10006 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
BUILDING PROJECT 1 DENTI FICATION PERMIT NUMBER
BUILDING APPLICATION & PERMIT
`+/✓"J BUILDING - ELECTRICAL-PLUMBING-MECHANICAL 10006
OwNER'S PLAN CHECK VALIDATION
N /A' TV. ELECTRIC PERMIT FEE
^� YV IVr�✓fr/HONE ��-I �
NAMCONE OUTLETS
OUTLETS-SWITCHES-RECEP 10,00/1.00
LIC,No. LIGHTING FIXTURES 10.00/1.00
ADDRESS TORS APPLIANCES-,RESIDENTIAL 4.00
PHONE PANELS 10,00 DATE OF APPLICATION
OR
PANELS (OVER 200 AMP) 20.00 PLAN CHECK FEEP.C.NO.
RR
ENGINEER PAID
LIc.No. SIGNS TRANS. 3.00
ARCH.OR ENG. PERMIT VALIDATION
ADDRESS SPECIALCIRCUIT 5.00 NOVZIP EMP.METER OR POLE INS. 20.00 IY V - 4 1985
ADDRESS S MOTORS SEE FEE SCH.
SERVICE CHANGE 20.00 City of Cupertino
W o o LICENSED CONTRACTORS DECLARATION TEMP.POLE 30.00
< u u I hereby affirm that I am licensed Under provisions of Chapter 9
2 i ISSUANCE GATE
h <w (commencing with Section 7000)O(Division 3 Of the Business and BLDG. ELECT, I PLG. I MECH.
r M z Professions Code,and my license is in full force and effect. El ❑ El
0 a - License Class Lic.Number
0 w Dale Contractor
I-
/ Q y
M C, w a OWNER-BUILDER DECLARATION BUILOIN PERMIT
° ' U MISC.- REFER TO ORD INFOR ATION
E
; N I hereby affirm that I am exempt from the Contractor's License VALUATION
u O ar Law fertile following reason.(See.7031.5,Business and Professions E/FT.
- PERMIT ISSUANCE 10.00
Code:Any city or county my which reyuires a permit to construct alter,
Se G improve,demolish,or repair any structure,prior m its issuance,also ELEC.CONTR. LIC.NO. ELEC.
°LL requires the applicant for such permit to file a signed statement that TOTAL
Se w $y he is licensed pursuant to(he provisions of the Contractor's License PERMIT TO
r t a Law(Chapter 9(commencing with Section 7000)of Division 3 ofthe
5 2 0 Business and Professions Code)or that he is exempt therefrom and OTY. PLUMBING PERMIT FEE
IS $ the basis for the alleged exemption.Any violation of Section 7031.5 STORIES PE CONSTR.
by any applicant for a permit subjects the applicant toe civil penalty ALTER-DRAIN& VENT-WATER IEA.) 5.00
of not more than five hundred dollars($500).):
❑ 1,as owner of the property,or my employees wish wages as BACK FLOW PROTECT.DEVICE 4.00 OCC.GROUP RES.UNITS
their sole compensation,will do the work,and the structure is no[
intended or offered for sale (Sec. 7044, Business and Professions DRAINS-FLOOR,ROOF,AREA,COND. 5.00 '
Code:The Contractor's License Law does not apply to an owner of
property who builds or improves thereon,and who does such well FIXTURES-PER TRAP 5.00 SO.FT.FLOOR AREA TOTALACREAGE
himself or through his own employees.provided that such improve-
ments are not intended or offered for sale.It however.the building GAS•EA.SYSTEM-1 INC.4 OUTLETS 6,00
or improvement is sold within one year of completion,the owner- GAS-EA.SYSTEM-OVER 4 IEA.) 2.00
builder will have the burden of proving that he did not build or in. BUILDING USE
prove]or purpose of sale.). S IND CON PS Other
❑ 1,as owner of the property,am exclusively contracting with INDUSTRIAL WASTE INTER. 30.00 El El El 1:1licensed Contractors to construct the project(Sec. 7044,Business LAWN SPR INKLERS-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 IEA.) 1.00
contracts for such projects with a contract orfs)licensed pursuant to
the Contract Lilco w. SEWER-SANITARY-STORM EA.200ft/10.00 TRACT NO, PARCEL NO.
lam tun a ,B.&P.C.For this WATER HEATER W/VENT 6.00
ason
caner Date WATER SYSTEM 5.00 ACC.DATE ACC.FILE NO.
WORKERS' MPENS ION DECLARATION WATER TREATING EQUIP, 5.00
1 hereby at Firm that I have a certificate of consent to self-in sure,
or a certificate of Workers'Compensation Insurance,nr a Certified ZONING ENG.SITE NO.
copy thereof(See.3800,Lab.C.).
Policy No. Company'
O D Certified Copy is hereby furnished. FIRE SPRINK ENERGY T-24Z Z ❑ Certified copy is filed with the city inspection division.
H O Applie:utt IMISC.- REFER TO ORD. Y ❑ N❑' ' Y ❑ N❑
X W CER1IF'ICATF.OF EXEMPTION FROM WORkERS' PERMIT ISSUANCE 110.00 FLOODZONE A.L.U,C.
LU �! COMPENSATION INSURANCE: PLG.CONTR. LIC.NO. PLG.
CL a Z NE]
section need not be Completed if the permit is for one TOTAL Y❑ N❑ Y❑ N
hundred dollars IS 100)or less.)
U O I certify that in the performance of the work for which this per. CITY. MECHANICAL PERMIT FEE FEE SUMMARY
LL U mil is issued,I shall not employ uny person in any niamter so as to
become subject to the Workers'Compensation Laws of California.
i
Duce Applicant BUILDING
>_ so NOTICE TO APPLICANT: If,after making this Certificate of Ex- ALTER OR ADD TO MECH. 5.00
Z emp(ion,you should become subject to the Workers'Compensation APPLIANCE
F.
provisions of the Labor Cade, you must forthwith comply with 5.00 PLAN CHECK
U such provisions or this permit shall be deemed revoked. AIR HANDLING UNIT(TO 10=C.F.M.) , 4.00 FEE
CONSTRUCTION LENDING AGENCY AIR HANDLING UNIT(OVER 1000C.EM.) 6.00 SEISMIC FEE
I hereby affirm that there is a Construction lending agency for EXHAUST HOOD(WITH DUCT) 5.00
the performance of the work for which(his permit is issued(Sec. MICROFILM
3097,Civ.0.). HEATING UNIT(TO 100,000 B.T.U.) 8.00
Lender's Name
Lender's Address H EATING UNIT IOVER 100,000 B.T.U.)9.50 ELECTRIC
I certify that I have read this application and state that the above VENTILATION FAN (SINGLE) 4.00
• information n correct I agree to comply with all city and county BOILER-COMPI3 H,P,Of 100,000 B.T.U.) 6.00 PLUMBING
ordinances and state laws relating to building l city
co and
hereby authorize representatives of this city to enter upon the BOILER-COMP(Over 100,000BTU)SEE FEESCH. MECHANICAL
above mentioned property for inspection purposes,
(We) agree to save, I demni and keep harmless the City of MISC.- - REFER TO ORD.
Atnot liab'I' es,lu menta, costs andexpk CONST.TAX
�c ii City in Conseq cote f the PERMIT ISSUANCE 10.00 1TAEcH.CONT. LIC.NO. MECH.TOTALTOTAL
ica /Contract u
OFFICE COPY