18870APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
DUI LDI NG PROJECT 1 DENTI FICATI ON
APPLICATION & PERMIT
BUILDING - ELECTRICAL -PLUMBING -MECHANICAL
PERMIT NUMBER
q 1� O
' f
BUILDING
,D R
OWNER '$
N"
VC 1 1 PHON93-�/l�Y�
CITY. ELECTRIC PERMIT FEE
PLAN CHECK VALIDATION
DATE OF APPLICATION �
CONTRACTOR. O
NAMt�
SE 4
e�'v No.
UTLETS-SWITCHES-RECEP 10.00/1.00
LIGHTING FIXTURES 10.00/1.00
CONTRACTOR'S
Og ess
E
APPLIANCES - RESIDENTIAL 4.00
PANELS 10.00
ARCHITECT
OR
ENGINEER
LIC. No.
PANELS (OVER 20
AMP) 20.00
PLAN CHECK FEE P.C. NO.
SIGNS TRANS.
3.00
ARCH. OR ENG.SPECIAL
ADDRESS
ZIP
C RCU S.QQ
PERMIT VALIDATION
L
F ` A•.
ISSUANCE DATE
EMP. METER P S. 20.00
A
ADDRESS
ADDRESS
MOTORS SEE FEE SCH.
SERVICE A G 20.00
LICENSED CONTRACTORS DECLARATION
I hereby aflinn (hot 1 mn licensed mWerprovisions of Chapter 9
(commencing with Section 7000) of Division 3 of le Bustn s a>
Profcssin 11,10 0 d y Iicensc is in full forco-mddtaCU( �S
Dater Iass�Co Nenbc L/Y•/'f '-r
Dare �-'> Convacmr
OWNER-BUILDFR DECLARATION
1 herebyal firm that I am exempt from the Contractor's License
' 1
Law for the following reason,wh ch r 703L5. Business and Pnhlcssiani
Code: Any city or county which St HI sa pennil (oto nsuanc alLLc
improve, demolish, or repair any s(n¢(ure, prior to its issuance, also
requires the applicant for such permit m file a signed statement lira(
he is licensed pursuant to the provisions of the Contractor's License
Law (Chapter (confinement,9with Section 7000) of Division 3 oflhe
Business and Professions Code) or that he is exempt therefrom and
the basis for the alleged exemption. Any violation of Section 7031.5
by any applicant for a permit subjects the applicant ma civil penalty
of no( more than five hundred' dollars ( 5500).):
❑ I, as owner of the properly. or my employees with wages as
their sole compensation, will dD (he work, and the structure is not
Intended or offered for sale (Sec. 7044, Business a...I Professions
Code: The Contractor's License Law docs not apply to an owner of
property who builds or improves (hereon, and who does such work
himself Or through his own employees, provided that fish unloose-
memsareno( intended or offered for sale. If, however, the building
or improaclnellt is sold "within one year of completion, the owner-
builder will have (he burden of proving that he did mo build or int-
prove for purpose of sale.).
Cl I, as owner of the property, am exclusively contracting with
licensed contractors to construct the inject (Sec. 7044, Business
and I'roftoacm, Code: The Comrucmr's License Law docs not apply
to an owner of property who builds or improves thereon. and who
...tHwts for such projects with it contractors) lieensvd pursuant to
the Contractor's License Law.
❑ lam exempt under Sea ,B.&1'.C. tot this
ream..
Ay V, 1p:4,112 1.11
�� e s
v
r •�
BLDG.
❑
ELECT.
❑
PLG. MECH.
(�-y ❑
LE
If -I �f nrr�OrtlRn
BUILDING PERMIT
INFORMATION
C. REFER TO ORD
VALUATION
$/FT.
ERMIT ISSUANCE 10.00
ELEC CONTR. LIC. NO.
ELEC.
TOTAL
PERMIT TO
1•r
YV ��� L r�--�L-1
1111 TrTTr«T�--uaakk----1117
OTY. PLUMBING PERMIT FEE
STORIES
TYPE CONST .
ALTER -DRAIN -WATER (EA.) 5.00
BACK FLOW PROTECT. DEVICE 4.00
OCG GROUP
RES. UNITS
DRAINS -FLOOR, ROOF, AREA, COND. 5.00
FIXTURES - PER TRAP 5.00
SO. FT, FLOOR AREA
TOTAL ACREAGE
GAS - EA. SYSTEM - I INC.4 OUTLETS 6.00
GAS - EA. SYSTEM - OVER 4 (EA.) 2.00
BUILDING USE
RES IND CON PB Omar
❑ ❑ ❑ ❑ ❑
INDUSTRIAL WASTE INTER. 30.00
LAWN SPRINKLERS -I INC 5 V.B. 6.00
ASSESSORS PARCEL NO.
LAWN SPRINKLERS - OV ER 5 (EA.) 1.00
SEWER -SANITARY -STORM EA. 200tt 110.00
TRACT NO.
PARCEL N0.
WATER HEATER W/VENT. •151,011
Owner Date
5.00
WORKERS'COMPENSATION DECLARATION
I hereby infirm that 1 have a certificate of consent to sel&insure•
or u certificate of Workers' Compensation Insurance, or a certified
copy (hereoflSic. 3800, Lab.C.).
Policy NO. Collipary
❑ Certified copy is hereby furnished.
�1 CerliUed copy a Med with (he city inspection division.
ph Cee
WATER SYSTEM
WATER TREATING EQUIP. 5.00
ACC. DATE
ACC. FILE NO.
ZONIrvG
ENG. SITE NO.
FIRE SPRINK
V N
❑ ❑
ENERGY T 24
V N
❑ ❑
MISC.- REFER TO ORD.
CER 'I'IFICA'I E OF I:XEM1'[']ON PROM WORKERS'
CO,MITNSATION INSURANCE
(This section need net be completed if the permit is for one
hundred hall... ($100) or Iess.l
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
became subject to the Workers' Cumpelsution Laws of California.
Date Applicant
PERMIT ISSUANCE -11:00 .U(J
FLOOD 20NE
V❑ N❑
A.L.U. C.
V❑ N❑
PLG. CONTR. LIC. NO.PLG.
TOTAL
CITY. MECHANICAL PERMIT FEE
FEE SUMMARY
BUILDING
ALTER OR ADD TO MECH. 5.00
NOTICE TO APPLICANT: If, alter making this Certificate of Ex-
emption. you should become subject to lire Workers''Compensation
provisions of the Labor Code, you must forthwith comply with
Such provisions or this permit shall be deemed revoked.
CONSTRUCTION LENDING AGENCY
I hereby affirm that there is a construction lending agency fist
the performance of the work tot which this permit is issued (Sea
3097, Civ.C.).
Lender's Nao
APPLIANCE - 5.00
PLAN CHECK
FEE
AIR HANDLING UNIT (TO 10SMCF.M.) 4.00
AIR HANDLING UNIT(OVER 10=C.F.M.) 6.00
SEISMIC FEE
EXHAUST HOOD (WITH DUCT) 5.00
MICROFILM
HEATING UNIT (TO 100,000 R.T.U.) 8.00
HEATI NG UNIT (OVER 100,000 B.T.U.) 9.50
ELECTRIC
Lender's Address
I certify that I have read this application and sure that the above
i nlornlalion is correct I .gree m comply with all city and county
ordinances and slate laws relating to building construction. and
hereby authorize representatives of this city to enter upon the
above mentioned property for inspection purposes.
, (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 Said City in consequence of the
a g this p alt
VJVUKzw�'j 71
VENTILATION FAN (SINGLE) 4.00
PLUMBING
BOILER - COMP (3 H.P. or 100,000 B.T.U.) 6.00
BOI LER-COMP (Over 100,000 BTU) SEE FEE SCH.
MECHANICAL
MISC. - REFER TO ORD.
CONST. TAX
PERMIT ISSUANCE 10,00
MECH. CONT. LIC. NO. MECH.
TOTAL
I
TOTAL
nature of Applicant/COnt actor Date
OFFICE COPY