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APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
• BU LD1 NG PROJECT I DENTI FICATI ON
APPLICATION & PERMIT
BUILDING - ELECTRICAL- PLUMBING - MECHANICAL
.PERMIT NUMBER
�,(, 17970
BUILDING
aDORE55
03/o
OWNERS
PLAN CHECK VALIDATION
NAMES(
1CONTRACTORSa
RaR 96
DTV. ELECTRIC PERMIT FEE
OUTLETS -SWITCHES -RECEP 10.00/1.00
LIGHTING FIXTURES 10.00/1.00
uc.N
DATE OF APPLICATION
DRESS Rs
a oae�sJs '/�
(�(J� /ice NONE
APPLIANCES -RESIDENTIAL 4.00
PANELS 10.00
ARCHITECT
OR
ENGINEER
LIC. No.
PANELS (OVER 200 AMIN 20.00
PLAN CHECK FEE P.C. NO.
SIGNS TRANS. 3.00
ADDRESS EAG'
SPECIAL CIRCUIT 5.00
PERMIT VALIDATION
EMP. METER OR POLE INS. 20.00
nv
1 - rl'M- H •1�
V AI'1 IL.J �/
ADDRESS Ts
MOTORS SEE FEE SCH. „
q, ,2`I U 1
'Vtl�
SERVICE CHANGE 20.00
LICENSED CONTRACTORS DECLARATION
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vu
1 hereby affirm that I am licensed muter provisions of Chapter 9
(commencing with Section 7000) of Division 3 of the Business and
PIOIIYf'IOn6l.'nd an
• d nae Is ly ICCm toll fnlyy'cc��a9rytff f I
License Clas_Lic. Number�'Y_
a ISSUANCE DATE
BLDG. ELECT. PLG. MECH.
e�tlj:a ❑
Dam Conta
BUILDING PERMIT
INFORMATION
OWNER -BUILDER DECLARATI
I hereby atfinn that I am exempt from the Contractor's License
Law for the following reason. (See. 703 1.5, Businessand Professions
Code: Any city orcounty which requires a permit to construct, alter,
improve, demolish, or repair any structure, prior to its issuance, also
requires.the applicant for such permit to file a signed statement that
he is licensed pursuant to the provisions of the Contractor's License
Law (Chapter 9 (commencing with Section 7000) of Division 3 of the
Business and Professions Code) or that he is exempt therefrom and
MISC.- REFER TO ORD
PERMIT ISSUANCE 10.00
VALUATION
$/FT.
ELEC. CONTE. LIC. NO.
ELEC.
TOTAL
PERMIT TO
4 M
I LI1 _'
MUH W7
OTY, PLUMBING PERMIT FEE
STORIES
TYPE CO STR.
the basis for the alleged exemption. Any violation of Section 7031.5
by any applicant for a permit subjects the applicant ton civil penalty
of not more than five hundred dollars ($5001.1'.
ALTER -DRAIN -WATER (EA.) 5.00
❑ I, as owner of the property, or my employees with wages as
their sole compensation, will do the work, and the structure is not
BACKFLOW PROTECT. DEVICE 4.00
Oce. GROUP
RES. UNITS
DRAIN$ -FLOOR, ROOF, AR EA, D. 5.00
intended or offered for sale (Sec. 7044, Business and Professions
Code: The Contractor's License Low dues not apply to an owner of
properly who builds or improves thereon, and who docs such work
himself or through his own employees, provided that such ingnmo-
mentsarenotintendedorofferedforsale. I L however, the building
FIXTURES - PER TRAP 5.00
SO. FT. FLOOR AREA
TOTAL ACREAGE
GAS-EA.SYSTEM-11NC.40UTLETS 6.00
or improvement is sold within one year nl' completion, the owner-
on will have the burden of proving that he did not build or im-
provefor purpose ofsale.).
❑ I, as owner of the property, am exclusively contracting with
GAS - EA. SYSTEM -OVER 4 (EA.) 2.00
BUILDING USE
RES IND CON. PB Other
❑ ❑ ❑ ❑ ❑
INDUSTRIAL WASTE INTER. 30.00
licensed contractors to constnret the pro,icct (Sec. 7044, Business
and Professions Code: T'he 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. 6.00
LAWN SPRINKLERS - OVER 5 (EA.) 1.00
ASSESSORS PARCEL NO.
contracts for such projects with a in ntractoRS) licensed pursuant to
ill, Contrucloi a License Law.
SEWER -SANITARY -STORM EA. 200ft/10.00
TRACT NO,
PARCEL N0.
❑ I am exempt tmdcr Sec. ,B.&P.C,fo, this
reason
WATER HEATER W/VENT 6.00 0
Owner Date
WATER SYSTEM 5.00
ACC. DATE
ACD. FILE N0,
WATER TREATING EQUIP. 5.00
WORKERS'COMPENSATION DECLARATION
1 hereby affirm that I have a ccnifieate of consent to stir-inuue'
or.y�c�)elBrrttiyiffi�ippco f mgren nsurmwc,,,o�er lified
ZONING
ENG. SITE NO.
Q�6}:rs' g.1
g1i6y4(N�C'ompnY )-dC/ "t
❑ Certifie copy is hereby ft nished.
crIT •J py in Bled w II to city inspection division.
moot
�'
FIRE SPRINK
Y ❑ N❑
ENERGY T 24
Y ❑ N❑
MISC. - REFER TO ORD.
PERMIT ISSUANCE 'eb
pp
CERTI' ,ATE OIr IiXEMYTION 17RONI WORKERS'
FLOOD ZONE
A.L.U.C.
COMPENSATION INSURANCE
(This section need not be .completed if the permit is for one
PLO. CONTE, LIC. NO.
PLG, ,1
TOTAL G%y
Y ❑ N❑
Y ❑ No
hundred dollars IS 100) or ass.)
I certify that In the performance of the work for which oris Per
a
not is issued, 1 shall not employ any person in any nnner so as to
DTV. MECHANICAL PERMIT FEE
FEE SUMMARY
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'Compensut ion
provisions of the Labor Code, you must forthwith comply with
such provisions or this permit shall he deemed revoked.
APPLIANCE 5.00
PLAN CHECK
FEE
AIR HANDLING UNIT (TO 10=11F.M.) 4.00
AIR HANDLING UNIT(OVER 10=C.F.M.) 6.00
SEISMIC FEE
CONSTRUCTION LENDING AGENCY
I hereby affirm that there is a construction lending agency for
EXHAUST HOOD (WITH DUCT) 5.00
the performance of the work far which this permit is issued (Sec.
3097, Civ.C.).
MICROFILM
HEATING UNIT (TO 100,000 B.T.U.) 8.00
Lender's Name
HEATING UNIT (OV ER 100,000 B.T.U.)9.50
ELECTRIC
Lender's Address
VENTILATION FAN (SINGLE) 4.00
I certify that l have read this application and state that the above
information is correct. I agree to comply with all city and county
ordinances and state Iaws�relating to building construction, and
'PLUMBING
UV
BOILER -OLIMP I3 H.P. or 100,000B.T.U,1 6.00
BOILER -COMP (Over 100.000 STU) SEE FEE SCH.
MECHANICAL
hereby aulhorim representatives of this city to enter upon the
aboveenienlio d p,Gpern for inspceI ion pugtosos.
MISC. - REFER TO ORD.
PERMIT ISSUANCE 10.00
CONST. TAX
(We) agree t save, indemnify and keep harmless the City of
Cupertino against 'abilities, judgments, costs and expenses which
in any way a true againat said City In consequence of the
can 'ng of his perm
MECH. CONT, LIC. NO.
MECH,
TOTAL
TOTAL
1 Qf0
Si a[ eof Apph t/Contractor Date
-A
OFFICE COPY