18211APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
BU LDI NG PROJECT IDENTIFICATION
APPLICATION & PERMIT
PERMIT NUMBER
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aUILDwc
ADDREs�O^�� e
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BUILDING -ELECTRICAL -PLUMBING -MECHANICAL
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OwNER'a
27T ^
NAME , /L /
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DTV. ELECTRIC PERMIT FEE
'
PLAN CHECK VALIDATION
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CONTRACTORS-
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UTLETS-SWITCHES-RECEP 10.0011.00 -11
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-
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LIGHTING. FIXTURES�e
CONTRACTOR'S
ADDRESS
APPLIANCES -RESIDENTIAL 4.00
PANELS 10.00
PHONE
DATE OF APPLICATION
ARCHITECT
OR
ENGINEER A Luf NO.
PANELS (OVER 200 AMP) 20.00
PLAN CHECK FEE P.C. NO,
SIGNS TRANS. 3.00
ARCH, OR ENG.,
ADORESS/�r �� r,
. %�, (l �'� • zIP
SPECIAL CIRCUIT 5.00
PERMIT VALIDATION
/1
v
tLl
EMP. METER OR POLE INS. 20.00
APPLICANT
DDRESSMOTORS
ADDRESS /
Say«e CGV Ll�i�2
SEE FEE SCH.
SERVICP CHANGE 20.00
LICENSED CONTRACTORS DECLARATION
„�
A, ('
1 .j J
I hereby affirm that I am licensed under provisions of Chapter 9
(carnounieing will, Section 7000) of Division 3 of the 1lueiness:uut
Professions Code, and my license is in full force and effect.
License Class Lia Number
ISSUANCE GATE
BLDG. ELECT. PLG. MECH.
J
Date Contractor
1/KJI
BUILDING PER
INFORMATION �•`v„
OWNER -BUILDER DECLARATION
d Contractor's License
I hereby affirm That I am exempt from the Business
Law forthecitylorcountyng Whih e. Tequiresa Heapto and Professions
Coda. Anycityor county structure ptrmittnconstructo Bur,
.b -Ift
MIS REFER TO ORD
pERMI UANCE 10.00 �, D'p
VALUATION O
S/FT.
ELEC LIC. NO.
C^
ELEC.
TOTAL
improves demolish, or repair any structure, toff prior to cls issuance, also
requires the applicant Ibr such permit to file a Signed actor's License that
he is licensed pursuant to the provisions of the Contractor's 3 fth
Law (Chapter Pmfic same Code)
with Secthat h 7000)of Dthapenona and
Business Professions Codt) or that he is exempt and
qD 000
PERMIT TO
1•,
DE+4 �
/
QTY. / PLU PERMIT FEE
for ectionn0
of Section so3I.5
the basis for the alleged exem subjects
Any applicant
by any applicant for hemi sdollars$5 applicant loacivil penally
of not amts than five hundred dollars (5500).):
STORIES
TYPE CONSTR,
NS
ALTER- RAIN&YEN TER IEA.) 5.00 -:10
❑ 1, as owner of the properly, or my employees with wages as
HIM solo Cam PUIGN01an, will do Dae work, land flat structure is Hol
BACK F LOW PROTECT. DEVICE 4.00
OCC. GROUP
RES. UNITS
DRAINS -FLOOR, ROOF, AREA, COND. 5.00
intended or offered for sale (Sea 7044, Business mad Professions
Code: 'The Contractor's License Law Jots not apply to an owner of
property who builds or improves thereon, and who thatdoes Such work
th improve-
ownemred lors,IT le. If,
mems um not inter Jed Orofin
Owse arc cti intended I'or rule. If, however, the building
however,
'
FIXTURES - PER TRAP 5.00 W o
SO. FT, FLLOOOR A EA
X %P,
v
TOTAL ACREAGE
GAS -EA. SYSTEM OUTLETS 6.00
on
is sold within one year of completion, the owner-
or improvement have
builder will have the harden of proving That he did not build or im-
GAS - EA. SYSTEM - OVER 4 IEA.) 2.00
BUILDING USE
prove for purpose of sale.).
❑ I, as owner of the property, am exclusively contracting with
RES IND CON PB Other
❑ C1 • 0 El
INDUSTRIAL WASTE INTER. 30.00
licensed contractors to construct the project (Sec. 7044, Business
and Professions Code: The Contractors License Law does not apply
to an owner of property who builds or improves Daemon. and who
ILAWN SPRINKLERS- 1 INC 5 V.B. 6.00
ASSESSORS PARCEL NO.
LAWN SPR IN KLERS - OVER 5(EA.) 1.00
conlmcls for such projects with a contractoH s) licensed pursuant to
the Ccntnmlor's License Law.
SEWER -SANITARY -STORM EA. 200ft/10.00
TRACT N0,
PARCEL NO.
reasonl nln exempt under Scc. ,It.&1'.C. Ibr lllls
WATER HEATER W/VENT 6.00 I'.V
Owner Date
WATER SYSTEM 5.00
qCC. GATE
ACO. FILE N0,
WORK(: RS'COMPIiNSATIONDFCLARA'rION
WATER TREATING EQUIP. 5.00
1 heathy a(finn that I have a certificate of consent In self -i azure,
or a certificate of Workers' enrol ion Insurance, or,a reified
ZONING
ENG. SITE NO.
copy (hereof fSec. 3800, L .).
Policy No.0 pa y
-
❑ Car had scop tare] ('urn' J.
yry�Q�' Cerlified y` is f a tl city im cliaa Jivisima.
Allplicenl
FIRE SPRINK
Y N
ENERGY T-24
Y ❑, NE]
MISC. - REFER TO ORD.
CER'TIFICA'1' E OF EXEMPTION PROM WORKERS'
PERMIT ISSUANCE 10.00 LOE
FLOOD ZONE
A. L. u. C.
COMPENSATION INSURANCE
(This action need not be completed if the permit is for ane
Y F] NE]
Y E] NC]
PLG. CONTE. LIC. NO.
PLG. yS
TOTAL W
hundred dollar, (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 -pars.... in may mmmnur so as to
QTY. MECHANICAL PERMIT FEE
FEE SUMMARY
BUILDING
,.�'
become subject to the Workers' Compensation Laws of California.
Date Applicant
ALTER OR ADD TO MECH. 5.00 t)fl
NOTICE TO APPLICANT: If, after making this Certificate of Ex-
APPLIANCE 5.00
PLAN CHECK
.FEE'
emption, you Should become subject to the Workera Compensation
provisions of the Labor Code, you marl 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=01F.M.) 6.00
SEISMIC FEE
CONSTRUCT ION LENDING AGENCY
I hereby affirm tlmLlhe" is a construction lending agency I'll
EXHAUST HOOD (WITH DUCT) 5.00 j'
Hit performance of ilia work for which Il, is permil is issued (Sec.
3097, Civ.CL
MICROFILM
HEATING UNIT (TO 100,000 B.T.U.) 8.00
Lender's Name
Lender's Address - -
HEATING UNIT 100,000 B.T.U.) 9.50
ELECTRIC
3 F /O
f` l
I certify that l 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 stale laws relating to building Construction, and
PLUMBING
r
Or
BOILER -COMP 13 H.P. or 100,000 B.T.U.) 6.00
hereby authorise reiDesepUti •s of this City to enter upon the
ationod p "Part, h spection purposes,
- BOILER -COMP (Over 100,000 BTU) SEE FEE SCH.
MECHANICAL
_ IVabove-Un
(We) agree to save a entry and k • lar ess a City of
Cupertino against li' dies, judgmen osis d e eases which
may in any way true a ainst s ' Cil con uence of the
MISC. - REFER TO ORD.
CONST. TAX
PERMIT ISSUANCE 10.00
ranting of chi unit. Ln
MECH.CONT. LIC.NO. MECH.
TA
'.
TOTAL`
Signatu of Appmans/Contractor
OFFICE COPY /