10267 � PPLICANT TOFILL N INFORMTION WITHIN RED LINES - USE BALL POINT PEN ONLY
BUILDING PENTI FICAT . PERMITNUMBER
BUILDI ' APPLICATION & PERAODRE 10Z6
BUILDING-ELECTRICAL-PLUMBING-MECHANICALOWNER6 PLAN CHECK VALIDATION
"AME OTY. " " ELECTRIC PERMIT - FEE'"
PHONE
NON croR OUTLETS-SWITCHES-RECEP 10.00/1.00
uc.No. LIGHTING FIXTURES 10.00/1.00
po R r 's APPLIANCES-RESIDENTIAL 4.00 t,
PRO N PANELS 70.00 DATE OF APPLICATION.",
OR
PANELS (OVER 200 AMP) 20.00 PLAN CHECK FEE P.CINO.
ENGINEER P^t�
uc.rvo. ISIGNS TRANS. 3.00
ADDRESS ENG, SPECIAL CIRCUIT 5.00 PERMIT VALIDATION
zIP EMP. METER OR POLE INS. 20.00 MAR 2 8 1986
P A"T MOTORS SEE FEE SCH.
ES
SERVICE CHANGE 20.00 City of Cupertino
0 0 o LICENSED Co TRACTS S DECLARATION TEMP.POLE 30.00 "
¢ uu 1 hereby affirm that I am licensed under provisions of Chapter 9
a i w ISSUANCE DATE
y a m (commencing with Section 7000)of Division 3 of the Busi s d BLDG. ELECT. PLG. ECH.
Z Professions Cod ''ense Is in full force el'e
oi w o License Class Lic.Number
y r w Date Controdor
Q y E J
¢ ¢ ¢ a
OWNER-BUILDER DECLARATI N n xSUILDING;PERMIT�.s#r
a o d - he
s4,„
X g m I hereby affirm that I am exempt from the Contractor's License MISC.- REFER TO ORD -
u o a Law for the following reason(Sec.703 1.5,Business and Professions VALUATION $/F .
- PERMIT ISSUANCE 10.00
sA Code:Any city or county which requires a permit to construct,alter,
¢ ¢ Q 0O improve,demolish,or repair any structure,prior to its issuance,also ELEC.CONTE. LIC.NO. ELEC.
O u requires the applicant for such permit to file a signed statement that TOTAL
n w m w he is licensed pursuant to the provisions of the Contractors License PER IT TO
r z¢ Law(Chapter 9(contmencingwith Section 7000)of Division 3 ofthe
i3O Business and Professions Code)or that he Is exempt therefrom and DTV. - - PLUMBING-PERMIT- - FEE', PAk
It r $ the basis for the alleged exemption.Any violation of Section 7031.5 STORIES TYPE CONSTR.
a4 § by any applicant for a permit Subjects the applicant Goa civil penalty ALTER-DRAIN&VENT-WATER (EA.) 5.00
of not more than five hundred dollars($500).)'.
❑ 1,as owner of the property,or my employees with wages as BACK FLOW PROTECT. DEVICE 4.00
their sole compensation,will do the work,and the st racti A is not OCC.GROUP RES.UNITS
intended or offered for sale (Sec. 7044, Business and Profession'
Code: ROOF,AR EA,CON D. 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 FIXTURES-PER TRAP 5.00 BG.FT.FLOOR AREA TOTAL ACREAGE
himself or through,his own employees,provided that such Turn, -
ments are not intended or offered for sale.If,however,the building GAS-EA.SYSTEM-I INC.40UTLETS 6.00
or improvement is sold within one year of completion,the owner- GAS-EASYSTEM-OVER 4(EA.) 2.00
builder will have the burden of proving that h .e did not build or int- BUILDING USE
prove for purpose ofsaleJ' INDUSTRIAL WASTE INTER. 30.00 R B IND CON PB Other
❑ I,as owner of the property,am exclusively contracting with 11 El O
V.B.
licensed contractors to construct the project(Sec. 7044,Business LAWN SPRINKLERS- 1 INC 5 6.00 ASSESSORS PARCEL ,
and Professions Code:The Contractor's License Law.does not apply -
lo an owner of property who builds or improves thereon,and who LAWN SPRINKLERS-OVER 5(EA.) 1.00
contracts for such projects with a contractors)licensed pursuant to -
theContractor'sLicenseLaw. SEWER-SANITARY-STORM EA.200ft/10.00 TRACT NO. PARCELNO.
❑ lam exempt under Sec. ,B.&P.C.for this
reason WATER HEATER W/VENT 6.00
Owner Data WATER SYSTEM 5.00 ACC.DATE ACC.FILE No.
WORKERS'COMPENSATION DECLARATION WATER TREATING EQUIP, 5.00
1 hereby affirm that I have a certificate of consent to self-H sum,
or a certificate of W rkits ompensalion Insur �ee,or ac erci"at ZONING _ ENG.SITE NO.
Copy 11No ).
Policy No.
O C deo ry. terehy ' r shed FIRE SPRINK ENERGY T24
Z Z Certifie opy is Ele ith c icy inspection division.
O A cant MISC.- REFER TO ORD. Y 0 N Y ❑ NE]
O_ ti CE 9ET1 FROM PERMIT ISSUANCEF10.00 FLOOD ZONE A.L.U.C.
LU COMPENSATION
INSURANCE PLG,CONTR. LIC.NO. PLG. '
d a (This section need nob be completed if the permit is for one TOTAL V N� Y N�
Z hundred dollars($IDD)or less.)
U O 1 certify that in the performance of the work for which this per QTY. MECHANICAL PERMIT ` -FEE" ."FEE SUMMARY" n*+
LL mit is issued,I shall not employ any person in any manner so as to - - =x.#:L-' V
become subject to the Workers'Compensation Laws of California.
0. Dale -Applicant ALTER OR ADD TO MECH. 5.00 BUILDING
} rn NOTICE TO APPLICANT: If,after making this Certificate of Ex-
f- Z emption,you should become subject to the Workers'Compensation APPLIANCE 5.00 PLAN CHECK
provisions of the Labor Code, you must forthwith comply with U FEE such provisions or this permit shall be deemed revoked AIR HANDLING UNIT(TO 10=C.F.M.) 4.00
CONSTRUCTION LENDING AGENCY TAIR HANDLING UNIT(OVER 10,000C.RM.) 6.00 J 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. MICROFILM
3097,Civ.C.). HEATING UNIT(TO 100,000 B.T.U.) 8.00
Leader's Name
Lender's Address HEATING UN IT(OVER 100,000 B.T.U.)9,50 E ECTRIC -
I certify that I have read this application sad slate that tha above VENTILATION FAN (SINGLEI 4.00
.
information is correct. I agree to comply with all city and county PLUMBING
ordinances and state laws relating to building construction, and BOILER-COMP(3 H.P.Or 100,000 B.T.U.) 6.00
hereby authorize representatives othis
thipurposes.s city to enter upon the
above-mentioned property for inspectionBOILER-COMP (Over 100,000 BTU)SEE FEE SCH. MECHANICAL
W. Apr%"bit/Cofffract
e, indemnify and keep harmless the Cay.of MISC.- - REFER TO ORD.
bilities gments, costs and expenses which ONST.TAX
ccrue go st said City in consequence of the PERMIT ISSUANCE - 10.00
it. ME .CONT. " LIC.NO. MECH. '
TOTAL TOTAL
t/Ca frac or Date
dFFICIrCOPY