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APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
BUILDING PROJECT IDENTIFICATION
APPLICATION &PERMIT
BUILDING - ELECTRICAL- PLUMBING - MECHANICAL
PERMIT NUMBER
� � 0
GDILNiND
ADDRESS
OWNER'5
ns4eQ-SeY
%7o/L6M .0
-
DTV. ELECTRIC PERMIT - !FEE'
PLAN CHECK VALIDATION
CONTRACTORS
NAME
NAME
UTLETS- SWITCHES -RECEP 5.00/1.00
LIGHTING FIXTURES 5.00/1.00
LIC. No,
CONTRACTOR na
AD
AGDREss
PPLIANCES- RESIDENTIAL 4.00
PANELS 5.00
PRONE
DATE OF APPLICATION
ARCHIi LCT
OR
ENGINEER
sec. No.
SIGNS 6.00
PLAN CNECK FEE P.C. NO,
SIGNS TRANS. - 3.00
ARC .0 ENG.
ADDREss E
SPECIAL CIRCUIT S.00
PERMIT VALIDATION
TEMP. METER OR POLE INS. 15.00
• ZIP
c
J
1;
APPLICANT'S
ADDRESS
MOTORS SEE FEE SCH.
SERVICE CHANGE 10.00
LICENSED CON TRACTORS DECLARATION
d ?r
( (t
1 herehy affirm Unit I um licensed under provisions of Chapter 9V
(coo oncvcing with Section 7000) of Division 3 of the Business and
Professions Code, and ma y license in full force and of Peal.
Lie. Number
Dale Contractor
ISSUANCE DATE
(
V✓ �- I-e.d �t G 1- f4t4
BLDG. ELECT.
EJ❑
PLG. MECH-
E3License,Clan
❑
Ga V s (4(. e. jClJ1- I'0 d
BUILDING PERMIT
OWNER-RUI LEER DECLARATION
1 herr by ubthus I,G exempt from the Contract or's License
Lav, for tM foIIollowing revsoa (Set. 7031.5, &IsinessanA l'mfemions
Code: Any city orcounly which requires a permit to construct, alter,
improve, demolish. or repair any structure, prior to its issuance, also
,
INFORMATION.
MISCREFER TO ORD -
. -
va WAT10N
q
$/FT.
PERMIT ISSUANCE 6.00
ELEC. CONTR. LIC. NO.
ELEC.
equfR•s the applicant for such permit to file a signed Statement that
he is licensed pursuant to the provisions of the Contractor's License
Low (Chapter 9(commencing with Section 7000) of Division 3 of the
Business and Professions Code) or that hu is exempt therefrom and
tiro basis for the allcgrA rxcmplion. Any violation of Secw... 7031.5
by any applicant for a permit subjects the applicant me civil penalty
of not more than five hundred dollars (5500).):
TOTAL
PERMIT TO
11.0 �Sr
OTY. PLUMBING PERMIT FEE
ALTER -DRAIN& VENT -WATER (EA.) 4.0
RIES
per
A� C
TYPE CONSTR.
❑ I. as owner of the property, or my employees with wages as
their Sale compensation, will do the work, and the structure is not
intended or offered for sale (Sea 7044. Business and Professions
BACK FLOW PROTECT. DEVICE 2.00
OCC. GROUP -
RES. UNITS
DRAINS -FLOOR, ROOF, AREA, COND. 4.00
Code: l'he Contractor's License Law does not apply to an owner of
property who builds or Improves thereon, and will) does Such work
FIXTURES - PER TRAP 4.00
SQ FT. FLOOR AREA
TOTALACREAGE
himself or through lits own employees, provided that such Improve-
mentsare lot intended oroffered for sale. If, however, the building
GAS - EA. SYSTEM -11 NC. 4 OUTLETS 4.00
or improvement is sold within one year of completion, Rte owner-
builder will have the burden of proving that he did not build or im-
prove for purpose of sale.).
❑ I, as owner of the property, an, exclusively contracting with
Licensed contractors to construct the Project (Sec. 7044, Business
GAS - EA. SYSTEM - OVER 4 (EA.) 1.00
BUILDING USE
RES IND CON PB Other
El D ED ID 11
INDUSTRIAL WASTE INTER. 20.00
LAWN SPRINKLERS- 1 INC 5 V.B. 5.00
ASSESSORS PARCEL NO.
and Professions Code: Thu Contractor, License Low does ,III apply
to an owner of property who builds or inipros'es thereon, and who
LAWN SPRINKLERS - OVER 5 (EA.) 1.00
contracts for such projects with a contractorSo licensed pursuant to
the Contractor's License Law.
SEWER -SANITARY -STORM EA. 200ft/8.00
TRACT NO.
PARCEL NO.
WATER HEATER W/VENT 4.00
❑ l am exempt under Seq, BAP.C. frrr this
rL'llSflll L
Owner,( _�trZ'�"'-" - - - - L' --i' rz
WATER SYSTEM 4.00
ACC. DATE
ACC. FILE No.
WORK Ii RS'CUMPENSATION DECLARATION
WATER TREATING EQUIP. 4.00
1 hereby affirm that 1 have a certificate of elmocal m selpinsurc,
or a certificate of Workers' Compensation Insurance, or a certified
- ZONING
ENG. SITE N0.
copy thereof (Sec. 3800, Luh.C.L
Policy No. -Company
FIRE SPRINK
y N
ENERGY T 24
y No
❑ Cendied copy iS lum,by filum lied.
❑ Certified copy is fled with the city inspection division.
Applicant
MISC. - REFER TO ORO.
CERT'IFICAT'E OF EXESIPTION FROM WORKERS'
PERMIT ISSUANCE 6.00
FLOOD ZONE
A.L.U.C.
PLG. CONTE. LIC. NO.PLG.
TOTAL
C041-NSATION INSURANCE
(This section need not he completed if the permit is for one
v N
v N❑
CITY. MECHANICAL PERMIT FEE
FEE SUMMARY'
hundred dollen IS 100) or less.)
1 certify Unit in the performance of the work for which this per-
mit is issued. I shall not employ any person in any manner so as m
become subject to tile Wrkeri Compensation Laws of California.
Date Applin nt
BUILDING
3�a�
I ALTER OR ADD TO MECH. 4.00
NOTICE TO APPLICANT': If, after nuking this Certificate of Ex-
emption, you should become subject to the Workeri Compensation
Provision, of the labor Code, You must forthwith comply with
such provisions or this permit shall he deemed !evoked.
CONS'T'RUCTION LENDING AGENCY
APPLIANCE 4.00
PLAN CHECK
FEE
AIR HANDLING UNIT (TO loml .F.M.) 3.00
AIR HANDLING UNITIOVER I0AOOC.F.fa05.00
SEISMIC FEE
orb
EXHAUST HOOD (WITH DUCT) 2.00
MICROFILM
I hereby affirm that there is a construction lending agency for
the performance of the work for which (his permit is issued (Sec.
3097, Civ.CJ.
HEATING UNIT (TO 100,000 B.T.U.) 4.00
HEATING UNIT (OVER 100,000 B.T.U.)7.50
ELECTRIC
Lend:. -s Name
Lonho's Address
VENTILATION FAN (SINGLE) 3.00
PLUMBING
I certify that l have read this application and slate that the above
information is correct. I agree to comply with all city and county
i ordinances and state laws relating to building construction, and
hereby authorize representatives of this city to enter upon the
above-mentioned property for inspection purposes.
BOILER- OOMP(3 H.P. or 100,000 B.T.U.) 4.00
BOILER -COMP (Over 100,000 BTU) SEE FEE SCH.
MECHANICAL
MISC. - REFER TO ORD.
CONST. TAX
(We) agree m save, indemnify and keep harmless the City of
Cupertino against liabilities, judgments, costs and expenses which
may in any way accrue against mid City in consequence of the
PERMIT ISSUANCE 3.00
CONT. LIC. NO.
-
MECH.
TOTAL
TOTAL
A
gm 'n f this per.,(MECH.
ignalone of Appli nt/(.Imlracto! ate
OFFICE COPY