1720APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BI' PEN ONLY,,IzG1
BUILDING PROJECT IDENTI FICATi
APPLICATION&PER
BUILDING - ELECTRICAL- PLUMBING - MECHANICAL
RMI O BE
�7 fjo
1 G
IPJILDING
Aou E
OTY. �/ ELECTRIC PERMIT FEE.''
PLAN CHECK VALIDATION
N P'S
NAWE
rvE
'L
DATE OF APPLICATION
NT ACTOR'S}
N,Aylg
(�" D` yN6 Uc.No. 2 a76
3/OUTLETS-SWITCHES -RECEP 5.00/1.00
•%- LIGHTING FIXTURES 5.00/1.00 1
nooT ess TORS ' q,
Zd� ^T -• • PHONE
APPLIANCES - RESIDENTIAL 4.00
PANELS 5.00
ARCHITECTSIGNS
on
ENGINEER
LIC. NO, -
.
6OD
PLAN CHECK FEE P.C. N0.
1
gd. / /.
SIGNS TRANS. 3.00
ARCHHE R ENG
SS
SPECIAL CIRCUIT 5.00
PERMIT VALIDATION
TEMP.METER OR POLE INS. 15.00
ZIP
APPLRESCA
ADDS
MOTORS EE FEE S
-
pPCH.
SERVICE 10.00 '
LICENSED CONTRAC'T'ORS DECI.ARA'NOR
tsw l)e
I hereby affirm that 1 a n licensed under provisions of Chapter')
(commencing with Section 7000) of Division 3 of the Business and
rofessions Code, 3.4d my license is in full force and affect. 3
License Class' Contractor
Data Cmdructor
ISBuaNCE DATE
BLDG. ELECT.
ISI' ❑
PLG. MECH.
❑ ❑
}�-/L`d,
BUILDING PERMIT
INFORMATION
OWNER -BUILDER DI'.CI,ARAI'ION
I hereby infirm that I wn exempt from the Contractor's License
L. for the following reason. (Sec. 70J L5, Businessand Professions
Code: Any cilyorecunty which requires a permit toconstrucl,ether,
improve, demolish, or repair any structure, prior to its issuance, also
requires tire applicant for such permit IO file a Signed statement that
he is licensed pursuant to the provisions of the Contractor's License
il,
MISC. - REFER TO ORD
VALUATION
QO
/OC D -�
O
$/FT.
PERMIT ISSUANCE 6.00 •�
a
ELEC. CONTR, LIC. NO. ELEC. IO
IOTA L�qa �-
PERMIT T JJ
Law (Chapter 9(commencing with Section 7000) of Division 3 ofthe
Business and Professions Code) or that he is exempt therefrom and
OTY. PLUMBING PERMIT FEE
STORIES
TYPE�C/ONSTR.
the basis for the alleged exemption. Any violation of Section 7031.5
fore permit dailys(heapplican[mucivil penalty
by any ora than
of not more than five hundred dollars tiro applicant
/
3N11/P
ALTER -DRAIN T-WATER(EA.)4.00
❑ I, as owner of the property, or my employees with wages as
their sole compensation, will do the work, and the structure is not
intended or offered for sale (Sec. 7044, Business and Professions
BACK FLOW PROTECT. DEVICE 2.00
OCC. GROUP
RES. UNITS
DRAINS -FLOOR, ROOF, AREA, COND. 4.00
Code: *1 lie 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-
ments are not intended or offered for sale. 11, however, the building
FIXTURES - PER TRAP 4.00
SO. FT. FLOOR AREA
TOTAL ACREAGE
r�
GAS - EA. SYSTEM - I INC.4 OUTLETS 4.00
or improvement is sold within one year of completion, lire owner-
builder will have the burden of proving (hat he did not build or am-
prove for pvrposcofeule')'
❑ 1, as owner of the property, am exclusively contracting with
GAS - EA. SYSTEM -OVER 4 (EA.( 1.00
BUILDING USE
RES IND COJr PB OR,.,
❑ ❑ ❑ ❑
INDUSTRIAL WASTE INTER. 20.00
licensed contractors to constructContra the project (Sec. does, Business
and Professions Code: The ho builds o License s th does not apply
To an owner of prrperty who builds or improves Thereon, anA who
LAWN SPRINKLERS- 1 INC 5 V.B. 5.00
LAWN SPRINKLERS -OVER 5 IEA.) 1.00
ASSESSORS PARCEL NO.
q7/f r /
contracts for such projects with a contractors) licensed pursuant IF
the Contractor's License Law,
SEWER -SANITARY -STORM EA. 200ft/8.00
TRACT NO.
PARCEL NO.
❑ lam exempt under Sec. ,B.&P. C. for this
reason
-�
WATER HEATER W/VENT 4.00
Date Owner
WATER SYSTEM 4.00
ACC.DATE
ACC. FILE NO.
WORKS RS'COMPFNSA'I'ION DECLARATION
WATER TREATING EQUIP, 4.00
I hereby affirm that I have a certificate of cnreout to y,Hl !nsu rc,
or a certificate of Workers' Compensation Insurance, (ir a certified
c them �CLScLab.C.).
copy
TTCompun Qrw5a N-.
zONING
�y
ENG. SITE NO.
FIRE SPRINK
Y ❑ N ❑
ENERGY TQa
- Cert iHed copy is her yy f urnished.
❑ Certified c is ed vei ty inspection division.
Applicant
MISC. - REFER TO ORD.
CERT1171CATIi OFIAENIP110. FROMWORKERS'
PERMIT ISSUANCE 6.00
FLOOD ZONE
w.ete:C!
COWWFNSAT ION INSURANCE
This section need not be campletud if the permit is for one
Y ❑
- LJ IvlJ"
PLG.CCNTR. LIC. NO.
PLG.
TOTAL
hundred dollars (S 100) or less.)
-
I certify that in the performance of the work for which this per
mit is issued, I shell not employ any person in any manner so as to
QTY. MECHANICAL PERMIT FEE
FEE SUMMARY
BUILDING
became subject to tire Workers' Compensation Laws of California.
Date Applicant
NOTICE TO APPLICANT'. If, after nuking this Certificate of fix-
ALTER OR ADD TO MECH. 4.00
APPLIANCE F 4.00
PLAN CHECK
FEE
emption, you should become subject to the Workers'Compensation
provisions of the Labor Code, you mus( forthwith comply with
such provisions or This permit shall be deemed revoked.
AIR HANDLING UNIT (TO 10=C.F.M.) 3.00
AIR HANDLING UNITIOVER 10=C.F.M.15.00
SEISMIC FEE
CONST RUCTION LENDING AGENCY
1 hereby affirm that there is a construction lending agency for
EXHAUST HOOD (WITH DUCT) 2.00
the performance of the work for which this permit is issued (Sec.
-3097, Civ.C)HEATING
MICROFILM
UNIT (TO 100,000 B.T.U.) 4.00
Lender's Name
Lender's Add.e. �
HEATING UNIT (OVERB.T.U.)7.50
ELECTRIC
yp
�-�
VENTILATION FAN (SINGLE) 3.00
at
I certify thI have read This application and state that the above
information is correct. I agree to comply with all city and county
ordinances and state laws refuting to building conrtruatiaa, and
PLUMBING
BOILER -COMP13 H.P. or 100,000 B.T.U.) 4.00
BOILER -COMP (Over 100,000 BTU) SEE FEE SCH.
MECHANICAL
hereby authorize representatives of this city to enter upon the
above-mentioned property ]or inspection purposes.
MISC. - REFER TO ORD.
(We) agree to save, indemnify and keep harmless the City of
Cupertino against liabilities, judgments, Costs and expenses which
may in any waccrue against said City in consequence of the
CONST. TAX
:PERMIT ISSUANCE 3.00
gmntingoft s crnit.
G r
SqnKRmIiTA,pHcarT7Cb u r Date
MECH. CONT. LIC. NO.
MECH.
TOTAL
TOTAL
OFFICE COPY