10064 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
BUILDING PROJECT IDENTIFICATION APPLICATION & PERMIT PERMIT NUMBER
AU IDDRESS 10064
LORING
ADDRESS
I LMV _ BUILDING -ELECTRICAL-PLUMBING-MECHANICAL
OWNER'S ,/((�p j.AJV� �/!j rfT� PLAN CHECK VALIDATION
ME V/Y yy� „ IT ex/V G QTY. ELECTRIC PERMIT FEE
(J 4`///- PHONE
A< 1-1y),
I UTLETS-SWITCHES-RECEP 10.00/1.00
G '
LHo. 3 LIGHTING FIXTURES 10.00/1.00
CONTRACTORS PPLIANCES-RESIDENTIAL 4.00
ADDRESS �I�
L III&E 6/ PANELS 10.00 DATE OF APPLICATION
AR
OR /HiET D PANELS (OVER 200 AMP) 20.00 PLAN CHECK FEE P.C.NO.
V
ENGINEER
uc.No. SIGNS TRANS. 3.00
ARCH.OR END. SPECIAL CIRCUIT 5.00 PERMIT VALIDATION
ADDRESS
ZIP TEMP.METER OR POLE INS. 20.00
APPLICANTS MOTORS SEE FEE SCH.
ADDRESS
SERVICE CHANGE 20.00
0 0 o LICENSED CONTRACTORS DECLARATION TEMP.POLE 30.00 /�/�R(/�✓
¢ U u 1 hereby affirm that I am licensed under provisions of Chapter 9 ISSUANCE/HATES
N <w (commencing with Section 7000)of Division 3 of the Business and BLDG. ELECT. PLG. MECH.
H m z Professions Code,and my license is in full force and force and C ❑ ❑ ❑ ❑
Z' o m - License Class �! Lic.Number
o Contracto
�( L, BUILDING PERMIT
¢ ¢ w ¢ OWNIi R-tl UILDCR UECLAR I
K
3 LL I- 1 hereby affirm that 1 am exempt from the Contractor's License
MISC.- REFER TO ORD INFORMATION
LL04 Law for the following reason.ISec.7031.5.Businessand Professions PERMIT ISSUANCE 10.00 VALUATION $/FT.
� -w Code:Anycity orcounly which requiresa permit to construct,alter, 00
¢ a,¢ improve,demolish•or repair any structure,prior to its issuance,also ELEC.CONTR. LIC.NO.
ELEC.
o¢ requires the applicant for such permit to file a signed statement that TOTAL PERMIT TO
n w m" he is licensed pursuant to the provisions of the Contractor's License /
Law(Chapter 9(Commencing with Section 7000)ofDivision 3 of the
a Business and Professions Code)or that he is exempt therefrom and QTY. PLUMBING PERMIT FEE
¢ r o the basis for the alleged exemption.Any violation of Section 7031.5 STORIES TYPE CONSTR.
ow. 3� by any applicant for a permit subjects the applicant to a civil penalty ALTER-DRAIN -WATER (EA.) 5.00
of not more thao five hundred dollars($500)J'.
❑ I,as owner of the property,or my employees'with wages as BACK F LOW PROTECT. DEVICE 4.00 OCC.GROUP RES.UNITS
Ihcir sole compensation,will do thtr
e work,and lire sucture is not
intended or offered for sale ISce. 7044, Business and Professions DRAINS-FLOOR,ROOF,AREA,GOND. 5.00
Codec The Contractor's License Law docs not apply to an owner of
property who builds or improves thereon,and who does such work FIXTURES-PER TRAP 5.00 SO.FT.FLOOR AREA TOTAL ACREAGE
•
himself or through his own employees,provided that such imDrovc- GAS-EA.SVSTEM-l 6.00
merits are not intended or offered for sale.If,however,the building
m
or improvement is sold within one year of completion, . .) 2.
the owner- GAS-EASYSTEM-OVER 4 (EA.) BUILDING USE
builder will have the burden of proving that he did nal build or ire- RES IND CON PB Oma,
prove for purpose ofsale.). INDUSTRIAL WASTE INTER. 30.00 El 1-1 13 1:1 ❑
❑ 1,as owner of the properly,am exclusively contracting with
licelrsed contractors to construct the project(Sec. 7044,Business LAWN SPRINKLERS- 1 INC 5 V.B. 6.00 ASSESSORS PARCEL NO.
ane
Professions Code'.The Contractor's License Law does not apply
to un owner of property who builds or improves thereon,and who LAWN SPRINKLERS-OVER 5(EA.) 1.00
contracts for such projects with u conitactons)licensed pursuant to
the Contractor's License Law. SEWER-SANITARY-STORM EA.2001t/10.00 TRACT NO. PARCEL NO.
❑ l am exempt under Sec.-,B.&P.C.for this WATER HEATER W/VENT 6.00
tcsson
Owner Date WATER SYSTEM 5.00 ACC.DATE ACC.FIL NO.
WORKF.RS'COMPENSAT10N DECLARATION WATER TREATING EQUIP. 5.00
1 hereby affirm that I have a certificate ofconsenl to self-insure. ZONING
or a certificate of Workers'Compensation Insurance,ora Certified ENG.SITE NO.
copy thereof(Sec 3800,Lab.C. n
•T policy No. Company-/2f/t/Afy
O ❑ Certilled COPY isharehy furnished. FIRESPRINK ENERGYT-24
Certif�Q�ypy i, filey� wi Ir'I t ctio divi'mn.
Z p• App�plicam n-11 J4i�j.U� L MISC.- REFER TO ORD. Y ❑ N❑ Y ❑ N❑
y CERTI FICAT17 OP EXEMPTION FROM WORKERS' PERMIT ISSUANCE 10.00 FLOOOZONE A.L.U.C.
LU >_ COMPIiNSAT10N INSURANCE PLG.CONTR. LIC.NO. PLG.
CL 0 IThis section need not be completed if the permit is for one TOTAL Y❑ N❑ I Y❑ N❑
Z) Z hundred dollars(SI00)or less.)
U 0 1 certify that in the performance of the work for which this per- OTY. MECHANICAL PERMIT FEE FEE SUMMARY
LL I- mit is issued,I shall not employ any person in any manner so as to
U become subject to the Workers'Compensation Laws of California. 4-'oQ tD Date Applicant ALTER OR ADD TO MECH. 5.00 BUILDING �[�C
} N NOTICE TO APPLICANT: It,after making this Certificate of Ex
F Z Cmptiun,you should becomC subject to the Workeri Compensation APPLIANCE 5.00 PLAN CHECK Q �L
provisions of the Labor Code, you must forthwith comply with FEE
U such provisions or this pOrnnit sl all be deemed revoked. AIR HANDLING UNIT(TO 10M)CF.M.) 4.00
CONSTRUCTION LENDING AGENCY AIR HANDLING UNIT(OVER 10PWC.FM.) 6.00 SEISMIC FEE SZ
1 hereby effmn that there is a construction lending agency for EXHAUST HOOD(WITH DUCT) 5.00
the performance of the work for which this permit is issued ISec. MICROFILM
3097,Civ.CJ. HEATING UNIT(TO 100,000 B.T.U.) 8.00
1.endC,s Name HEATING UNIT(OVER 100,000 B.T.U.)9.50 ELECTRIC
Lender's Address
I Certify that 1 have read Misapplication and state that the above VENTILATION FAN (SINGLE) 4.00
information is correct. I agree Io comply with all city and county PLUMBING
ordinances and state laws relating to building construction, and BOILER-COMP(3H.P.or100,000B.T.U.) 6.00
Imreby authorise representatives of this city W enter upon the BOILER-COMP (Over 100000BTUISEE F&ESCH. MECHANICAL
above-mentioned properly for inspection purposes.
(We) agree to save• indemnify and keep harmless the City of MISC.- REFER TO ORD.
Cupertino against liabiliti• judge Is, cos m expenses which pERM1T ISSUANCE 10.00 CONST.TAX
may in any ay a cn ainst d Cit m onsequcnce f the
Stan in f is i MECH.CONT. LIC.NO. MECH.
OTAL TOTAL 2, �e
gmature ar
of kt/Cmm'rR r aDa
`�- OFFICE COPY