2533APPLICANT,TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
BUILDING PROJECT IDENTIFICATION
APPLICATION & PERMIT
BUILDING - ELECTRICAL- PLUMBING - MECHANICAL
PERMITN dIMB,
/�
J
BUILDING
ADD fl ESS
OWNER'S
NAME
1 P
I
- -
ELECTRIC PERMIT FEE
PLAN CHECK VALIDATION
,
NTRACTOR'S
NAMEOUTLETS
- SWITCHES -RECEP 5.00/1.00
LIGHTING FIXTURES 5.00/1.00
.ACE Lic. ND,
-
noo�OMBING SERVICE
APPLIANCES - RESIDENTIAL 4.00 -
PANELS 5.00
'"
DATE OF APPLICATION
AIAWFIRSTPLAN
UR q�1
ENaSN JOSE, CA 9qJ rt9
SIGNS 6.00
CHECK FEE P.C. NO.
SIGNS TRANS. 3.00
ARCH. ORE )'
ADDRESS ,
SPECIAL CIRCUIT 5,80
PERMIT VALIDATION
EMP. METER OR POLE INS. 15.00
ZIP
'
- "
APPLIDACESS b s
ADDRESS
MOTORS SEE FEE SCH.
SERVICE CHANGE 10.00
-
LICENSED CONTRACTORS DECLARATION
I hereby affirm that I am licensed under provisions of Chapter 9
(commencing with Section 7000) of Division 3 of the Business and
Professions C sjeyy y license is in full foryllffi of eta
Licen ax Lic. NumM1e -01
ISSUANCE DATE '
BLDG.ELECT.
PLG. MEC..
BUILDING PERMIT
INFORMATION
OWNER -BUILDER DECLARATION
1 hereby affirm that I am exempt from the Contractor's License
Law for the following reason. (Sec. 7031.5, Businessand Professions
Code: Any city or county which requires a permit to construct, alter,
MISC.- - REFER TO ORD
vALUATtON
$/FT.
PERMIT ISSUANCE 6.00
ELEC. CONTR. LIC. NO. ELEC.
TOTAL
OTY. PLUMBING PERMIT FEE
improve, demolish, or repair any structure, prior to its issuance, also
requires the, applicant for such permit to file a signet) statement that
he is licensed pursuant to the provisions of the Contractor's License
Law (Chapter 9(commencingwith Section 7000) of Division 3 of01e
Business and Professions Code) or that he is exempt therefrom and
PERMIT TO
�L CIH B//17Cs-
STORIES
TYPE CONSTR.
the basis for the alleged exemption. Any violation of Section 7031.5
by any applicant for a permit subjects the applicant Loa civil penalty
of not more than five hundred doll."(E500L):
ALTER -DRAIN -WATER (EA.) 4.00
❑ 1, as owner of the property, or my employees with wages as
their sole compensation, will do the work, and the structure is not
BACK FLOW PROTECT. DEVICE' 2.00
OCC. GROUP
RES. UNITS
DRAINS -FLOOR, ROOF, AREA, COND. 4.00
intended or offered I'or sale (Sec. 7044, Business and Professions
Code: The Contractor's License Law does not apply to an owner of
FIXTURES - PER TRAP 4.08
GAS-EA.SYSTEM-11NC.4OUTLETS 4.00
SO. FT. FLOOR AREA
TOTAL ACREAGE
property who builds or improves thereon, and who doessuch work
himself or through his own employees, provided that such improve-
mentsarenotintendedorofferedforsale. I L however, the building
or improvement is sold within one year of completion, the owner
builder will have the burden of proving that he did not build or im-
prove for purpose ofsale.).
C11, as owner of the pmperty,.am exclusively contracting with
GAS : EA. SYSTEM - OVER 4 (EA.) 1.00
BUILDING USE
RES IND CON PB Door
El D 0 13 13
INDUSTRIAL WASTE INTER. 20.00
licensed contractors to construct the project (Sec. 7044, Business
and Professions Code: The Contractor's License Law does not apply
to an owner of property who builds or improves thereon. and who
LAWN SPRINKLERS- 1 INC 5 V.B. 5.00
LAWN SPRINKLERS - OVER 5 (EA.) 1.00
ASSESSORS PARCEL NO.
contracts for such projects with a contractovs) licensed pursuant to
the Conractors.License Law.
SEWER -SANITARY -STORM EA. 200ft/8.00
TRACT NO.
PARCEL NO.
❑ I um exempt under Sec. ,B.&P.C. for this
reason
WATER HEATER W/VEN 4p
Date Owner
WATER SYSTEM 4.00
ACC. DATE
ACG. FILE No.
WORKERS'COMPENSATION DECLARATION
.. WATER TREATING E(PRIKIb RI, 0
I hereby affirm that I have a certificate fconsent to self -insure,
or a certificate of Workers' Compensation -Insurance, ora rt if
ZONING
ENG. SITE NO.
CitV Of r1Prt10
;OR a'reo ' QQ,.,i^n} Y.)./'�1�„ -
Pol ' J(GXI)/aI �.1(
�r Bled copy is herehy fur9glied
Cerlified py. is fled w Illi lac y inspection division.
pplicant IAV _
'
FIRE SPRINK
YF] N❑.
ENERGY T-24
Y0 NQ
MISC.-' REFER TO ORD.
CERTIFICATE OF EXEMPTION FRO ORKEBS'
- COMPENSATION INSURANCE
(This section need not he completed if the permit is for one
PERMIT ISSUANCE 6.00
FLOOD ZONE
Y N�
A.L.U:C.
V NE]
PLG. CONTR. LIC. NO.
PLG.
TOTAL
hundred dollars IS 100) or less.)
I certify that in the PerlOrmalIC0 of Om work for which thio per-
mir is issued, I shall not employ any person in any manner so as to
OTY. MECHANICAL PERMIT FEE
FEE SUMMARY
BUILDING
become subject to the Workers' Compensation Laws of California.
Date Applicant
NOTICE TO APPLICANT: If, after making this Certificate of IN.
ALTER OR ADD TO MECH. 4.00
APPLIANCE" 4.00
AIR HANDLING UNIT (TO 10=C.F.M.) 3.00
PLAN CHECK
FEE
emption, you should become subject to the Workers'Compensation
provisions of the Labor Cade, you must forthwith comply with
such provisions or this permit shall be deemed revoked.
AIR HANDLING UNIT (OVER 10=C.EM.)5.00
SEISMIC FEE
" CONSTRUCTION LENDING AGENCY
I hereby affirm that there is a construction lending agency for
the performance of the work for which this permit is issued (Sec.
3097, Civ,C.L
I EXHAUST.HOOD (WITH DUCT) 2.00
MICROFILM
HEATING UNIT (TO 100,000 B.T.U.) 4.00
Lender's Name
Lender's Address
HEATING UNIT [OVER 100,000 B.T.U.17.50
ELECTRIC
VENTILATION FAN (SINGLE) 3.00
I certify that I have read this application and state that the above
information is correct. I agree to comply with all city and county
ordinances and state laws relating to building construction, and
PLUMBING
BOILER- COMP 13 H.P. or 100,000 B.T.U.) 4.00
BOILER -COMP (Over 100,000 BTU) SEE FEE SCH.
MECHANICAL
r 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 file
gof as pi""'..
MISC. - REFER TO ORD.
PERMIT ISSUANCE 3.00
CONST. TAX
MECH, CONT. LIC. NO.
MECH.
TOTAL
TOTAL
Sig lure of Applicant ontradnr ate
OFFICE COPY