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APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
BUILDING PROJECT IDENTIFICATION
1
APPLICATION & PERMIT
BUILDING - ELECTRICAL- PLUMBING - MECHANICAL
PERMITNUMBER
12626
Byl DING ,_.-
ADDRESS
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OWN$ E ��
p PHONF
OTV. ELECTRIC PERMIT FEE
PLAN CHECK VALIDATION
DATE OF APPLICATION
c NTA CTORS
NA �
6 ,1•�/ LIC. No.'
UTLETS- SWITCHES -RECEP 10.00/1.00
LIGHTING FIXTURES 10.00/1.00
CONTRACTOR'S 'J rA°.7
OGREPS
C HONE LL �OF .
PPLIANCES-RESIDENTIAL 4.00
PANELS 10.00
_
ARCHITECT'PANELS
OR
ENGINEER
LIC. No.
(OVER 200 AMP) 20,00
PLAN CHECK FEE
P.C. NO.
SIGNS TRANS. 3.00
ARCH. OR ENG.SPECIAL
ADDRESS
CIRCUIT 5,00
PERMIT VALIDATION
EMP. METER OR POLE INS. 20.00
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l//lq,•,"•,'/k"�
AD DRESS
ADDRE55
MOTORS SEE FEE SCH.
SERVICE CHANGE 20.00
LICENSED CONTRACTORS DECLARATION
I hereby affirm that 1 am licensed under provisions of Chapter 9
ISSUANCE DATE
(commencing with Section 7000) of Division 3 of the Business and
Professions Code nd m license is in full for- nd • •
-..
License pas Lic. Number
BLDG, ELECT, I
❑ ❑
PLG. MECH.
❑
Date -Con tractor '
BUIL ING IT
OWNER -BUILDER DECLARATION
I hereby affirm that I so exempt from the Contractor r License
Professions
Lew fornycitthe llorcountywhi Sec.7031.5, imsaermit to
Code: Any city or county my which requires a permit to construct, alter,
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
Business and Professions Code) or that he is exempt therefrom and
the basis for the alleged exemption. Any violation of Section 7031.5
INFORMATION
INFORMATION
MISC. - REFER TO ORD
VALUATION
$/FT.
PERMIT ISSUANCE 10.00
ELEC. CONTR. LIC. NO.
ELEC.
TOTAL
PERMIT TO /
S 7 KH �RL(�'ti
/
DTV. PLUMBING PERMIT FEE
STORIES
TYPE CONSTR.
ALTER -DRAIN -WATER (EA.) 5.00
by any applicant for u permit subjects the applicant m a civil penalty
of not more than five hundred dollars (S500h):
❑ 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 4.00
DCC. GROUP
RES. UNITS
DRAINS -FLOOR, ROOF, AR EA, COND. 5.00
Code: The Contractor's License Law does not apply to an owner of
property who builds or improves thereon, and who docs such work
F IXTUR ES - PER TRAP 5.00
SO_ FT. FLOOR AREA
TOTAL ACREAGE
himself or through his own employees, provided that such improve.
ments are not intended or offered for sale. If, however, the building
-
GAS-EA.SVSTEM-I1NC.4OUTLETS 6.00
or improvement is sold within one year of completion, the owner -GAS
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
- EA. SYSTEM -OVER 4 IEA.) 2.00
BUILDING USE
RES IND CON PB Other
INDUSTRIAL WASTE INTER. 30.00
LAWN SPRINKLERS- 1 INC 5 V.B. 6.00
ASSESSORS PARCEL NO.
and Professions Code: The Contractor's License Law does not apply
to an owner of property who builds or improves thereon, and who
LAWN SPRINKLERS - OVER 5 (EA.) 1,00
contracts for such projects with a contractor(s) licensed pursuant to
the Contractor's License Law.
SEWER -SAN ITARY-STO A. 200f(/10.00
TRACT NO,
PARCEL NO.
WATER HEATER Wq 6.00
❑ I am exempt under Sea , B.&P.C. for this
reason
Owner Date
WATER SYSTEM 5.00 ^_
ACC. DATE
ACC. FILE NO.
WORKERS'COMPENSATION DECLARATION
WATER TREATI qU P. 5.00
I hereby a(Firm that I have a cert it icae of consent to self -insure,
or a certificate of Workers' Compensation Insurance, or a ccrljfied
copy thereof(Sec. 3800, Lab.C.)�or
- -" Pi
ZONING
ENG. SITE NO.
Q
Policy No. _Companyl=lLGl(
❑ Cenifie +y is hereby furnished �(%� ) !
❑ Cerlif Yf is f.; wi 1 he ly nap c l Ivi o
ADPlicam I
IM REFER TO ORD.
FIRE SPRINK
Y N
ENERGY T 24
N�
Ch II'ICAT}i OI' F, M N I' 11iRBM WORKIiRS'
PERMIT ISSUANCE 10.00 W✓
FL000 ZONE.L.
u.C.
rl
PLG.CONTR. LIC. NO.
PLG. /RC1
TOTAL OO
COMPENSATION INSU ANCF-
(This section need not be completed if the permit is for one
Y� N0�
N�
OTY. MECHANICAL PERMIT FEE
FEE SUMMARY
hundred dollars($100) or less.)
I certify that in the performance at the work for which this per-
Hit is issued, I shall not employ any person in any manner so as to
become subject to the Workers' Compensation Laws of California.
Dam Applicant
NOTICE TO APPLICANT: If, after making this Certificate of Ex-
emption, you should become subject to the Workers'Compensation
BUILDING
ALTER OR ADD TO MECH. 5.00
APPLIANCE 5.00
PLAN CHECK
provisions of the Labor Code, you must forthwith comply with
such provisions or this permit shall be deemed revoked.
FEE
AIR HANDLING UNIT (TO 10=1 .F.M.) 4.00
AIR HANDLING UNIT (OV 10,000 C.F.M.I 6.00
SEISMIC FEE
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.L
EXHAUST HOOD (WITH DUCT) 5.00
MICROFILM
HEATING UNIT (TO 100,000 B.T.U.) 8.00
HEATING UNIT I0 VER 100,000 B.T.U.19.50
ELECTRIC
Lender's Name
Lender's Address
VENTILATION FAN (SINGLE) 4.00
PLUMBING
I certify that I have read this application and stale that the above
information is correct. I agree to comply with all city and county
Ordinances and state laws relating to building construction, and
BOILER- OOMP(3 H.P. or 100,000 B.T.U.) 6.00
BOILER -COMP (Ovnr, 100,000 BTU) SEE FEESCH.
MECHANICAL
hereby authorize representatives of this city to enter upon the
above-men0oned property for inspection purposes.
MISC. - REFER TO ORD.
CONST. TAX
(We) agree to save, indemnify and keep harmless the City of
Cupertino against liabilities, judgments, costs and expenses which
may i way accrue ag inst said City in consequence`uf the
gran' go this permit,
PERMIT ISSUANCE 10.00
ECH. CONT. LIC. NO. MECH.
TOTAL
TOTAL
Si tureof Ap ant/ odtra t U
OFFICE COPY