10258 (2) APPLICANT TO FILL IN INFORMATIONAMAIN RED LINES - USE 4l!. POINT PEN ONLY
• BUILDINGPR J CT IDENTIFI AI)NG
gppLICATION & P TPERMITNUMBER
m waLDcADDR -ELECTRICAL-PLUMBING -MECHANICAL 10258
OwN r PLAN CHECK VALIDATION
NA j QTY. ELECTRIC PERMIT FEE
ouE
*ZDRS
OUTLETS-SWITCHES-RECEP 10.00/1.00
u D LIGHTING FIXTURES 10.00/1.00
/
APPLIANCES-RESIDENTIAL 4.00
O PANELS 10.00 DATE OF APPLICATION
ORRrt
L ECT PANELS (OVER 200 AMP) 20,00 PLAN CHECK FEE P.C.NO.
ENGINEER
LIC NO. SIGNS TRANS. 3.00
AR H.DR ENG. PERMITVALIDATIONTION
aooarss SPECIAL CIRCUIT 5.00
ZIP TEMP.METER OR POLE INS: 20.00
qvP as MOTORS SEE FEE SCH. 'JAN 14 )��u
SERVICE CHANGE 20.00 IY U
0 30.00
Hoo LICENSED CONTRACTOR DfiCLARATION TEMP.POLE City Of Cupertino
rtu Or 1 herehy affirm that I am licensed under provisions of Chapter 9
H Z i ISSUANCE DATE
a (commencing with Section 7000)of Division 3 of the Business an BLDG. ELECT. PLG. MECH.
H h i Professions Co license is in full force ❑ ❑ ❑
im o Licvnac las_ Lic.Number
H m H j Dale •Qsntraclur
a ,F BUILDING PERMIT
xt , w a NE -BUILDER DECLARA I
°'0 MISC.- REFER TO OR
INFORMATION
w ; LL h 1 hereby affirm that I am exempt from the Contractor i License
u O a Law for the following reason.(Sec.7031.5,Businessand ProfessionsVALUATION S/FT.
Code:Any cit or count PERMIT ISSUANCE 10.00
y ywhichreyui«sn permit toconstnml,allCq
rt2 ¢ 0 improve,demolish,or repair any structure,prior to its issuance,also ELEC.CONTR. LIC.NO. ELEC.
A. K c u requires the applicant for such permit to file u signed statement that TOTAL -
w C, he is licensed pursuant to the provisions of Ilse Contre tor's License PE T TO
z aLaw(Chapter 9(commencing with Section 7000)of Division 3 ofthe
s i o Business and Professions Code)or that he is exempt therefrom and QTY. PLUMBING PERMIT FEE
re H$ the basis for the alleged exemption.Any violation of Section 7031.3 STORIES TYPE CO STq.
ate _ by any applicant fora permit subjects theam toaeivil penlly ALTER-DRAIN&VENT-WATER (EA.) 5.00
Ln [tic
not more than five hundred dollars(S500).):emp
❑ as ower o1' property, my employees with wages as BACK FLOW PROTECTDEVICE 4.00
their sole compensation,will do thea work,and the structure is not . OCC.GROUP RES.UNITS
intended or offered for sale (Sec. 7044, Business and Professions DRAINS-FLOOR,ROOF,AREA,COND. 5.00
Code:The Contractor's License Law docs not apply to an owner of
Property who builds or impose,thereon,and who docs such work FIXTURES-PER TRAP 5.00 SO,FT,FLOOR AREA TOTAL ACREAGE
himself or through his own employees,provided that such improve.
ments are not intended oroffercd for sale.If,however,the building GAS-EA.SYSTEM-1 INC.4 OUTLETS 6.00
or improvement is sold within one year o1completion,the owner-
builder .will have the burden of proving that he did not build or im- GAS-EA.SYSTEM-OVER 4 (EA.) 2.00 BUILDING USE
prove for purpose of the
INDUSTRIAL WASTE INTER. 30.00 RES I❑ ❑N PEI❑ Gore,❑
❑ L as owner of the property,be rojectvc a contracting with
licensed contractors to construct the project(Sec. 7044,Business LAWN SPRINKLERS-1 INC 5 V.B. 6.00 ASSESSORS PARCEL NO.
and Professions Code:The Contractor i License Law does not apply
to anowner of property who builds orUtn
improves thereon.and who LAWN SPRINKLERS-OVER 5(EA.) 1.00
Contract,Icor such ne with o comrucn s)licensed pursuant m
the Contractah License Law. SEWER-SANITARY-STORM EA,2001t/10.00 TRACT NO. PARCEL NO.
❑ I am exempt under Sec.-,B.&P.C. in this WATER HEATER W/VENT 6.00
reason
Owner Date WATER SYSTEM - 5.00 ACC.DATE ACC.FILE NO.
WORK ERS'COMPENSATION DECLARATION WATER TREATING EQUIP. 5.00
1 hcn:hy alflrm that I have a certificate ofconsent to Sell'-Insure,
or a certificate of Workers'Compensation 1 ranee,I rtificd ZONING ENG.SITE NO.
copy thcr .CJ. L
Policy NU- nY _
0 Certified b I fished' RE SPR INK ENERGY T-]<
Z Z Js Cmtife opy is til ith t inspection division.
F- O plic:mt MISC.- REFER TO ORD. Y E] N[3 Y ❑ NEI
CC CFR IIFIC 'f 3U'EXEMPTION PROM WORK; , PERMIT ISSUANCE 10.00 FLOOD ZONE •A.L.U.C.
LU > COAIPI!NSATION INSURANCE. PLG.CONTE. LIC.NO. PLG.
d O (This section need nm be completed it the permit is for one TOTAL Y❑ N[] Y [] IN
Z hundred dollar,IS 100)or less.)
V O 1 certify that in the performance of the work for which tlsis par- QTY MECHANICAL PERMIT FEE FEE SUMMARY
LL 1- mit is issued. I shall not employ any person in any manner us as to
U become subject to the Workers'Compensation Laws of California.
0 a Date-A,,, ALTER OR ADD TO MECH. BUILDING
j- N NOTIGI. 'f0 APPLICANT: If,after making this Certificate of Ex-
. 5.00
F ? enlptjon,you should become subject to the Workers'Compensation APPLIANCE 5.00 PLAN CHECK
provisions of the Labor Code, you must forthwith Comply witll
V such provisionsor this permit shall be deemed revoked. AIR HANDLING UNIT(TO 10MC.F.M.) 4.00 FEE
CONSTRUCTION LENDING AGENCY AIR HANDLING UNIT(OVER I0,0DOQEM.) 6.00 SEISMIC FEE
I hereby affirm that there is a Comtrucfiun lending agency for EXHAUST HOOD(WITH DUCT) 5.00
the perfornwnee of the work for which this permit is issued(Sec. ICROFILM
3097,Civ.C.). HEATING UNIT(TO 100,000 B.T.U.) 8.00
Lendds Name
Lender's Address HEATI NG UNIT(OVER 100,000 B.T.U.)9.50 ELECTRIC
I certify that I have read this application and state that the aboveVENTILATION FAN (SINGLE) 4.00
. information is correct. 1 agree to comply with all city and county - PLUMBING
ordinances and state laws relating to building ci,n,truclinn, and BOILER-COMP(3 H.P.or 100,000 B.T.U.) 6.00
hereby enthorirn representatives fatties ec this city to enter upon the BOILER-COMP (Oycr 100,000 BTU)SEE FEE SCH. MECHANICAL
above-mentioned property forinsp 01thi purposes.
(We) agree t save, irW Ify and keep harmless the City of MISC.- REFER TO ORD.
Cupertino ag 'R9s�,v habil' Cs, Wgreents, costs and expenses which NST.TAX
may in an AS• acc c toll said City in consequence of the PERMIT I SUANCE 10.00
I g o' us perm'.
l� ME .CONT. LIC.NO. MECH.
'e TOTA
ignaturc ul App ant/Conlmctor Ua[c Qk-�'a]4r{// TOTAL
OFFICE COPY