3660APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALI_ POINT PEN.ONLY
BU LDI NG PROJECT IDENTIFICATION
Is ILDNIG I APPLICATION & PERMIT - -
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( PLAN CHECK VALIDATION
OWNER'S
NAME OTV. ELECTRIC PERMIT FEE
PNONE 'Q%
'
'
CONTRacroRs -
NAME
I
' G/ p/'• LIC. No.
OUTLETS - SWITCHES -RECEP 5.00/1:00
LIGHTING FIXTURES 5.00/1.00
f,OrvTR SS
ADORESS
APPLIANCES=RESIDENTIAL 4.00
S.00
PHONE -'31PANELS
DATE OF APPLICATION
ARCHITECT-
OR •ti.
ENGINEER
LIC. No.
SIGNS 6.00.
PLAN CHECK FEE P.C. NO.
SIGNS TRANS. 3.00
ARCH. OR ENG.
ADORE55
SPECIAL CIRCUIT 5.00
PERMIT VALIDATION
TEMP. METER OR POLE INS. 15.00
ZIP
-
avvucanrs
REss
Aoo�
MOTORS SEE FEE SCH.
SERVICE CHANGE 10.00
va y
6 /�
LICENSED CON'I'RACfORS DECLARATION
1 hereby offlna that I :un licensed under provision. of Chapter 9
(commencing with Section 7000) of Division 3 of the Business and
Professions Cod` r f n erne is in full for ct
License lass Lic. Number
ISSUANCE DATE
BLDG.
ELECT.
�.
PLG. MECH.
0
-
•
Uate Cmaracmr -s�—
B LOIN PERMIT
INFORMATION
OWNER-IIUILDER DECLARATION /
1 hereby affirm that I am exempt from the Contractor's License
Law for the following reason. (Sec, 7031.5, Business and Professions
Any city or county which requirese permit t0 construct, , aCq
improve,
improve, demolish, or repair any structure, prior to its issuance, also
requires the applicant for such revisit to file a signed statement that
Ile Is (Chapticenseder
9(rsuant ommen the with provisionsofthe CO If Division
LicensSof the
Law (Cs,and9(commenCde) or Section is exemfttheefoofthe
Business and Professions Code) or That he is exempt therefrom and
MISC. — REFER TO ORD
_
PERMIT ISSUANCE . ' "6.00
VALUATION
�9 70
$/FT.
ELEC. ODNTR, LIC. NO.
ELEC.
TOTAL
PERMIT TO '
%J ('
({'vf RfidP (�lr,J
- -
OTV. PLUMBING PERMIT FEE
STORIES
/Nt:J .S h/9
q
TV E CONSTR.
s? ..vGCCi
the basis for the alleged exemption. Any violation otonction malty
by any applicant for hundred dUll.ra($50pplicant ora civil penalty
o (my em1:
of not more than five hundred property,
❑ I, as owner at the will do t or my employees with wages as
their sole compensation, will the work, the structure is not
ALTER-DRAIN&VENT-WATER(EA.Y4.00
BACK FLOW PROTECT. DEVICE 2.00
24,
OCG GROUP-
RES. UNITS
DRAINS-FLOOR„ROOF, AREA,COND. 4.00
(S Business
Code: The Contractor's License Low does not apply to an owner of
Coote, dor offered for Lice (Sec. 7044, Business and n owner f
FIXTURES - PER TRAP 4.00
50.,r. FLOOR AREA
TOTAL ACREAGE
property who builds or improves thereon, and who (Iucs such work
himself or through his own employees, provided that such improve-
mentsarerimintendedoroffetedforsale. If, however, the building
GAS-EA.SVSTEM-1 q,00
or improvement is sold within one year of completion, the owner-
builder will have the burden of proving that he did not build or am.'
prove for purpose of sale.).
❑ I, as owner of the property, am exclusively contracting with
GAS - EA. SYSTEM -OVER 4 (EA.) 1.00
BUILDING USE
tNO CON PB Omer
RE ❑ ❑ ❑ ❑
INDUSTRIAL WASTE INTER. 20.00
licensed contractors 1. condouri the project (Sec. 7044, Rldlaaaa
and Professions Code: The Contractor's License Law does not apply
to an owner of property who builds or improves thereon, and who
LAWNSPRINKLERS- 1 INC 5 V.B.
LAWN SPRINKLERS - 5 (EA.) 1.00
- ASSESSORS PARCEL NO.
contracts for such projects with a contractors) licensed pUHaUnt 10
the Contraetoi s License Law.
SEWER -SANT -STORM EA. 200ft/8.00
ACT NO,
PARCEL NO. .
❑ 1 am exempt under Ser.—. B.&P.C. for this
reason
WATE ATER W/VENT 4.00
Date Owner—
W ER SYSTEM. q,
AC .DATE
ACC. FILE NO.
WORKERS'COMPENSA'I' ION DECLARATION
WATER TR EATING.EDUIP' 4.0
I hereby affirm that I have a certifiicate.fconsent toself-insure,
or a certificate of Workers' Compensation Insurance, or p -r
copy thereof (Sec, 3800, Lob.CJy.�p��p 5�'� f
•
Policy No. Company .-���pc{
NINE
ENG. SITE NO.
N Is"
❑ Certified copy is hereby furnished. e
❑ CertifiuA .,w Is iced w�JI Ikity inslpection div' 'n
Applicant / �.. _�. 0-,
fIRE SPRINK
V ❑ ,N❑
ENERGY T 24
V ❑ N❑
_!
MIS - RE ER TO ORD.
CERTIFICATED EXIiMPTION FROM WORKER.
PER T S 6.00
FLOOD ZONE
A.L.UC.
COMPENSATION INSURANCE
(T[is section need not be Completed if the permit i. lot one
PLG. CONTR. LIC. NO. -
PLG.
TOTAL
Y. E] N ❑
'V E] N E]
hundred dollars (5100) or less.) '
I certify that in the performance of the work for whic this per-
mit is issued. I shucc not enc ploy any p,ensoa in any marine so Its to
DTV. MECHANICAL PERMIT FEE
_
FEE SUMMARY
BUILDING
3,F�
become subject tothe Workers'Contensation Laws of Coli nsia.
Date ApplicantALTER
NOTICE TO APPLICANT: If, after making this Certificate
OR ADD TO MECH. - 4.00
,
APPLIANCE 4.00
_PLAN CHECK
FEE'
emotion, you should become subject to the Workers'COmPellfa7l
in
provisions of the Labor Code, you must forthwith comply with
such provisions .,this permit shall be deemed rcockeJ.
R-ftAl�6Ll T (TO 10,000 C. F. M.) 3.00
CLING UNIT(OVER 10)000CF.M.) 5.00 -
SEISMIC FEE
CONSTRUCTION LENDING AGENCY
EXHAUST HOOD (WITH DUCT) 2.00
I 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.).
MICROFILM
HEATING UNIT (TO 100,000 B.T.U.) 4.00
H EATI NG UN IT (OV ER 100,000 B.T.U.) 7.50
ELECTRIC
Lender's Name
Lender's Address
VENTILATION FAN (SINGLE) 3.00
I certify that I have read this application and state that the above
information is correct. I agree to comply with all city and c.Only
ordinances and state laws totaling to building construction, and
PLUMBING
BOILER - COMP (3 H.P. Or 100,000 B.T.U.) 4.00
BOILER -COMP Ove, 100,000 BTU) SEE FEE SCH.
MECHANICAL
hereby authorize representatives of this city to enter upon the
abave-menfjoned property for inspection purposes.
(We) agree 7o save, indemnify and keep harmless the City of
Cupertino against liabilities, judgments, costs and expenses which
may in any way accrue against said Cit in consetluence of the
grantingofthis penniL
MISC. REFER TO ORD.
CONST. TAX
PERMIT ISSUANCE 3.00
MECH. CONT. LIC. NO.,
-
MECH.
roTAL
TOTAL
pqq AY
&gnature of scan ontram ate
INSPECTOR COPY