10160APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
BU LDI NG PROJECT I DENTI FICATIO
APPLICATION &PERMIT
BUILDING - ELECTRICAL- PLUMBING - MECHANICAL
PERMIT NUMBER
10160
euaDINc
ADDRESS
N ME
ONE
DTV.
ELECTRIC.PERMIT FEE
PLAN CHECK VALIDATION
DATE OF APPLICATION
NAANMEA °Rs ry
,1- LI .No. Sg p
'OUTLETS-SW
ITCH ES-RECEP 10.00/1.00
.
LIGHTING FIXTURES 10.00/1.00
CONTRACT
AooREsis °/ A` $b
PHONE
APPLIANCES - 4.00
PANELS 10.00
PANELS
_
O
ENGINEER
LIC, NO.
I
00RCHrtEcT
PANELS (OVER 200 AMP) 20.
PLAN 77FEE P.C. N0.
SIGNS TRANS. 3.00
ARCH OR ENG.
ZIP
SPECIAL CIRCUIT. 5.00
PERMIT VALIDATION
317
ISSUANCE DATE
BLDG. ELECT. ,PLG. MECH.
11i�J'/J'I El 0
TEMP. METER OR POLE INS. 20.00 -
APPLICANTS
AooREss
MOTORS SEE FEE SCH. 3-
SERVICE CHANGE 20.00
LICENSED CONTRACTORS DECLARATION(/TEMP.
1 hereby affirm that 1 am licensed under provisions of Chapter 9
(commencing with Section 7000) of Division 3 of the Business and
Professions CO and I license Is m full force It f eC
License fJa Lic. Number
Date _/ Cmramvtora �r
POLE 30,00
- JE)
T
AUG 3 ' 1-„ 7
OWNF. R -BUILDER DECLARATION
I hereby affirm that I am exempt from the Contractor's License
Law for the following reason. (Sec. 7031.5, Business and Professions
Code'. Anw
ycityorunty 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(commencingwith Section 7000) of Division 3 of the
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 toa civil penalty
of not more than five hundred dollars($500)J,
❑ I, as owner of the property, or my employees with wages as
their sole compensation,' will do the work, and the structure is not
intended or Offered for. sale (Sec. 7044, Business and ProfessionsDRAINS-FLOOR,
Code: The Contractor's License Law does not apply to an owner of
property who builds or improves thereon, and who does such work
himselfor through his own employees, provided that such improve
'ments are not intended or offered for sale. If, 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 int-
prove for purpose of sale.).
❑ Las owner of the property, am exclusively contracting with
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
contracts for such projects will, o contmetom) licensed pursuant to
the Contractor's License Law.
❑ lam exempt under Sea ,B.&P.C. for this
reason
BUILDING PERMIT S
- ' c INFORMAT,ION;; ' ' x ;
-
MISC. -' REFER TO ORD
PERMIT I A C�-
_ 10.00
VALUATION
$/FT.
ELEC. CONTH. - LIC. NO.
ELEC.
TOTAL
PERMIT TO_
- "'
QTY. '" PLUMBING PERMIT, "FEE '
STORIES
TYPE CONSTR.
ALTER -DRAIN -WATER IEA.) 5.00
BACK FLOW PROTECT. DEVICE 4.00
OCC. GROUP
RES. UNITS
"
ROOF, AREA, COND. 5.00
FIXTURES - PER TRAP 5.00
GAS-EA.SVSTEM-l 6.00
SQ FT. FLOOR AREA
TOTAL ACR EAGE .�
- . -.
GAS EASYSTEM OVER 4 (EA.) 2.00
BUILDING USE
RES IND CON PB Other'
C1.licensed El
INDUSTRIAL WASTE INTER. ,30.00
LAWN SPRINKLERS- 1 INC 5 V.B. 6.00
LAW 'SPRINKLERS - OVER 5 (EA.) 1.00
ASSESSORS PARCEL NO.
SEWER -SANITARY -STORM EA. 200ft/10.00
TRACT NO.
PARCEL NO-
WATER HEATER W/VENT 6.00
Owner Date
WORKERS'COMPF-NSATION DECLARATION
I hereby affirm that 1 have a certificate Of consent to self -insure,
or a certificate of Workers' Compensation Insurance, or a certified
copy thereof (Sec. 3800, Lab.CJ.
Policy No. Company
WATER SYSTEM -5.00
ACC. DATE
_
ACC. FILE NO.
WATER TREATING EQUIP. 5.00
-
ZONING
'
ENG. SITE NO.
❑ Certified copy is hereby furnished
yf. Certifieyt copy is fd ith}W- inspection division.
C G C.1.0
FIRESPRINK
y� N�
ENERGY T-24
v[]. NE]Applicant-
MISC.- REFER TO OR D.
CERTIFICATE. OF Ii XEMPTION FROM WORKERS'
COMPEN�AION
beINSURANCE
(This section need not T com
completed if e permit Is for one
hundred dollars IS 100) or less.)
1 certify that in the performance of the work for which this per-
mit is issued, I shall not employ any person in any mannerso as to
become subject to the Workers' Compensation Laws of California.
Date Applicant -
PERMIT ISSUANCE 10.00
FLOOD ZONE
Y 0 N
A.L.U.C.
, Y C] N F]
PLG. CONTR. LIC. NO.
TOTAL
_ -
QTY. MECHANICAL PERMIT' . - FEE
FEE'SUMMARY" 4"
BUILDING
ALTER OR ADD TO MECH. 5.00
NOTICE TO APPLICANT: If, after making this Certificate OFF.
you should become subject to the Workers' Compensation
provisions of the Labor Code, you must forthwith comply with
such provisions or this permit shall be deemed revoked.
CONSTRUCTION LENDING AGENCY
1 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.).
Lender's Name
APPLIANCE 5.00
,PLAN CHECK
FEE .
AIR HANDLING UNIT (TO 10,000C.F.M.) 4.00
AIR HANDLING UNIT (OVER 10=C.RM.) 6.00,
SEISMIC FEE
EXHAUST HOOD (WITH DUCT) 5.00
MICROFILM
HEATING UNIT ITO 100,000 B.T.U.) 8.00
Lender's Address
Icertify that l have road this application and stole that the above
information is correct. 1 agree to comply with all city and county
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.
(We) agree to save, ind � nify and keep harmless the City of
Cupertino against IiabiliC ,judgmentsr, aco�sts and expenses which
may in any way ace' against said CP in ousequence of lite
granting o 1 pey �r
A
HEATI NG UN IT (OV ER 100,000 B.T.U.) 9.50
ELECTRIC
193.
VENTILATION FAN (SINGLE) 4.00
BOILER-COMP(3 H.P. or 100,000 B.T.U.) 6.00
PLUMBING
BOILER -COMP (Over 100,000 BTU) SEE FEE SCH.
MECHANICAL
MISC. - REFER TO ORD.
PERMIT ISSUANCE 10.00
CONST. TAX
-
MECH. CONT. LIC. NO.
MECH.
TOTAL
TOTAL
A
Signa ore Applicant/Comtmc[o[
/L.�/iLOQa1FICE COPY
= . "'�