10014 APPLICANT TO FILL IN INFORMATI RED LINES - USE BALL POINT PEN ONLY
BUI LDI NG PROJEC I DENTI FIVCAT - PERMIT NUMBER
V BUILDING APPLICATION & PERMIT
LA, tILDING - ELECTRICAL-PLUMBING-MECHANICAL 10 014
JPLAN CHECK VALIDATION
" M s O 5��n-/ OTV. ELECTRIC PERMIT FEE
C/ c PHONE
IW CONTRACTORS OUTLETS-SWITCHES-RECEP 10.00/1.00
LIC.NO. LIGHTING FIXTURES 10.00/1.00
ADDRESS TORS APPLIANCES-RESIDENTIAL 4.00
PHONE PANELS 10.00 DATE OF APPLICATION
ARCHITECT PLAN CHECK FEE P.C.NO.
OR PANELS (OVER 200 AMP) 20.00
ENGINEER
LIC NO. SIGNS TRANS. 3.00
ARCH.OR ENG.
SPECIAL CIRCUIT 5.00
IDATION
ZIP EMP.METER OR POLE INS. 20.00
APPLICANTOf MOTORS SEE FEE SCH.DDR .NO
V. - 51985
SERVICE CHANGE 20.00
w O o LICENSED CONTRACTORS DECLARATION TEMP.POLE 30.00 City of Cupertino
a u w I hereby affirm that I am licensed under provisions of Chapter 9 ISSUANCE DATE
n G n (commencing with Section 7000)of Division 3 of the Business and BLDG. ELEC PLG. MECH.
Professions Code•and my license is in full force and effect. ❑ ❑
o0 W License ClassLic.Number E]
w Date Contractor
Q Y E
a ¢w ¢ OWNER-BUILUF,R DECLARATION BU LDING PEflMIT
w ;a- y I hereby affirm that I am exempt from the Contractor's License MISC.- REFER TO ORD FORMATION
H .. o¢ Law for the following reason.(Sec.7031.5,Business and Professionsy y VALUATION $/FT.
Code:An cit PERMIT ISSUANCE 10.00
orcounty which requiresupermil to construct,alter,
QQ ¢Qimprove, or repair any structure,prior to its issuance.also ELECCONTR. LIC.NO. ELEC.
O requires the applicant for such permit to file a signed stateethat TOTAL ER
S, mnt MIT TO
A w m he is licensed pursuant to the provisions of the Contractor's License14�1
z a
Law(Chapter 9(commencing with Section 7000)of Division 3 of the
F i o Business and Professions Code)or that be is exempt therefrom andOTV. PLUMBING PERMIT FEE
¢ r the basis for the alleged exemption.Any violation of Sec[ion 7031.5
n 3 by any applicant for a permit subjects the applicant to a civil penalty STO IES TYPE CONSTR.
of not more than five hundred dollars($500).): ALTER-DRAIN&VENT-WATER (EA.) 5.00
❑ I,as owner of the property,or my employees with wages as BACK FLOW PROTECT.DEV ICE 4.00
their sole compensation,will do the work,and the structure is not OCC.GROUP RES.UNITS
intended or offered for sale (Sea 7044, Business and Professions DRAINS-FLOOR,ROOF,AREA,COND. 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 SD.FT.FLOOR AREA TOTAL ACREAGE
• himself or through his own employees,provided that such improve-
mentsarenotinlendedorofferedforsale.If.however,the building GAS-EA.SYSTEM-11 NC.4 OUTLETS 6.00
or improvement is sold within one year of completion,the owner- GAS-EA.SYSTEM-OVER 4 IEA.) 2.00
builder will have the burden of proving that he did not build or am. BUILDING USE
pride for purpose of sale.). INDUSTRIAL WASTE INTER. 30.00 I❑ CON ❑ Done,
I,as owner a property,am exencively'contracting with
I.
a sed contrac rs t construct the proico(Sec. 7044,Business LAWN SPRINKLERS- 1 INC 5 V.B. 6.00 ASSESSORS PARCEL NO.
nd Profession o ontraclor's Lic Law does not apply
o an owner pro riy so builds ori r ves thereon,and whoWSPRINKLERSERS-OVER 5(EA.) 1.00contracts f such is ith a contr o s)licensed pursuant tothe Contra or's ons La Y-STORM EA.200ft/10.00 TRACT NO. PARCEL NO.
exe un S C. B.&RC.for this W/VENT 6.00Owner D" 5.00ACC.DATEACC.FILENOWOI C MP.NSATION DECLARATION NG EQUIP, 5.00l hereby affirm ha have a certificate of consent to self-insure,
or a certificate of W kers'Compensation Insurance,or a certifiedZONING ENG.SITE N0.
copy thereof(Sec. 00,Lab C.).
Policy No. Company
O ❑ Certified copy is hereby furnished.
Z Z ❑ Certified copy is filed with the city inspection division. FIRE SPRINK ENERGY T.24
�:: O Applicant MISC.- REFER TO ORD. Y [] N Y0 NI
OCT CERTIFICATE OF EXEMPTION FROM WORKERS' PERMIT ISSUANCE 10.00 FLOOD ZONE A.LU.C.
LU > COhIPEMAIION INSURANCE. PLG.CONTR,
LOC.No. PLG.
COL.
This section need not be completed if the permit is for one TOTAL Y❑ NY[:] N[]
2 hundred dollars(S 100)or less,)
U O 1 certify that in the performance of the work for which this per- OTV MECHANICAL PERMIT FEE FEE SUMMARY
LL U mit is issued,I shall not employ any person in any manner so as to
O W become subject to the Workers'Compensation Laws of California.
D- Dal` Applicant ALTER OR ADD TO MBUILDING
} m NOTICE TO APPLICANT: If,after making this Certificate of Ex MECH. 5.00
? emption,you should become subject to the Workers Compensation APPLIANCE 500 PLAN CHECK
provisions of tile .
e Labor Code, you must forthwith comply with
U such provisions or this permit shall be deemed revoked. AIR HANDLING UNIT(TO 10,000C.F.M.) 4.00 FEE
CONSTRUCTION LENDING AGENCY AIR HANDLING UNIT(OVER IO,OODC.F,M.) 6.00 SEISMIC FEE
1 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 ISec.
3007,Civ.CJMICROFILM
. HEATING UNIT(TO 100,000 B.T.U.) 8.00
Lender's Name
Lemdor's Address HEATI NG UNIT(OVER 100,000 B.T.U.)9.50 ELECTRIC
I certify that I have read this application and state that the above VENTILATION FAN (SINGLE)• 4.00 information is correct. I agree(0 comply with all city and county PLUMBING
ordinances and state laws relating to building construction, and BOILER-CO MPOOH.Ror100,000B.T.U.) 6.00
hereby u o¢e representatives of this only to enter upon the
a my mem ed rop"Iy for' Pection purposes. , BOILER-COMP (Over 100,000 BTU)SEE FEE BCH. MECHANICAL
P) a c to ave, ind n fy and keep harmless the City of MISC.- REFER TO ORD.
C cortin aga ist iabilitie , ' it cars, costs an J expenses which
'
OR in an ace e - ainst said Cfly i o q cone of the PERMIT ISSUANCE 10.00 CONST.TAX
g nt t SO MECH,CONT. LIC.NO. MECH.
3-
ignalurco licam/Contractor Untc TOTAL TOTAL
OFFICE COPY