1046APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALI.. POINT PEN ONLY
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BUILDING PROJECT IDENTIFICATION
APPLICATION & PERMIT
UILDING - ELECTRICAL- PLUMBING - MECHANICAL
PER T ER
1046
BUILDING
ADDRESS J
OWNER'S
"AME 1
veoNE 3
rr''" 'r,{met .,;�
OTV NTMI, In? ELECTRIC PERMIT tsX, .FEE;.'
- k:r f
PLANCHECK VALIDATION
DATE OF APPLICATION
CONTRACTOR'S
NAMF
LIC NO.
UTLETS •SWITCHES-RECEP 5.00/1.00 °D
LIGHTING FIXTURES 5.00/1.00
CONTRACTOR'S
ADDRESS
PHONE
APPLIANCES - RESIDENTIAL 4.00
PANELS 5,00
ARCHITECT -
OR
ENGINEER se
LIC rvo.
SIGNS 6.00
PLAN CHECK FEE P.C. NO.
SIGNS TRANS. 3.00
ARCH. OR ENG.
ADDRESS
ZIP
SPECIAL CIRCUIT S.00
PERMIT VALIDATION
EMP. METER OR POLE INS. 15.00
APPLICANTS
ADDRESS
MOTORS SEE FEE SCH.
SERVICE CHANGE 10.00
LICENSED CONTRACTORS DECLARATION
I hereby affirm that I am licensed under provisions of Chapter 9
(commencing with Section 7000) of Division 3 of the Business and
ISSUANCE DATE
BLDG. ELECT.
PLG. MECH.
Professions Code, and my license is in full force and effect.
. LisenA Class Lic. Number
❑ ❑
❑ ❑
Date ComrannrUILDING
OWNER -BUILDER DECLARATION
1 hereby collo that 1 am exempt from the Contractor's License
Law Code: Any city countywhihng reason. e. requires 5. a peminessana Professions
Code: Any city or county which requires a permit Io construct, alter,
improve, demolish, or repair any structure, prior to its issuance, also
PERMIT r y_k,,
: ".',!lr,j;;$ INFORMATIOWrik
MISC. - REFER TO ORD
VALUATION
SIFT.
PERMIT ISSUANCE 6.00
ELEC. CONTR. LIC. NO.
ELEC.
requires the applicant for such permit to file a signed statement that
TOTAL
PERMIT TO
he is licensed pursuant to the provisions of the Contractors License
Law(Chapter 9(commencing with Section 7000) of Division 3 of the
Business and Professions Code) or that he is exempt therefrom and
the basis for the alleged exemption. Any violation of Section 7031.5
_
'ywv 5 s+Y .J1. -'
CITY {{ "f "PLUMBING PERMIT.Zj'.Gat' a FLEE
}
STORIES
TYPE CONSTR.
by any applicant for a permit subjects the applicant to a civil penalty
of not marc than five hundred dollars (5500).):
ALTER -DRAIN St VENT•WATER(EA.) 4.00
BACK FLOW PROTECT. DEVICE 2,00
OCC. GROUP
RES. UNITS
❑ 1, 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
DRAINS -FLOOR, ROOF, AREA,COND. 4.00
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 4.00
SQ FT. FLOOR AREA
TOTAL ACREAGE
himself or through his own employees, provided that such improve-
menta are not intended or offered for Sale. If, however, the building
GAS•EA.SVSTEM-11NC.40UTLET$ 4.00
or improvement is Sold within one year of completion, the owner-
builder will have the burden of proving that he did not build or im-
prove for purpose of sale.).
1, as owner of the property, am exclusively contracting with
licensed contractors to construct the project (Sec. 7044, Business
GAS - EA. SYSTEM •OVER 4 (EA.) 1.00
BUILDING USE
REB IND CON PB Other
11 El ❑ ED 1:1❑
INDUSTRIAL WASTE INTER. 20.00
LAWN SPR LERS - 1 INC 5 V.B. 5.00
ASSESSORS PARCEL NO.
and Professions Code: The Contractors License Law does not apply
to an owner of property who builds or improves thereon. and who
LAWN SPRI L • OVER 5 I EA.1 1.00
Contracts forsuch projects with a conlractods) licensee pursuant to
the Contractor's License Law.
SEWERS R M EA. 200tt/8.00
TRACT N0.
PARCEL NO.
WATER HEXTEF W %•/VE 4,00
❑ I am exempt under Sec.-. BAP.C. for this
reason
Date Owner
WATER SYSTEM 4.00
ALC. DATE
ACC. FILE NO.
W'ORKERS'COMPENSATION DECLARATION
WATER TING E 4.00
I hereby affirm that I have a cerliBcale of consent to self -insure.
or a certificate of Workeri Compensallon Insurance, or a certified
ZONING
ENG. SITE NO.
copy thereof(Sec. 3800, � � •i /u p
CoCo pangLabC.).
Policy N -Company
FIRE SPR INK
ENERGY T-24
❑ Certified copy is hereby famish
❑ Certified is filed ith the the city inspection division.
Applicant
Y ❑ N ❑
Y [:]NC]
MISC. • REFER TO ORD.
PERMIT ISSUANCE 6.00
FLOOD ZONE
A.L.U.C.
CERTIFICATE OF EXEMPTION FROM WRKERS'
PLG. CONTR. LIC. NO.
PLG.
TOTAL
COMPENSATION INSURANCE
(This Action need not be completed if the permit is for one
Y ❑ N ❑
Y ❑ N ❑
c :,: ;-• �.'.' +'-
DTVI?.. ' ' MECHANICAL PERMIT ` FEE :
_
-' """'
-
% • ;• FEE SUMMARY t�
-
hundred dollars IS 100) or less.)
1 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 the Workers' Compensation Laws of California.
Date Applicant
BUILDING
_
ALTER OR ADD TO MECH. - 4.00
NOTICE TO APPLICANT: If, after making this Certificate of Ex
emption, you should become subject to the Workers' Compensation
APPLIANCE 4.00
PLAN CHECK
O,%
provisions of the Labor Code, you mail forthwith comply with
such provisions at this permit shall be deemed revoked.
FEE
S
AIR HANDLING UNIT (TO 10=C.F.NL) 3.00
AIR HANDLING UNIT (OVER I0,000C.F.M.) 5.00
SEISMIC FEE
rh
CONSTRUCTION LENDING AGENCY
EXHAUST HOOD (WITH DUCT) 2.00
MICROFILM
1 hereby affirm that there is a construction lending agency for
the performance of the work for which this permit is issued (Sec.
3097, OP.C.).
Lender's Name
HEATING UNIT (TO 100,000 B.T.U.) 4.00
HEATING UN IT (OVER 100,000 B.T.U.)7.50
ELECTRIC
. e-xts'
Lends s Address
I certify that 1 have read this application and state that the ubove
information is correct. I agree to comply with all city and county
ordinances and state laws relating to building Construction, and
VENTILATION FAN (SINGLE) 3.00
PLUMBING
BOILER•COMPI3 H.P. or 100,0008.T.U.) 4.00
BOILER -COMP IDvs, 100.000 BTU) SEE FEE SCH.
MECHANICAL
hereby authorize representatives of this city to enter upon the
above-mentioned property for inspection purposes.
(We) agree to save, indemnify and keep harmless the City of
Cupertino against liabilities, judgments, costs and expenses whichCONST.
may in any way accrue against Said City in consequence of the
MISC. • REFER TO ORD.
TAX
PERMIT ISSUANCE 3.00
MECH. CONT. LIC. NO.
TOTAL
TOIAL'^_r
`"ti '".• ^µ'
%S -
granting of this permit. P
qo.-EtivP+E�,.tiSL 9//-fj�
Sigmsw of Applicmnt/Contractor OF Date
OFFICE COPY