10263 / APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY V
TYAv///JJJ��r BUILDING PROJECT I,6914TI FICATIgo PERMIT NUMBER n
RUILDIN APPLICATION & PERMIT /� ///��Y
4DDRE5 1 0 2 C I
BUILDING —ELECTRICAL—PLUMBING—MECHANICAL I rV1J
r
OWNER'S I PLAN CHECK VALIDATION
NAME QTY. ELECTRIC PERMIT FEE
HONE
WARCHITICT
°R$ OUTLETS-SWITCHES-RECEP 10.00/1.00
uc.N LIGHTING FIXTURES 10.00/1.00
ss TO PPLIANCES-RESIDENTIAL 4,00
PANELS 10.00 DATE OF APPLICATION
oPHON PANELS (OVER 200 AMP) 20,00 PLAN CHECK FEE P.C.NO.
ENGINEER
LIC.No, SIGNS TRANS. 3.00
ARCH,OR PM,
ADDRESS ENG. SPECIAL CIRCUIT 5,00 ALOATION
ZIP rrEMP.METER OR POLE INS. 20.00 opC
APPLICANTS MOTORS SEE FEE SCH. MAR 28 1986
A E
SERVICE CHANGE 20,00
,02 LICFNSED CONTRACTORS DECLARATION TEMP.POLE 30.00 .City.Of Cupertino
Fi W I hereby allinn that I am licensed under provisions of Chapter ISSUANCE DATE
a (commencing with Section 7000)of Division 3 of the Business a BLDG. ELECT. PLG. ME
r o i Professions Cod Ji license is in full fort ❑ O ❑
Z o — License Cluss_ I —Liu.Number
0 m �_w DWe Contractor `
Q y
¢ ¢ ¢ OWNER-BUILDER D17CLARATIO BUILDING PERMIT
A o a INFORMATION
X g r I hereby affirm that I am exempt from the Contractor's License MISC.— REFER TO ORD
u O J Law for the following reason.(Sec.7031.5,Business and Professions VALUATION /FT.
H — PERMIT ISSUANCE 10.00
mj Code:Any city ar county which requires permit mconsDucl,alter,
¢ a a 0 improve,demolish,or repair any structure,prior to its issuance,also ELEC.CONTR. LIC.NO. ELEC.
o¢ requires the applicant for such permit to file a signed statement situs TOTAL
u w 9 of he is licensed pursuant to the provisions of the Contractor's License PERMIT TO
r Z >0 Law(Chapter 9 fcommencing with Section 7000)ofDivision 3 of the
s 4 o Business and Professions Code)or that he is exempt therefrom and OTY. PLUMBING PERMIT FEE
¢ I-$ the basis for the alleged exemption.Any violation of Section 7031.5 STORIES TYPt CONSTR.
i; — by any applicant far a permit subjects the applicant to a civil penalty ALTER-DRAIN -WATEfl IEA.) 5.00
of not more than five hundred dollars($5001):
❑ I,as owner of the property,or my employees wills wages as BACK FLOW PROTECT.DEVICE 4.00 OCC.GROUP RES.UNITS
their sole compensation,will Jo 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 to an owner of
property who builds or improves thereon,and who does such work F IXTUR ES-PER TRAP 5.00 50.FT FLOOR AREA TOTAL ACREAGE
• himself or through his own employees,provided that such improve-
ments are not intended or offered for sale,if,however,the budding GAS-EA.SYSTEM-1 INC.4 OUTLETS 6.00
or improvement is sold within one year of completion,the owner- GAS-EASYSTEM-OVER 4 IEA) 200
builder will have tile . . .
e burden of proving that he did not build or im- BUILDING USE
INDUSTRIAL WASTE INTER. 30.00 IN CON PB Orae,
move 1,as owner
of sale). ❑ 1❑ ❑ ❑
❑ d as owner of the property,he exclusively. 7044, ins with
licensed contractors to construct the project(Sec. 7044,Business LAWN SPRINKLERS- 1 INC 5 V.B. 6.00 ASSESSORS PARCEL NO.
and Professions grope The Contractor's s License Law does not apply
to tr owner of property who builds tr improves thereon,and who LAWN SPRINKLERS-OVER 5(EA.) 1.00
contracts et.r'sor hprojectswishacomramorts)licensed pursuant to SEWER-SANITARY-STORM EA.'200ft/10,00
the Contractor's License Law. TRACT N0, PARCEL NO.
❑ lam exempt under Sec.—,B.&P.C.for this
reason WATER HEATER W/VENT 6.00
Owner Date WATER SYSTEM 5.00 ACC.DATE ACC.FILE NO.
WORKERS'COMPENSATION DECLARATION WATER TREATING EQUIP, 5.00
I hereby affirm that I have a certificate of consent to scifinsure,
ora certificate of Worker'Compensation Insu' Te,or a certified ZONING ENG.SITE NO.
copy No ly.).
Policy No, ty
O rIi copy is he faro J. FIRE SPRINK ENERGY T-24
Z Z Certified cop fit w' the it nspection division. MISC.- REFER TO ORD.
O A I¢ant Y[] NC:] Y [3 N�
H CF:RTI FI CA EEXEMPTION FROM WORKERS' RMIT ISSUANCE 10.00 FLOODZONE A.L.U.C.
L COMPENSATION INSURANCE PLG.CONTR. LIC.NO. PLG
CL 0 (This section need not be completed if the permit is for one TOTAL Y❑ Nr Y❑ NFJ
D Z hundred dollars(S100)or less,)
U O I certify that in the performance of the work for which this per- OTY. MECHANICAL PERMIT FEE FEE SUMMARY
LL F mit is issued,1 shall not employ any person in any manner sons to
O w become subject to the Workers'Compensation Laws of California.
Ume Applicant BUILDING
Is. ALTER OR ADD TO MECH. 5.00
} to NOTICE TO APPLICANT: If,after making this Certificate of Ex-
FZ empisionyou should become subject to tile Workers'Ccomply Willi APPLIANCE 5.00 PLAN CHECK
provisions io the Labor Code, you mull forthwith comply will! FEE
U such provisions or this permit shall he deemed revoked. AIR HANDLING UNIT(TO 10,000 C.F.M.) 4.00
CONSTRUCTION LENDING AGENCY AIR HANDLING UNITIOVER 10A00C.EM.) 6.00 EISMIC FEE
I 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. ICROFILM
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 TRIC
1 certify that I have read this application and state that the above VENTILATION FAN (SINGLE)
information is correct.1 agree to comply with all city and county 4.00
BOILER-COMP(3 H.P,or 100,000 B.T.U.) 6.0 PLUMBING
ordinances and state laws relating to building construction, and
hereby above-mentioned
ropertyfor ins inspection
this city to enter upon the BOILER-COMP (Over 100,000 BTU)SEE FEESCH. MECHANICAL
hereby authorize
properly forinspofth purposes.
(We) agree to save, inrJc tnify and keep harmless,thc City of MISC.- REFER TO ORD.
Cupertino again liabilyyTEs, udgments, casts and expenses which PERMIT ISSUANCE 10,00 CONST.TAX
may ' ny accsUe a .inm sail City in consequence of the
gr in f tl pen s ME .CONT. LIC.NO. MECH.
�a Torn 7� TOTAL
to Appcanl onlra 4or Ume ��
OFFICE COPY