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APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
IOU LDI NG PROJECT I DENTI FICATI ON
KATION &PERMIT
_
U�I RICAL-PLUMBING-MECHANICAL
PERMIT NUMBER
10846
BUILDING
ADDRESS 5 .� I
OWNER'S
NAME -r 1111-•
ONE
�^^
T
ELECTRIC PERMIT FEE
PLAN CHECK VALIDATION
CONTRACT s
NAME
Uf
LETS - SWITCHES -RECEP 10.0011.00
IGHTING FIXTURES 10.00/1.00
-
CONTRACT rs
AQ PE��
S
P IANCES- RESIDENTIAL 4.00
A LS 10.00
/ 1 N
DATE OF APPLICATION
ARC I ITE T
OR
ENGINEER
LIC. NO.
PA ELS (OVER 200 AMP) 20.00
PLAN CHECK FEE P.C. NO.
SIGNS TRANS. 3.00
ADOHESS ENG'
SPECIALCIRCUIT 5,00
PERMIT VALIDgTION
EMP. METER OR POLE INS. 20.00
ZIP
A
oR
ADDRESS
MOTORS SEE FEE SC,
SERVICE CHANGE 20.00
'
LICENSED CON TRACTORS DECLARATION
I hereby affirm that 1 am licensed under provisions of Chapter 9
(commencing with Section 7000) Of Division 3 of the Business a
Professions Code, and my license is in full farce
License Class Tic. Number ...(`
Dale Contractor
'ISSUANCE DATE
BLDG.
❑
ELECT. I
❑
PLG. MECH.
ED
BUILDINGPERMIT
INFORMATION
L.... DECLARATION
I hereby offal that I am exempt from the Contractor'sMISC.
License
Law for the following reason. (Sec. 703 t.5, Business and Professions
Code: Any city or county which requiresa permit t. construc I, alter,
improve, demolish, or repair any structure.muctu, prior toils 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�L
Law (Chapter 9 (commencing with Section 70000.1'Division 3 fthe
Business and Professions Code) or that he is exempt therefrom and
- REFER TO ORD
PERMIT ISSUANCE 10.00
VALUATION
$/FT.
ELEC. CENTR. LIC. N0.
ELEC.
TOTAL
PERMIT TO
n
�O
QTY. PLUMBING PERMIT FEE
STORIES
TYPE CONSTR.
the hasis for the alleged excurptlon. Any violation of Suction7031.5
by any applicant for a permit subjects the applicant ton civil penalty
of not more than five hundred dollars (4500).):
ALTER -DRAIN -WATER IEA.) 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
BACK FLOW PROTECT. DEVICE 4.00
DCC. GROUP
RES. UNITS
DRAINS -FLOOR, ROOF, AREA, COND. 5.00
intended .r offered for sale (Sec. 7044, Business and Professions
Code: The Cnntraetor's License Law does not apply to an owner of
Property who builds or improves thereon, and who docs such work
himself or through his own employees, provided that such improv.
merits are not intended or offered for sale. If, however, the building
FIXTURES - PER TRAP 5.00
GAS - EA. SYSTEM -1INC. 4 OUTLETS 6.00
50. FT. FLOOR AREA
TOTAL ACREAGE
Or improvement is sold within one year of completion, the owner-
builder will have the burden of proving that h e did not build or an.
prove for purpose of sale.).
❑ 1, as Owner of the property, am exclusively contracting with
. -..
GAS - EASYSTEM OVER 4 IEA) 200
BUILDING USE
RES IND CON PB Other
❑ El 1:1❑ ❑
INDUSTRIAL WASTE INTER30.00
.
licensed contractors to emsstruct 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. 6.00
LAWN SPRINKLERS - OVER 5 (EA.) 1.00
ASSESSORS PARCEL NO.
contracts forsuch projectswith a contructons) licensed pursuant In
the Contractors License Law.
SEWER -SAN EA. 200ft 10,00
/
TRACT NO.
PARCEL NO.
❑ 1 am exempt under Sec. ,B.&P.C. for this
reaxon
WATER HEATER W/VENT 6.00 t
Owner Dnte
WATER SYSTEM 5.00
ACC. DATE
ACC. FILE NO,
WATER TREATING EQUIP.
WORKF.RS'COMPENSAT10N DECLARATION
I hereby affirm that I have a certificate Of consent I elf -insure,
Or a cert c er' e n Insurrm���pppcc, cer 'F
coP t 5 3 C -�
m IIsizi
ZONING
ENG. SITE NO.
!*ERMIT
FIRE SPANK
v N ❑
ENERGY T-24
v ❑ No
C fifi c p s sereby furl a
❑ Certified c y is fded ith B c'ty 'I peel ion division.
Applicant
SC. - REFE Q
ISSUANCE 10.00
CERTIFIC Te E EXE 1 FROM WORKERS'
DO ONE
A. L. U.C.
PLG. CONTE. LIC. NO.
TOTAL L
M F.NSATION INSURANCE
fThis section ne not he completed if the permit is for one
Y N ❑
V ❑ N ❑
hundred dollars (S 100) or less.)
I certify that in the performance of the work for which this per-
mit is issued, I shall not employ any person in any manner so as to
QTY. MECHANICAL PERMIT EE
FEE SUMMARY
BUILDING
become suhjeet to the Workers' Compensation Laws of California.
Date - Applicant
NOTICE TO APPLICANT: If, after making this Certificate of lix-
ALTER OR ADD TO MECH. 5,00
APPLIANCE 5.00
PLAN CHECK
FEE
emption, 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.
AIR HANDLING UNIT (TO 10=C.F.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 for which this permit is issued (Sec.
3097, CN.C.).
MICROFILM
HEATING UNIT (TO 100,000 B.T.U.) 8.00
Lendor's Name
Lender's Address
H EATI N G U N IT (OVER 100,000 B.T.U.) 9.50
ELECTRIC
I certify that 1 have read this application and state that the above
VENTILATION FAN (SINGLE) 4.00
information is correct. I agree to comply with all city and county
ordinances and state laws relating to building construction, and
PLUMBING
x
BOILER- COMP (3 H.P. or 100,000 B.T.U.) 6.00
BOILER -COMP (Over 100,000 BTU) SEE FEE SCH.
MECHANICAL
above-mentioned property rfor epresentativesorthis city es anter upon the
hereby authorize representatives inspection purposes.
MISC. - REFER TO ORD.
CONST. TAX
/
(We) agree to save, indemnify and keep harmless the City of
Cupertino again liabilities, judgments, costs and expenses which
may in any wu accrue against said City in con rice of the
PER IT ISSUANCE 10.00
ling of tl `e . . aa11[]
ME CO T. LIC. NO. MECH.
TOTAL
S,
Si , t Ire o pylic [ .I acloM r` Uatl
t
OFFICE COPY