12611 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
BU LDING PROJECT IDENTIFICATION PERMIT NUMBER
r BUILDING APPLICATION & PERMIT
77n,y M0 k17-E7 [767( 1? BUILDING-ELECTRICAL-PLUMBING-MECHANICAL 12611
OWNER'S - PLAN CHECK VALIDATION
NAME r TY. ELECTRIC PERMIT FEE
(/r //S/ /jlo/r iT'4NONE
CONTRACTORS
NAME OUTLETS-SWITCHES-RECEP 10.00/1.00
N
LIC.NO. LIGHTING FIXTURES 10.00/1.00
ATOR'S
DDRESSPPLIANCES-RESIDENTIAL 4.00
GRESS
PHONE PANELS 10.00 DATE OF APPLICATION
ARCHITECTPANELS (OVER 200 AMP) 20,00 PLAN CHECK FEE P.C.NO.
OR
ENGINEER
LIC,NO. SIGNS TRANS. 3.00
ARCH.OR ENG. SPECIAL CIRCUIT SOO PERMIT VALIDATION
ADDRESS .
ZIP TEMP. METER OR POLE INS. 20.00
APPLICANT'S MOTORS SEE FEE SCH.
ADDRESS
SERVICE CHANGE 20.00
O
'02 LICENSED CONTRACTORS DECLARATION
a i u I hereby affirm that 1 am licensed under provisions of Chapter 9 ISSUANCE DATE
(commencing with Section 7000)of Division 3 of the Business and BLDG. ELECT. PLG. MECH.
Z,
iProfessions Code,and my license is in full force and effect. ❑
G i=O License:Class-Con Number � W� er ❑ ❑
Date Contractor L V
a Y f-1 BUILDING PERMIT
E IC w u OWNER-BUILDER DECLARATION INFORMATION
wOy MISC.- REFER TO ORD
g n r I hereby affirm that.I am exempt from the Contractor's License
u0a Low forthe following reason.(See.7031.5,Business and Professions PERMIT ISSUANCE 10.00 VALUATION $/FT.
HN -i Code:Any City Dreamily which requires a permit to Construct,alter,
al C < p improve,demolish,or repair any structure,prior 10 its issuance,also ELEC.CONTE. LIC.NO. ELEC.
i O u requires the applicant for such permit to file a signed statement that TOTAL PERMIT TO fti'
whe is licensed pursuant to the provisions of the Contn¢tor's License l
Fzi Law(Chapter 9(commencing with Section 7000)of Division 3 ofthe
a Business and Professions Code)or that he is exempt therefrom and DTV. PLUMBING PERMIT FEE V/4 (� C
M r Oo the basis for the alleged exemption.Any violation of Section 7031.5 STORIES TYPE CONSTR.
by any applicantfora permit subjects the applicantloacivilpenallY / ALTER-DRAIN&VENT-WATER (EA.) 5.00
of not more than five hundred dollars(55001.): l �
❑ 1,as owner of the property,or my employees with wages as BACK FLOW PROTECT.DEVICE 4.00 Occ.GROUP RES.UNITS
their sole compensation,will do the work,and the structure is not
intended or offered for sale (Sec. 7044, Business and Professions DRAINS-FLOOR,ROOF,AREA,COND. 5.00
Code:The Contractor's License Law does not apply 10 an owner of
• property who builds or improves thereon,and who does such work FIXTURES-PER TRAP 5.00 SO.FT.FLOOR AREA TOTAL ACREAGE
himself or through his own employees,provided that such improve-
mentsamnot intended or offered for sale.If,however,the building GAS-EA.SVSTEM-11NC.4OUTLETS 6.00
or improvement is sold within one year of completion, the owner- GAS-EA.SYSTEM-OVER 4 (EA.) 2.00
builder will have the burden of proving that he did not build or im- BUILDING USE
prove for purpose ofsale.). INDUSTRIAL WASTE INTER3000 RES IND CDN PB Omer
❑ 1,as owner of the property,am exclusively contracting with . .
❑ ❑ ❑ ❑ ❑
licensed contractors to construct the project(Sec. 7044,Business LAWNSPRINKLE 5 V.B. 6.00 ASSESSORS PARCEL NO.
and Professions Code:The Contractor's License Luw does not apply
to an owner of properly who builds or improves thereon,and who LAWN SPRINKLE -OVER 5 IEA.) 1.00
contracts for such projects with a contractor(s)licensed pursuant to
the Contractor's License Law. SEWER-SAN I 00ft/10.00 TRACT NO. PARCEL NO.
❑ I amexempt under Sea ,B.&P.C.for this WATER HEA /VENT 6.00
reason
�( ,Owner Date WATER SVSTE , I{I(IO 5.00 ACC.DATE ACC.FILE NO.
WORK F.RS'COMPENSAT10N DECLARATION WATER TREATM EbUIP. 5.00
1 hereby affirm that I have a certificate ofconsest to self-insure. ZONING
or a certificate of Workers'Compensation Insurance,or a certified ENG.SITE NO.
copy thereof(Sec 3600,Lab.C.L
Policy No. Company
O ❑ Certified copy is hereby furnished. FIRE SPRINK ENERGY T-24
Z Z ❑ Certified copy is filed with the city inspection division.
MISC.- REFER TO ORD.
O Applicant Y ❑ N❑ Y ❑ N❑
Hy PERMIT ISSUANCE 10.00 Q FLOOD ZONE A.L.U.C.
CC CF:RTI FICATfi OF EXEMPTION FROM WORKERS'
LU COMPENSATION INSURANCE PLG.CONTE. LIC.NO. PLG.
IL C1 (This section need not be completed if the permit is for one TOTAL A3-gyp V[:] N❑ Y❑ N❑
hundred dollars(8100)or Tess.)
U O 1 certify that in the performance of the work for which this per- OTY. MECHANICAL PERMIT FEE FEE SUMMARY
LL 5mit is issued,I shall not employ any person in any manner so as to
O become subject to the Workers'Compensation Laws of California.
0. Dale Applicant ALTER OR ADD TO MECH. 5.00 BUILDING
} m NOTICE TO APPLICANT: If,after making this Certificate of IN'
? emption,you should become subject to the Workers'Compensation APPLIANCE 5.00 PLAN CHECK
provisions of the Labor Code, you must forthwith comply with FEE
U such provisions or this permit shall be deemed revoked. AIR HANDLING UNIT(TO 10.000C.F.M.) 4.00
CONSTRUCTION LENDING AGENCY AIR HANDLING UNITIOVER 10=C.F.M.) 6.00 SEISMIC FEE
1 hereby affirm that there is a construction lending agency for EXHAUST HOOD(WITH DUCT) 5.00
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
Lender's Name HEATING UNIT(OVER 100,000 B.T.U.)9.50
Lender's Address ELECTRIC
. I certify that 1 have read this application and state that the above VENTILATION FAN (SINGLE) 4.00
information is correct. I agree to comply with all City and County PLUMBING
ordinances and slate laws relating to building construction, and BOILER•COMP(3 H.P.or10G,000B.T.U.) 6.00
hereby authorize representatives of this city to enter upon the BOILER-COMP (Over 100,000 BTU)SEE FEE SCH. MECHANICAL
above-mentioned property for inspection purposes.
(We) agree to save, indemnify and keep harmless the City of MISC.- REFER TO ORD.
Cupertino against liabilities,judgments, costs and expenses which PERMIT ISSUANCE 10.00 CONST.TAX
may in any way accrue against said City in consequence of the
gra ng of"this per '1. MECH.CONT. LIC.NO. MECH.
1
�101&7
TOTAL TOTAL
Signature o pplicant/Contactor ate
OFFICE COPY
APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
BU LDING PROJECT IDENTIFICATION PERMIT NUMBER
r BUILDING APPLICATION & PERMIT
77n,y M0 k17-E7 [767( 1? BUILDING-ELECTRICAL-PLUMBING-MECHANICAL 12611
OWNER'S - PLAN CHECK VALIDATION
NAME r TY. ELECTRIC PERMIT FEE
(/r //S/ /jlo/r iT'4NONE
CONTRACTORS
NAME OUTLETS-SWITCHES-RECEP 10.00/1.00
N
LIC.NO. LIGHTING FIXTURES 10.00/1.00
ATOR'S
DDRESSPPLIANCES-RESIDENTIAL 4.00
GRESS
PHONE PANELS 10.00 DATE OF APPLICATION
ARCHITECTPANELS (OVER 200 AMP) 20,00 PLAN CHECK FEE P.C.NO.
OR
ENGINEER
LIC,NO. SIGNS TRANS. 3.00
ARCH.OR ENG. SPECIAL CIRCUIT SOO PERMIT VALIDATION
ADDRESS .
ZIP TEMP. METER OR POLE INS. 20.00
APPLICANT'S MOTORS SEE FEE SCH.
ADDRESS
SERVICE CHANGE 20.00
O
'02 LICENSED CONTRACTORS DECLARATION
a i u I hereby affirm that 1 am licensed under provisions of Chapter 9 ISSUANCE DATE
(commencing with Section 7000)of Division 3 of the Business and BLDG. ELECT. PLG. MECH.
Z,
iProfessions Code,and my license is in full force and effect. ❑
G i=O License:Class-Con Number � W� er ❑ ❑
Date Contractor L V
a Y f-1 BUILDING PERMIT
E IC w u OWNER-BUILDER DECLARATION INFORMATION
wOy MISC.- REFER TO ORD
g n r I hereby affirm that.I am exempt from the Contractor's License
u0a Low forthe following reason.(See.7031.5,Business and Professions PERMIT ISSUANCE 10.00 VALUATION $/FT.
HN -i Code:Any City Dreamily which requires a permit to Construct,alter,
al C < p improve,demolish,or repair any structure,prior 10 its issuance,also ELEC.CONTE. LIC.NO. ELEC.
i O u requires the applicant for such permit to file a signed statement that TOTAL PERMIT TO fti'
whe is licensed pursuant to the provisions of the Contn¢tor's License l
Fzi Law(Chapter 9(commencing with Section 7000)of Division 3 ofthe
a Business and Professions Code)or that he is exempt therefrom and DTV. PLUMBING PERMIT FEE V/4 (� C
M r Oo the basis for the alleged exemption.Any violation of Section 7031.5 STORIES TYPE CONSTR.
by any applicantfora permit subjects the applicantloacivilpenallY / ALTER-DRAIN&VENT-WATER (EA.) 5.00
of not more than five hundred dollars(55001.): l �
❑ 1,as owner of the property,or my employees with wages as BACK FLOW PROTECT.DEVICE 4.00 Occ.GROUP RES.UNITS
their sole compensation,will do the work,and the structure is not
intended or offered for sale (Sec. 7044, Business and Professions DRAINS-FLOOR,ROOF,AREA,COND. 5.00
Code:The Contractor's License Law does not apply 10 an owner of
• property who builds or improves thereon,and who does such work FIXTURES-PER TRAP 5.00 SO.FT.FLOOR AREA TOTAL ACREAGE
himself or through his own employees,provided that such improve-
mentsamnot intended or offered for sale.If,however,the building GAS-EA.SVSTEM-11NC.4OUTLETS 6.00
or improvement is sold within one year of completion, the owner- GAS-EA.SYSTEM-OVER 4 (EA.) 2.00
builder will have the burden of proving that he did not build or im- BUILDING USE
prove for purpose ofsale.). INDUSTRIAL WASTE INTER3000 RES IND CDN PB Omer
❑ 1,as owner of the property,am exclusively contracting with . .
❑ ❑ ❑ ❑ ❑
licensed contractors to construct the project(Sec. 7044,Business LAWNSPRINKLE 5 V.B. 6.00 ASSESSORS PARCEL NO.
and Professions Code:The Contractor's License Luw does not apply
to an owner of properly who builds or improves thereon,and who LAWN SPRINKLE -OVER 5 IEA.) 1.00
contracts for such projects with a contractor(s)licensed pursuant to
the Contractor's License Law. SEWER-SAN I 00ft/10.00 TRACT NO. PARCEL NO.
❑ I amexempt under Sea ,B.&P.C.for this WATER HEA /VENT 6.00
reason
�( ,Owner Date WATER SVSTE , I{I(IO 5.00 ACC.DATE ACC.FILE NO.
WORK F.RS'COMPENSAT10N DECLARATION WATER TREATM EbUIP. 5.00
1 hereby affirm that I have a certificate ofconsest to self-insure. ZONING
or a certificate of Workers'Compensation Insurance,or a certified ENG.SITE NO.
copy thereof(Sec 3600,Lab.C.L
Policy No. Company
O ❑ Certified copy is hereby furnished. FIRE SPRINK ENERGY T-24
Z Z ❑ Certified copy is filed with the city inspection division.
MISC.- REFER TO ORD.
O Applicant Y ❑ N❑ Y ❑ N❑
Hy PERMIT ISSUANCE 10.00 Q FLOOD ZONE A.L.U.C.
CC CF:RTI FICATfi OF EXEMPTION FROM WORKERS'
LU COMPENSATION INSURANCE PLG.CONTE. LIC.NO. PLG.
IL C1 (This section need not be completed if the permit is for one TOTAL A3-gyp V[:] N❑ Y❑ N❑
hundred dollars(8100)or Tess.)
U O 1 certify that in the performance of the work for which this per- OTY. MECHANICAL PERMIT FEE FEE SUMMARY
LL 5mit is issued,I shall not employ any person in any manner so as to
O become subject to the Workers'Compensation Laws of California.
0. Dale Applicant ALTER OR ADD TO MECH. 5.00 BUILDING
} m NOTICE TO APPLICANT: If,after making this Certificate of IN'
? emption,you should become subject to the Workers'Compensation APPLIANCE 5.00 PLAN CHECK
provisions of the Labor Code, you must forthwith comply with FEE
U such provisions or this permit shall be deemed revoked. AIR HANDLING UNIT(TO 10.000C.F.M.) 4.00
CONSTRUCTION LENDING AGENCY AIR HANDLING UNITIOVER 10=C.F.M.) 6.00 SEISMIC FEE
1 hereby affirm that there is a construction lending agency for EXHAUST HOOD(WITH DUCT) 5.00
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
Lender's Name HEATING UNIT(OVER 100,000 B.T.U.)9.50
Lender's Address ELECTRIC
. I certify that 1 have read this application and state that the above VENTILATION FAN (SINGLE) 4.00
information is correct. I agree to comply with all City and County PLUMBING
ordinances and slate laws relating to building construction, and BOILER•COMP(3 H.P.or10G,000B.T.U.) 6.00
hereby authorize representatives of this city to enter upon the BOILER-COMP (Over 100,000 BTU)SEE FEE SCH. MECHANICAL
above-mentioned property for inspection purposes.
(We) agree to save, indemnify and keep harmless the City of MISC.- REFER TO ORD.
Cupertino against liabilities,judgments, costs and expenses which PERMIT ISSUANCE 10.00 CONST.TAX
may in any way accrue against said City in consequence of the
gra ng of"this per '1. MECH.CONT. LIC.NO. MECH.
1
�101&7
TOTAL TOTAL
Signature o pplicant/Contactor ate
OFFICE COPY