10110APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
BUILDING PROJECT IDENTIFICATION
APPLICATION & PERMIT
BUILDING - ELECTRICAL -PLUMBING -MECHANICAL
PERMIT NUMBER
10110
BUILDING
ADORES
CANER,
NA
PLAN CHECK VALIDATION
QTY. ELECTRIC PERMIT FEE
E PHONE
Nam nacions �.
UTLETS- SWITCHES -RECEP 10.00/1.00
Llt. rvo.
LIGHTING FIXTURES 10.00/1.00
CONTRACTOR S
APPLIANCES -RESIDENTIAL 4.00
PNON
PANELS 10.00
DATE OF APPLICATION
A.c.11mir
on
ENGINEER
LIC. NO.
PANELS (OVER 200 AMP) 20.00
PLAN CHECK FEE P.C. NO.
ISIGNS TRANS. 3.00
ADDRESS ENG.
SPECIAL CIRCUIT 5.00
PERMIT VALIDATION
ZIP
TEMP. METER OR POLE INS. 20.00
)
APPLICA
ADDRESS rs
i
MOTORS R, SEE FEE SCH.
SERVICE CHANGE 20.00
1
LICENSED CONTRACTORS DECLARATION
TEMP. POLE 30.00
I hereby affirm that 1 am licensed under provisions o(Chapler 9
(commencing with Section 7000) of Division 3 of the Business and
ISSUANCE DATE
C
i 17
Professions Cod as d ty license is in full fore a d f
License las Lia. Contractor
Date humble
Contractor
OWNER -BUILDER DECLARATION
BLDG.
❑
ELECT.
PLG. MECH.
r �(/u 3 City of Cupertino
BUILDING PERMIT
1 hereby affirm that I um exempt from the Contractor's License
Law for the following reason. (Sec. 7031.5. Business and Professions
Code: Any city or county which requires a permit to construct, alter,
INFORMATION
MISC. - REFER TO ORD
PERMIT ISSUANCE 10.00
VALUATION
$/FT.
ELEG NT LIG NQ
y!/
ELEC. G
TOTAL
improve,demolish, or repair any structure, prior to its 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
Law (Chapter 9 (commencing with Section 7000) of Division 3 of the
PERMIT TO
IL -71-6-c-
E T
Business and Professions Code) or that he is exempt therefrom and
the basis for the alleged exemption. Any violation of Section 7031.5
by any applicant for a permit subjects the applicant to a civil penalty
ofnot more than live hundred dollars(SS00).):
OTY. PLUMBING PERMIT FEE
ALTER-DRAIN (EA.) 5.00
STORIES
TYPE CONSTR.
O I, as owner of tire property, or my employees with wages as
their sole compensation, will do the work, and the s[ruetum is net
intended or offered for sale (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 does such work
himself or through his own employees, provided that such improve
BACK FLOW PROTECT. DEVICE 4.00
OCC. GROUP
RES. UNITS
DRAINS -FLOOR, ROOF, AREA, COND. 5.00
FIXTURES - PER TRAP 5.00
SO. FT. FLOOR AREA
TOTAL ACREAGE
merits are not intended or offered for sale. If, however, the building
or improvement is sold within one year of completion, the owner -
builder will have the burden of proving that he did not huild or int.
from 1, as ownerose Of file J.
❑ d as owner of the property, am exclusively contracting with
licensed contractors to construct 0m project La does Business
and Professions Code: The Contractor's License Law does not apply
GAS - EA. SYSTEM -1 INC.4 OUTLETS 6.00
GAS - EA. SYSTEM - OVER 4 IEA.) 2.00
BUILDING USE
RES IND CON PB Other
it i3 ❑ it it
INDUSTRIAL WASTE INTER. 30.00
LAWN SPRINKLERS- 1 INC 5 V.B. 6.00
ASSESSORS PARCEL NO.
LAWN SPRINKLERS - OVER 5 (EA.) 1.00
to an owner of property who builds or improves thereon, and who
contracts for such projects with a contractors) licensed pursuant to
the Contractor's License Law.
❑ 1 am exempt under Sec. , B.&P.C. for this
reason
SEWER -SANITARY -STORM EA. 200ft/10.00TRACTNO.
WATER HEATER W/VENT 6.00
PAgCEL NO.
Owner Date
WATER SYSTEM 5,00
woRKIi that I have
DECLARATION consent
I hereby ate that I have a certificate
a certiAI ficate consent tos
self -insure.
ACC. DATE
ACC. FILE -NO
ENO.
WATER TREATING EQUIP. 5.00
if
or a certificate of Workers' Compensation 1 urance, or a certified
I or
copythereof (Sec.3 LAC
ZONING
ENG. SITE NO.
Policy N Cm pmly YN
Co y
MISC.- REFER TO ORD.
rt hereby
Certified copy is hereby famished. .
Certifyp� }y1 u I d with (bc ms etion Division.
Ap cant IYU��QfnFC-
CERTIFICATE OF EXEMPTION FROM WORKERS'
COh1PF.NSATION INSURANCE
(This section need not be completed if the permit is for one
hundred dollars (S 1001 or IessJ
FIRE SPRINK
Y[3 N�
ENERGY T 24
PERMIT ISSUANCE 10.00
FLOODZONE
Y i� NEI
A.L.U.D.
V N�
PLG. CONTR. LIC. NO.
PLG
TOTAL
QTY MECHANICAL PERMIT FEE
FEE SUMMARY
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
become subject to I e Workers' Compensation Laws of California.
Date ICAN :
NOTICE TO APPLICANT: If, after making this Certificate of lix-
BUILDING
ALTER OR ADD TO MECH. 5.00
emption, you should became subject to 0tu workers'Compensation
provisions of the Labor Code, you must forthwith comply with
such provisions or this permit shall be deemed revoked.
APPLIANCE 6.00
PLAN CHECK
FEE
AIR HANDLING UNIT (TO 10=CF.M.) 4.00
CONSTRUCTION LENDING AGENCY
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.).
Lender's Name -
AIR HANDLING UNIT (OVER 10=1QEM.) 6.00
SEISMIC FEE
EXHAUST HOOD (WITH DUCT) 5.00
MICROFILM
HEATING UNIT (TO 100,000 B.T.U.) 8.00
LendersAddress i
1 certify that 1 [IS se read this application and state that the aboveTION
information is correct. I agree to comply with all city and county
ordinances and state laws relating to building construction, andMP(3H.P.or100,000B.T.U.)
hereby authorise representatives of this city to enter upon the
above mentioned property for inspection purposes
(We) a see to save, indemnify and keep harmless the City of
Hi a in st liabilities, j dgments, costs and expenses
UNIT 100,000 B.T.U.) 9.50
ELECTRIC
/S
FAN (SINGLE) 4.00
6.00
A.EC.
PLUMBING
OMP(over 100,000 BTU) SEE FEE SCH.
MECHANICAL
REFER TO ORD.
which
may any ay ace agg n City in con ue ce of theSUANCE
gr ni Oft spur it.. t
10.00
CONST. TAX
LIC. NO.
MECH.
I oat re p moot actor ate
TOTAL
TOTAL
OFFICE COP