10851 (2) I ' APPLICANT TO FILL IN INF�MATION WITHIN REDLINES — LISE,BALL POINT PEN ONLY
W-BUILDING PROJECT I DENTI FI IONPERMIT NUMBER-
!� BUILDING 'APPLICATION & 1T
ADDRESS G A T �DI BUILDING-ELECTRICAL-PLUMBING-MECHANICAL 10851
OWNER2eeS PLAN CHECK VALIDATION
NAW A, /JOTY. ELECTRIC PERMIT FEE -
J OV ,l )eiCHONE
CONTRACTORS UTLETS-SWITCHES-RECEP 10.00/1.00
6-4 p4Rell& UC.NA4,6077J— LIGHTING FIXTURES 10.00/1.00
ADDRCONTAEAcrrns 'I• APPLIANCES-RESIDENTIAL 4.00
ADO/R,Ess /I ��/
VG OT S- - PHONVE j,G-3p&, PANELS 10.60 DATE OF APPLICATION
ARCHITECT/"T, q Gp - PANELS (OVER 200 AMP) 20,00 PLAN CHECK FEE P.C.NO.
PNGINEER CiGe 61L -
UC,NO ISIGNS TRANS. - 3.00
ARC Ess ENG' _ SPECIAL CIRCUIT 5.00 PERMIT VALIDATION
ZIP TEMP.METER OR POLE INS. 20.00
APPLICANTS
ADDDRESSDRESS ' - MOTORS SEE FEE SCH.
SERVICE CHANGE 20.00
w o o LICENSED CONTRACTORS DECLARATION Y Q
a U I hereby affirm thaLl am licensed under provisions of Chapter 9 ISSUANCE DATE
(coinna'mmng with Section 7000)of Division 3pf the Eusimms and BLDG. ELECT. PLG. MECH.
H w z 1'rofessiont my license is in full fou ldf c{� ❑ ❑ ® ❑
i.O w License Clas Lic:Nwnber
or w Date �j-__Contractor
in a m X U BUILDING PERMIT
le a OWNER-BUILDER 111iCLARA'1'ION -
a o T a o :INFORMATION
1 hereby affirm that 1 am exempt from the Contractor's License MISC.- REFER TO ORD
w VALUATION - $/FT.
woo Code:Any city
ylor countywhng ich c.requires
a permit to construct,
Professions PERMIT ISSUANCE 10.00
Code:Anymolish countywhichstructure,prmittoconsuancalter,
¢ ¢O improve,demolish,or repair:my structure,prior to its issuance,also ELEC.CONTR. LIC.NO. ELEC.
sL iL m u requires the applicant for such permit to file a signed statement that - TOTAL PERMIT TO
he is licensed pursuant to the provisions of the Contractor's Licenu
FZQ Law(Chapter 9(commencingwith Section 7000)of Division 3 ofthe ?L A4
4 i O Business and Professions Code)or that he is exempt therefrom and O�X'. PLUMBING PERMIT :FEE
T r the basis for the alleged exemption.Any violation(it'Section 7031.5 //yy
STORIES TYPE CONSTR.
by any applicant for a permit subjects the applicant to a civil penally
of not more than five hundred dollars($5004.): ALTER-DRAIN&VENT-WATER (EA.) 5.00
❑ I,as owner of the properly,or my employees-with wages its BACK F LOW PROTECT.DEV ICE 4.00
their sole compensation,will do the work,and the structure is not . 00C.GROUP RES.UNITS
intended or offered for sale (Sec. 7044, Business and Professions DRAINS-FLOOR,ROOF,AR EA,COND. 5.00
Code:The Contractor's License Law does not apply to an owner of ,
_• properly who builds or improves thereon,and who does such work FIXTURES-PER TRAP 5.60 O O SD.FT.FLOOR AREA TOTAL ACREAGE
himself or d....h Iris own entployaes,provided that suet,improve-
ments are not intended or offered foraale.If,however,the building GAS-EA.SYSTEM=I INC.4OUTLETS 6.00
or improvement is sold within One year of completion, the owner GAS-EASYSTEM OVER 4 (EA) 2.00
builder will have the burden of proving that y . - .
e did not build or im- BUILDING USE
prove for purpose ofsaleJ. - INDUSTRIAL WASTE INTER. 30.00 , RES IND CON P8 other
❑ I,as owner of the property,on ax Clusivcly contracting with ❑ ❑ 0 ❑ 11
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's License Law does not apply
to an owner of property who builds or improves thereon,and who _ LAWN SPRINKLERS-OVER 5(EA.)- 1,00
contracts for such projects with a conliuctoos)license j pursuant to
the Contractor's License Law. SEWER-SANITARY-STORM EA.200ft/10.00 TRACT NO. PARCEL NO.
❑ I am exempt under Sec. ,B.&P.C.fur this WATER HEATER W/V . 6.00
reason
Owner Date WATER SYSTEM 5,00 ACC.OATE - ACC.FILE NO.
WORKERS'COMPENSATION DECLARATION WATER TREATIN I •.x . 5.00
I hereby affirm that I have a certificate ofconsent to self-insure,
Ora certificate of Workers'Compensut ion Insurance,ora certificel - - ZONING ENG.SITE NO.
copy thereof(Sea 3800,Lab.C.).¢'�.J_�.. � ]�
Policy No. CompunY_sT4Ze A_''_ALDCity of CUpertino
—
0 ❑ Cerlt in, Py is hereby urn r FIRE SPR INK ENERGY T-24
Z Z C Certififtl c -is fikJ w �Y inspection division.
o_ Appllcun 1, /K MISC.- REFER TO ORD. v E] NE] Y ❑ NE]
CC CERTIFICATE OF EXEMPTION FROM WORKERS' PERMIT ISSUANCE 10.00 V0 � FLOOD ZONE A.L.U.C.
LL It COMPENSATION INSURANCE PLG.CONTR. LIC.N0. PLG
CL . /� — ❑ ❑ ❑ N❑
O ('Phis section need not he compit,ed�if the pennit'is for one TOTAL V N Y
::) Z hundred dollar,($100)or less I
U O 1 certify that in the performance of the work for which this per. CITY. MECHANICAL PERMIT FEE FEE SUMMARY
LL I- mit is issued,I shall not employ any person in any roamer so as to
Q W' become subject to the Workers'Compensation Laws of California.
Q. Date Applicant BUILDING
>_ W NOTICE TO APPLICANT: If,after making this Certificate of Ex- ALTER'OR ADD TO MECH. 5.00 F. Z emption,you should become subject to the Workers'Compensation APPLIANCE 5.00 PLAN CHECK
'provisions of the Labor Code, you most forthwith comply with FEE
U such provisions or this permit shall he deemed revoked: AIR HANDLING UNIT(TO 10=C.F.M.) 4.00
CONSTRUCTION LENDING AGENCY AIR HANDLING UNIT(OVER 101C.F.M.) 6.00 SEISMIC FEE
I hereby affirm that there is a construction lending aguncy"for EXHAUST HOOD(WITH DUCT) 5.00 _
the performance of the work for which this permiM1is issued(Sec. MICROFILM
3097,Civ.C.). '. HEATING UNIT(TO 100,000 B.T.U.) 8.00
Lender's Name H EATI NG U N IT(OV ER 100,000 B.T.U.)9.50
Lender's Address ELECTRIC
I certify that 1 have read this application and state that the above VENTILATION FAN;(SINGLE) 4.00
\ information is correct. I agree to comply with all city and County PLUMBING 7 W
ordinances and slate laws relating to building construction, and B01LER-COMP(3H.P.or1OO,000B.TU.) 6.00
hereby aullorlm representatives of this city.to enter upon the gOILER•COMP IOver 100,000 BTU)SEE FEE SCH. MECHANICAL
above-mentioned'properly for inspection parpoms.
(We) agree to save, indemnify and keep harmless the Ctiy of MISC.- REFER TO ORO',
Cupertino against liabilities,judgments, costs and expenses which PERMIT ISSUANCE 10.00 'CONST.TAX '
GUY i any way accrue as(�sa�id City in consequence of the
gra n o Hti9 perm/ MECH.CONT. , LIQ NO. MECH. ,
TOTAL TOTAL
Signature o(App Apploc icant/Contractor OS DateO(�
OFFICE COPY - i -