE No.
WATER TREATIN 1 5.00
WORKERS'COMP. SAT DI:CLARATIO
1 hereby affirm that I have a certificate of consent to self -insure,
or a certificate of Workers' Compensation Insurance, or a certified
�n0
ZONING
ENG. SITE NO.
copy thereof (Sec. 3800, Lab.C.). ,
Policy No. Company _
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FIRE SPRINK
Y [3 E]
ENERGY T 24
Y [3 E3
❑ Certified copy is hereby furnished.
❑ Certified copy is filed with the city inspection division.
Applicant
MISC. - REFER -TO ORD.
CERTIFICATE OF EXEMPTION FROM WORKERS'
PERMIT ISSUANCE 10.00 '�
FLOOD ZONE
A.L.U.C.
PLG. CONTR. - LIC. NO.
PLG, /
TOTAL /6.
COMPENSATION INSURANCE
(This section need not be completed if the permit is for one
V ❑ N❑
Y ❑ N❑
OTY. MECHANICAL PERMIT FEE
FEE SUMMARY
hundred dollars IS 100) or less.) ,
I certify that in the performance of the work for which this per-
mit is. issued, I shall not employ any person in any manner so as to
BUILDING
become subject to the Workers Compensation Laws of California.
Date Applicant
ALTER OR ADD TO MECH. 5.00
NOTICE TO APPLICANT: If, after making this Certificate of Ex-
emption, you should become subject to the Workers' Compensation
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
AIR HANDLING UNIT (TO 10MC.F.M.) 4.00
AIR HANDLING UNIT (OVER 10=C.RM.) 6.00
SEISMIC FEE'
CONSTRUCTION LENDING AGENCY
EXHAUST HOOD (WITH DUCT) 5.00
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.).
HEATING UNIT (TO 100,000 B.T.U.) 8.00
HEATING UNIT (OVER 100,060 13.T.U.)9.50
VENTILATION FAN (SINGLE) 4.00
ELECTRIC
Lender's Name
Lender 1 Address -
I certify that Lhave iead this application and state that the above
information is correct. 1 agree to comply with all city and county
ordinances and state laws relating to building construction, and
PLUMBING
do
0 -/
BOILER -COMP(3 H.P. or 100,000 B.T.U.) 6.00
BOILER -COMP lover 100,000BTU1 SEE FEESCH.
MECHANICAL
hereby authorize representatives of this city to enter upon the
above-mentioned property for inspection purposes.
MISC. - REFER TO ORD.
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CONST. TAX
(We)- agree to save, indemnify and keep harmless the City of
Cupertino against liabilities, judgments, costs and expenses which
may in any way accrue against sa' City in consequence of the
PERMIT. ISSUANCE 10.00
MECH. CONT. LIC. NO. MECH.
TOTAL
TOTAL
grant g gf t rs permit.
Jp
J
Signat re of App licant/Contr or. ate
IV V ' OFFICE COPY