3052APSLICANT TO FILL IN INFORMATION WITHIN RED LINES -USE BALL POINT PEN ONLY
BUILDING PROJECT I DENTIFICATION
APPLICATION &PERMIT
BUILDING - ELECTRICAL- PLUMBING - MECHANICAL
PER IT NU
VILDIVG
DDR 55
k.05Z
O ER'a
NAME
CITY. ELECTRIC PERMIT FEE
PLAN CHECK VALIDATION
Gry
'
DATE OF APPLICATION
i
NONTRACTORS
S 0C,NO3/8163
OUTLETS - SWITCHES -RECEP 5.00/1.00
LIGHTING FIXTURES 5,00/1.00
CONTRACTORS
AD RES -71 C^ ate,
S ,N -S go..NE 3,03
APPLIANCES - RESIDENTIAL 4.00
PANELS 5.00
AARRCHITECT
ENGINEER
LIC. NO.
SIGNS 6.00
PLAN CHECK FEE P.C. NO.
00
SIGNS TRANS. - 3.00
ARCH. OR ENG.
ADDRESS
SPECIALCIRCUIT 5.00
PERMIT VALIDATION
EMP. METER OR POLE INS. 15.00
zap
o
A
ORE55
ADDRESS
MOTORS SEE FEE SCH,
SERVICE CHANGE 10.00
LICENSED CONTRACTORS DECLARATION
PAID
•
I hereby affirm that I am licensed under provisions of Chapter 9
(commencing with Section 7000) of Division 3 of the Business andjAN
Professions Code, a my license is in full fore, eft
License Class Lia Nwnber ?_L� b
Duh_` _4 contractor. iP. _ _��
OWNER -BUILDER DECLARATION
I hereby affirm that I am exempt from the Contractor's License
Law for the following reason. (Sec. 7031.5, Businessand Professions
Code: Any
ISSUANCE DATE
BLDG. ELECT. PLG. MECH.
'�
1. City of Cupertino
-
�I• B
I M P�4PIMOIIT;
MISC. - REFER TO ORD
PERMIT ISSUANCE `
6.00
VALUATION $/FT.
/480�Cup
ELEC. CONTR. LIC. NO. ELEC. N
TOTAL / 4'�
DTV. PLUMBING PERMIT FEE
improve, demolish, or repair any omit tof, prior no its issuance, also
e,demyshcounlywhinyrequiterspriorto its issuance,
requires the applicant for such permit to file a signed statement Li ethatnse
he is licensed pursuant to the provisions .1 the Contractor's License-PrER
D(vision 3 of the
Law (Chapter 9 (commencing with Section exempt
Business and Professions Code) or that he is is exam pn therefrom and
rtino
MIT TO
the basis for the alleged exemption. Any applicant
tof to action malty
fora permit dollars(he01.): am toacivil penalty
by any more
of nm more Than five hundred dollars (45001.1:
STORIES
TYPE CONSTR.
ALTER-DRAIN-WATER(EA.)4.00�-
❑ 1, as owner of the properly, or Illy CuIPlOyees with wages as
their sole compensation, will do the work, and the structure is not
BACK FLOW PROTECT. DEVICE 2.00
OCC. GROUP
RES. UNITS
DRAINS -FLOOR, ROOF, AREA, COND. 4,00
intended or offered for sale IS". 7044, Business and Professions
Code: The Contractor's License Law Anes not apply to an owner of
FIXTURES - PER TRAP 4.0D
GAS - EA. SYSTEM -1INC. 4 OUTLETS 4.00
SD. FT. FLOOR AREA
TOTAL ACREAGE
property who builds or improves thereon, and who docs such work
himself or through his own employees, provided that such improve.
plants are not intended or offered for sale. If, however, the building
or improvement is sold within one year of completion, the owner-
builder will have Ole burden of proving that he did not build or im-
of the.).
prove 1. as owner
❑ I, as owner of the property, am exclusively contracting with
GAS - EA. SYSTEM -OVER 4 (EA.) 1.00
BW LOING uSE
RES ND CON PB Omet
�❑ 0 ❑ 11
INDUSTRIAL WASTE INTER. 20.00
licensed contractors to const tact the project (Sec. 7044, Business
and Professions Code: The Contractor's License Law docs not apply
and who
to an owner of properly who builds or improvesensed
LAWN SPRINKLERS- 1 INC 5 V.B. 5.00
LAWN SPRINKLERS -OVER 5 (EA.) 1.00
ASSESSORS PARCEL NO.
�F l/
contracts mets for such Projects with a conlraelorf sl licensed pursuant to
u
the Contractor's Liccnsu Law.
❑ I one exempt under Sec. , B.&I'.C. for this
reason
SEWER -SANITARY -STORM EA. 200f[/8.00
TRACT N9.
PARCEL NO.
WATER HEATER W/VEFA'D 4,00
Date Owner.
WATER SYSTEM 4.00
ACC. ATE
ACC. FILE NO.
WORKERS'COAIPISNSAIION DECLARATION
�-
WATER TREATINr IP q 198'T4.00
I hereby affirm that I have a certificate of consent to self -insure.,
or a certificate of Workers' Compensation Insurance, or a certified
copy thercpf,(Scg��S or trany 1.STAT
Policy No. ��j66YYY�0 _Company--iPrW.gGr .._
ZONING
ENG. SITE NO.
--
- Cif of Cupertino
FIRE SPRINK
�
Y ❑ ^�1
ENERGY T 24
Y N❑
❑ Certified copy is hereby furnished.
❑ Cerlifie "o) filed It the cit inspection division.
Applicant _
MISC - REFER TO ORD.
CIIRTIFICATE OF EXEMPTION ;ROM WORKERS'
PERMIT ISSUANCE 6.00 E
-PLOODZONE
art.
COMPENSATION INSURANCE
(This section need not be completed if the permit is for one
Y ❑
PLG. CONTH. LIC. NO,
PLG, CH&
TOTAL 0
hundred dollars IS 100) or IcM.1
I certify that in the performance of the work for which this per-
mit is issued, 1 shall not employ any person in any nlonner so as In
QTY. MECHANICAL PER FEE
FEE SUMMARY
BUILDING
o
become subject to the Workeri Compensation Laws of Calilornia.J�
Date Applicant
NOTICE 1'0 APPLICANT: If, after making (ills Certificate of lix-
ALTER OR ADD TO MECH. 4.00
_
APPLIANCE 4.00
AIR HANDLING UNIT (TO 10=11F.M.) 3.00
PLAN CHECK
FEE
p
emption, you should become subject to the Workers' Compensation
provisions of the Labor Code, you must forthwith comply with
such provisions or this permit shall be deemed revoked.
AIR HANDLING UNIT (OVER 10=C.F,M.) 5.00 -
SEISMIC FEE
\S_0
CONSTRUCTION LENDING AGENCY
EXHAUST HOOD (WITH DUCT) 2.00
I hereby affirm that there is d construction lending agency for
the performance of the work for which this permit is issued (Sec,
3097, Cie.CJ.
MICROFILM
HEATING UNIT (TO 100,000 B.T.U.) 4.00
Lender's Name
Lender's Address
H EATING UNIT (OV ER 100,000 B.T.U.)7.50
ELECTRIC
VENTILATION FAN (SINGLE) 3.00
I certify that I have read this application and slate that the above
information is correct. I agree to comply with till city unit county
ordinances and state laws relating to building construction, and
PLUMBINGdV
BOILER- COMP (3 H.P. or 100,000 B.T.O.) 4.00
BOILER -COMP (Over 100.000 BTu1 SEE FEE SCH.
MECHANICAL
hereby authorize representatives of this city to enter upon the
above mentioned properly for inspection purposex.
(We) agree to save, indemnify and keep harmless the City of
Cupertino against liabilities, judgments, costs and expenses which
may in any way accrue against said City in consequence of the
granofit permi
Sig
Signature of Applicant/ ontractor Date
MISC. - REFER TO ORD.
PERMIT ISSUANCE 3.00
CONST. TAX
MECH. CONT. LIC. NO.
MECH.
TOTAL
TOTAL
0 fL
OFFIC9 COPY
'
NL T C HCC A,
P A N
G S
O N R
CITY 01' CUP!'.RT'INO
I11SPECTION RECORD (Office
Copy)
CI
3052 10973 Wilkinson Ave.
PCPd(I'f N0. SANITARY DIST. NO. T_oTri67 ADDRKSS _ ----
Solar for Pool James Barnett
PROJECT OWNER JOB SITE P11014E NO.
C`Ou c D
NL T C HCC A,
P A N
G S
O N R
O O R ill 0
CN4 c'y T e SLG 7-
9
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S t c unto 4 C
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I T
BUILDING
ELECTRICAL
PLUMBING
MECHANICAL
MISCELLANEOUS
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