10182 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
+ 01 LDI NG PROJECT I DENTI FICATI'ON PERMIT NUMBER
.BUILDING ' APPLICATION & PERMIT I � O
ADDRESS _
b� STCJC9✓5 C(C /� & ✓D BUILDING-ELECTRICAL-PLUMBING-MECHANICAL .:- _
182
DwNEn'S • - - PLAN CHECK VALIDATION
j NAM /I, OTY. ELECTRIC PERMIT FEE
I� YV PHONE
Nome acrORs p/� /[ UTLETS-SWITCHES,-RECEP. '10.00/1.00
2 �ti /Lu elf uc.NO.YT( 7 . L IG H T I
NG FIXTURES - 10.00/1.00 '
ADDR
aoDREss �p PPLIANCES-RESIDENTIAL - 4.00
✓ M w PHONE`9.7-n". PANELS 10.00 DATE OF APPLICATION
ARCHITECTonIPANELS (OVER 200 AMP) 20,00 PLANCHECK FEE P.C.NO.
ENGINEER
SIGNS TRANS. :3.00
ARCHOR ADDRESS ENG. - SPECIAL CIRCUIT 5.00 - AUDAnoN
ZIP EMP.METER OR POLE INS. 20.00 nC n •f �IeBC�
nooaessTs , MOTORS SEE FEE SCH: ULV 1 lel
SERVICE CHANGE . - 20.00 fs of Cupertino
0 o' LICENSED CONTRACTORS DECLARATION TEMP.POLE 30.00 CItY
a u u I hereby affirm that I am licensed under provisions of Chapter 9 -
2 w ISSUANCE DATE
in Q w (commencing with Section 7000)of Division 3 of the Business and BLDG. ELECT. PL MECH.
H m z Professions Code,m`AC y license is in full force and effect.n_'7� ❑ ❑
oi m I] DteLicense Class_ Lie.Number -
m H Date,'( -//��S Contmdnr_� - I
.¢ ¢ wa OWNER-BUILDER DECLARATION - BUILDING P RMIT
w- a > o - INFORM ION
g u w 1 herehy ONnn that I air exempt from the Contractor's License MISC.- - - ,'REFER TO ORD VALUATION '$/FT.
O < Law for the followin reason.(Sec.7031.5,Businessand Professions
g PERMIT ISSUANCE 10er, .00
Code:proe.d city ormulish County whiny requiresa permit riot ocnnivance,else
-
¢ K Q D improve,demolish,or repair any sVucLLrze,prior to its issuance,also ELEC.CONTR. LIC.NO. ELEC. _
u wDLL requires the applicaut for such permit to file a signed statement dist TOTAL
re in he is licensed pursuant to the provisions ol'the Contractor's License ZliRMIT TO ,
H z r
Law(Chapter 9(commencing with Section 7000)of Division 3 ofthe -
�.i Qo Business and Professions Code)or that lie is exempt therefrom and OTY. PLUMBING PERMIT FEE
¢I- the basis for the alleged exemption.Any violation of Section 7031.5 - - STOR S. TY E CONSTR.
u3 � by any�pplicantfor a permit subjects the applicant toa civil penalty - ALTER-DRAIN&VENT-WATER (EA.) 5.00
of not more than five hundred dollars(8500)):
.� ❑ I,as owner of the property,or my employees with wages as BACK FLOW PROTECT. DEVICE 4.00 •
their sole compensation,will do the work,and the structure is not Oce.CROUP RES.UNITS
intended or offered for sale(Sec. 7044, Business and Professions DRAINS-FLOOR,ROOF,AREA,COND. 5.00
Code:The Contractors License Low does not apply to an owner of '
property who builds or improves thereon,and who does such work F IXTUR ES-PER TRAP. - .S:OO 50.FT.FLOOR AREA TOTAL ACREAGE
• himself or droned,his own employees,provided that such improve"
.00
menta are not intended or offered for sale,If,however,the building I GAS-EA.SYSTEM-11NC.40UTLETS 6
or improvement is sold within one year of completion,Ote owner
builder will have the burden of proving Ihat he did not build or im- GAS-EA.SYSTEM-OVER 4 (EA.) .,2.00 BUILOIN SE
prove for purpose ofsale). INDUSTRIAL WASTE INTER. 30.00 RES IND PB Omer
❑ 1,as owner of the property,am exclusively contracting with El 1:1 N ED EDlicensed contractors to construct the project(Sec. 7044,Business LAWN SPR IN KLE RS- 1 INC 5 V.B. 6.00 ASSESS S PARCEL N0.
and Professions Code:The Contractor's License Law does not apply
to an owner of properly who builds Or improves thereon,and who LAWN SPR IN KLERS-OVER 5 (EA.) 1.00
contracts for such projects with a conlrac(ons)licensed pursuant to
the Contractors License Law. SEWER-SANITARY-STORM EA.200ft/10.00 TRACT NO. PARCEL NO.
❑ Iain exempt under Sec. ,tl.&P.C.Ibr this
reason WATER HEATER W/VENT 6.00
Owner Date WATER SYSTEM 5.00 - ACC.DATE ACC.FILE NO.
WORKERS'COMPENSA'f1ON DECLARATION WATER TREATING EQUIP. 5.00
1 herebyaffirm Out I I've' it df consent to sell-insurc, -
or a c 'free he of r o ation Insurance,or a cert ZONING ENG.SITE NO.
copy
Policy
O Cttl ific Lq yrs hereby furnis ed FIRE SPRINK ENERGY T.24
Z Z ❑ •rtifie fipy is filed it city inspection division.
H0 Applicm(/2G peg A,, wit city
MISC.- .. � REFER TOQR4Dl Y ❑ N❑ Y ❑ •,N❑ .
�.y iltl'IFICA'I'li O'TIixGMPTION OM WORKERS'RKERS' PERMIT ISSUANCE 10.00 _ - FLDDD ZONE A.L.u.c.
•W COh1PENSA'I'ION INSURANCE PLG.CONTH, LIC:NO. - PL
d 0' (This,ceetion need not be completed if the permit is for one TOTAL' '/( '+ Y❑ 'N❑ :Y ❑ No
Z hundred dollars($100)or less.)
U,0 1 certify that in the perRmmonce of file work for which this per- QTY. MECHANICAL PERMIT FEE. FEE SUMMARY
LL F mit is issued,I shall not employ any person in any manner ko ns to
O w become subject to the Workers'Compensation Laws of California.
Date0 ICANI: I ALTER OR ADD TO MECH. 5.00 BUILDING
} w comfloNOTICE TO APPLICANT: If,after making this rs'Compe sa fix-
. ♦- ? er vision you should eLbecome subject totheWorkers'Ccomply with APPLIANCE 5.00 PLAN CHECK
provisions io lilt his permit
shall
you mull forthwith comply with
U such provisions or this permit shall he deemed revoked. AIR HANDLING UNIT(TO 10,000GF.M.) 4.00 -FEE -
I CONSTRUCI'IONLENDINGAGENCY AIR HANDLING UNIT(OVER 109MC.F.M.) 6.00 SEISMIC FEE
I hereby affirm that (here is a construction lending agency for EXHAUST HOOD(WITH DUCT) 5.00
the performance of the work for which this permit is issued filet. MICROFILM
3097,Civ.CA HEATING UNIT(TO 100,000 B.T.U.) 8.00
Lender's Name
Lender,Addkss - HEATING UNIT(OVER 100,000 B.T.U.)9.50 ' - ELECTRIC
I certify Ihat 1 have read tllisuppliedlion and slate that the above VENTILATION FAN (SINGLE) 4.00
information is correct, 1 agree to comply with all city and county. BOILER-COMP(3 H.P.Gr 100,000 B.T.U.) 6.00 PLUMBING
ordinances and stale laws relating to building construction and
hereby anthentiorize representatives inspection
this city to enter upon the BOILER-COMP (Over 100,000 BTU)SEE FEE SCH. MECHANICAL
above-mentioned property forinsp of this
purposes.
(We) arye to save, undernify and keep harmless the City of MISC.- REFER TO ORD.
Cupertino �fainst Iiahihhes gments, costs and expenses which CONST.TAX
may it ly way accrue gut t said City in consequence of the - PERMIT ISSUANCE " 10.00
granti f this permit, . MECH.CONT. LIC.NO. MECH.
TOTAL TOTAL
s him ore of Ikon[/Contract pate
- OFFICE COPY
•r -