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APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
BUILDING PROJECT IDENTIFICATION
APPLICATION & PERMIT
BUILDING -ELECTRICAL- PLUMBING - MECHANICAL
PERMIT NUMBER
13001
BUILDING R ID�i2
OWNS 5
NAME
/ PHONE
ELECTRIC PERMIT FEE
'
PLAN CHECK VALIDATION
CONT Acr Rs
NAME 1
uc.Ncz a3 yy
�O UTLETS-SWITCHES-RECEP 10.00/1.00
Ap LIGHTING FIXTURES 10.00/1.00
AD HESc �5�3 O��p p
AD HESS W O��-
PPLIANCES- RESIDENTIAL 4.00
1j PANELS 10.00
PHONE
DATE OF APPLICATION
ARC ECT
Ofl
ENGINEER
uc.No.
PANELS (OVER 200 AMP) 20.00
PLAN CHECK FEE P.C. NO.
SIGNS TRANS. 3.00
ARCH, OR ENG.
ADDRESS
SPECIAL CIRCUIT 5,00
PERMIT VALIDATION
TEMP. METER OR POLE INS. 20.00
ZIP
APPLICANT rs
ADDRESS
MOTORS SEE FEE SCH.
SERVICE CHANGE 20.00
Sbelt7
LICENSED CONTRACT ORS DECLARATION
I hereby aflrm that I am licensed under provisions of Chapter 9
ISSUANCE DATE
(commencing with Section 7000) of Division 3 of the Business:md
Professions Cody and my a:ense is in full for a and eIT t
r License Class_(_._( Bic. Number-1-}jj�
'Dater /�-� Contractor,a.��-y...
BLDG.
El❑
ELECT.
PLG. MECH.
❑
BUILDI G PERMIT
OWNER -BUILDER DECLARA11
I hereby collo that I am exempt from the Contractor's is License
Lawforthe Business Professions
INFORMATION
MISC. - REFER TO ORD
VALUATION $/FT.
PERMIT ISSUANCE 10.00
Anyifyowingrcason.(heuires to
p roil to consuance, also
Code: e, de ly Or mu my which structure,
improve, demolish, or repair structure, prior to its issuance, also
ELEC. CONTR. LIC. NO.
ELEC.
requires the applicant for such permit to file a Signed actor's i that'
h p
pursuant to the provisions of the Contractor's License
he is (Chapter
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 Section7031.5
TOTAL
PERMIT TO
�L��
OTY. PLUMBING PERMIT FEE
STORIES
TYPE CONSTR.
ALTER -DRAIN & VENT -WATER (EA.) 5.00
by any applicant for a permit subjects the applicant toe civil penalty
of not more than five hundred dollars ($500).):
❑ 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
OCC. GROUP
RES. UNITS
DRAINS -FLOOR, ROOF, AREA, COND. 5.00
Code: The Contractor's License Law does not apply to an owner of
property who buildsorimproves thereon, and who does such work
FIXTURES - PER TRAP 5.00
sa FTFLOORAREA
TOTALACREAGE
himself re through his own employees, provided that such improve.building
menta are not intended co- offered for sale. lf however, the building
GAS-EA.SVSTEM-11NC.40UTLETS'6.00
orimprovement is sold within one year of completion, the owner-
builder will have the burden of proving that he did not build or ins-
prove for purpose of sale.).
as owner of the property, am exclusively contracting with
licensed contractors to construct the project (Sec. 7044, Business
GAS - EA. SYSTEM -OVER 4 IEA.) 2.00
BUILDING USE
REB IND CON PB Omar
E ❑ El11I,
11 1:1
INDUSTRIAL WASTE INTER. 30.00
ILAWN 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 Ihereon, and who
LAWN SPRINKLERS - OVER 5 (EA.) 1.00
contracts for such projects with a contructor(s) licensed pursuant to
the Contractor's License Law.
SEWER -SANITARY -STORM EA. 200ft/10.00
TRACT NO.
PARCEL NO.
WATER HEATER W/VENT 6.00
❑ I am exempt under Sec. , B.&P.C. for this
teasel
Owner Date
WATER SYSTEM 5.00
ACC. DATE
ACC. FILE NO.
WORKERS'COMPENSATION DECLARATION'
WATER TREATING EQUIP, 5.00
I hereby affirm thin I have a cerlifeate of consent to sell' -insure,
or a certificate of Workers' Compensation Insurance, 9L Certified
Copy there cc. 3800, Lab .C).AI _ _
ZONING
ENGSITE NO
. .a
Policy No Company � AVII1L6-✓NL'i-C..- -
FIRE SPRINK
y N
ENERGY T-24
y ❑ No
❑ Certifiedcopyisherby furnished
.❑ Certified copy 's do rich a city inspection division.
Applicant
MISC. - REFER TO ORD.
PERMIT ISSUANCE 10.00
FLOOD ZONE
A.L.U.C.
CERTIFICA1 F EXEMPTION FROM WORKERS'
PLG. CONTR. LIC. NO.
PLG.y
TOTAL
C MPF-NSATION INSURANCE
(This Section need not he completed if the permit is for one
N E]
v C] N❑
MECHANICAL PERMIT FEE
FEE SUMMARY
hundred dollars (S 100) or less.)
I certify that in the performance of the work for which this perQTY.
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
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=C.F.M.) 4.00
AIR HANDLING UNIT(OVER 10=0C.F.M.) 6.00
SEISMIC FEE
CONSTRUCTION LENDING AGENCY
EXHAUST HOOD (WITH DUCT) 5.00
MICROFILM
I hereby affirm that there is a construction lending agency for
the performance Of the work for which [his permit is issued (Sec.
3097, Civ.CJ.
HEATING UNIT (TO 100,000 B.T.U.) 8.00
HEATING UNIT (OVER 100,000 B.T.U.)9.50
ELECTRIC
Lender's Name
Lender's Address
I certify that I have read Ibis application and state that the above
information is correct. I agree to comply with all city and county
ordinances and state laws relating to building construction, and
VENTILATION FAN (SINGLE) 4.00
PLUMBING
BOILER-COMP(3 H.P. or 100,000 B.T.U.) 6.00
BOILER-COMPIOver100.000BTU1SEEFEESCH.
MECHANICAL
It authorize represen[atives of his 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 con quence of the
MISC. - REFER TO ORD.
TAX
PERMIT ISSUANCE 10.00
MECH.CONT. LIC. NO. MECH.
- TOTAL
TOTAL
granting of this permit. "
Signature of A pplican t/Contractor ' if, �
rU OFFICECOPY