10850 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
BU LD1 NG PROJECT I DENTI FICATI ON PERMIT NUMBER
BUILDING APPLICATION & PERMIT
ADDRESS 10850
107 Qp BUILDING - ELECTRICAL-PLUMBING-MECHANICAL
�
NAME PLAN CHECK VALIDATION� NRM
C 11�� ((''
r�,A,r I CS 'il.�H6Nq E .Z QTY. ELECTRIC PERMIT PEE
CONTRACTORS
\/ NAME - OUTLELS_-SWITCHES-RECEP 10.00/1.00
f S4-Gs+L z •C LIC.ND. LZ LIGHTING FIXTURES 10.00/1.00
\/X CONTRACTOR'S APPLIANCES-RESIDENTIAL 4.00
ADDRESS
pP'K1^ PHONE els^7 PANELS 10.00 DATE OF APPLICATION
A14OAC ITECT PANELS (OVER 200 AMP) 20.00 PLAN CHECK FEE P.C.NO.
ENGINEER
uC.NO. SIGNS TRANS. 3.00
ADDRESS ENG. SPECIALCIRCUIT 5.00 - VALIDATION
ADZIP EMP.METER OR POLE INS. 20.00 EB 13 1966
ADDDRREESSSS MOTORS SEE FEE SCH.
SERVICE CHANGE 20.00 ity. of Cupertino
000
Foo LICENSED CONTRACTORS DECLARATION '
a At W I hereby affirm that I am licensed under provisions of Chapter 9 SUANCE DATE
(commencing with Section 7000)of Division 3 of the Business and BLD ELECT. PLG. MECH.
Hr'N to Professions Code,' I my Iicense is in full force a t c -
Q i m License Class Lic.NumM1e ❑ ❑ ❑
Dale Contractor
a rc rc a OWNIiR- BUILDING PERMIT
D U BUILDER DECLARATION INFORMATION
X ; LL N 1 hereby affirm that I am exempt from the Contractor's License MISC.- REFER TO ORD
.. 0 a Law for the following reason.(Sec.]031.5,Business and Professions VALUATION $/FT.
F- - PERMIT ISSUANCE 10.00
wi Code:Anycity.,county which requimsa permit mennstrucLalter,
re C ¢ improve,demolish,or repair any structure,prior to its issuance,also ELEC.CONTR. LIC.NO. ELEC.
a
I[ requires the applicant for such permit to file a signed Mstatement that TOTAL PERMIT w S he is licensed pursuant to the provisions of the Contractor's License
F z Y Law(Chapter 9(commencing with Section 7000).f Division 3 ofthe
-q z o Business and Professions Code)or flus!he is exempt therefrom and DTV. PLUMBING PERMIT FEE
W H e the basis for the alleged exemption.Any violation of Section 7031.5 STORIES TYPE CONSTR.
nam by any applicant for a permit subjects the applicant to a civil penalty ALTER-DRAIN -WATER (EA.) 5.00
of not more than five hundred dollars($500).):
❑ I,as owner of the property,or my employees with wages as BACK FLOW PROTECT. DEVICE 4.00 OCC.GROUP RES.UNITS
their sole compensation,will do the work,and the sl mcmre is not
intended or offered for sale (Sec. 7044, Business and Profession 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 work FIXTURES-PER TRAP 5.00 so.FT.FLOOR REA TOTAL ACREAGE
himself or through his own employees,provided that such improve-
cGAS-EA.SVSTEM-11NC.40UTLETS 6.00
cents me not intended.r offered for safe.If,however,the building
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 irs- BUILDING USE
RE IND CON PB Other
prove for purpose of talc). INDUSTRIAL WASTE INTER. 30.00
❑ as owner of the property,he exclusively contracting wish ❑ ❑
adPlicensed contranod to Th
e
the project(Sec.7044,Business LAWN SPRINKLERS-1 INC 5 V.B. 6.00 ASSESSORS PARCEL NO.
end Professions Code:The Conbuilds s License Law Jars not apply
to tr owner of property who builds tr improves thereon,and who LAWN SPRINKLERS-OVER 5(EA.) 1.00
contracts for such License
with a contractor(s)licensed Pursuant to SEWER-SANITARY-STORM EA.200ft/10.00
the Contractor's License Law, TRACT NO. PARCEL N0.
❑ I am exempt under Sm.-,BAP.C.for this WATER HEATER W/VENT 6.00
reason
Owner Date WATER SYSTEM 5.00 ACC.DATE ACC.FILE NO.
WORKI!RS'COMPENSATION DECLARATION WATER TREATING EQUIP. 5,00
1 hereby affirm hot I have a certificate of Consent to sel&insure,
or a certificate Of Workers'Compenso'on.1 asum ne,or a certified ZONING ENG.SITE NO.
copy thereof(Sec 3800.Lab.C.).
Policy No. Company
0 ❑ Certified copy is hereby famis ed. FIRE SPRINK ENERGY T 24
Z^ ❑ Certified��ssoopn�yl�sfIIl}��d wit t city inspection division. ❑ ❑ ❑ ❑
p Appficant_GKE={ MISC.- REFER TO ORD. Y N v N
j ti CHRTIFICAT'I:0IF EXEMPTION FROM WORKERS' PERMIT ISSUANCE 10.00 FLOOD ZONE A.L.U.C.
W > COMP17NSATION INSURANCE PLG.CONTR. LIC.NaPLG.
d p (This section need not he completed if the permit is for one TOTAL Y N Y 1:1N❑
Z hundred dollars($100)or less.)
00 1 certify that in the performance of the work for which this per- CITY. MECHANICAL PERMIT FEE FEE SUMMARY
LL F mil is issued,I shall not employ any person in any ammo, so as to r
O Ubecome subject to the Workers Compensation Laws of California.111 ✓D
y Dme Applicant ALTER OR ADD TO MECH. 5.00 BUILDING
} w NOTICE TO APPLICANT: If,after making this Certificate of Ex-
F. ? emption,you should become subject to the Workers'Compensation APPLIANCE 5.00 PLAN CHECK
provisions of the Labor Code, you must forthwith comply with - FEE
U such provisions Or this permit shall he deemed,evoked. AIR HANDLING UNIT(TO 10=C.F.M.) 4.00
CONSTRUCTION LENDING AGENCY AIR HANDLING UNIT(OVER IO,OODC.F.M.) 6.00 SEISMIC FEE 0
I hereby affirm 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(Sec. MICROFILM
3097,Civ.C.). HEATING UNIT(TO 100,000 B.T.U.) 8.00
Lender's Name HEATING UNIT(OVER 100,000 B.T.U.)9.50
Lender's Address ELECTRIC
1 certify that 1 have read this application and stale that the above VENTILATION FAN (SINGLE) 4,00 -
information is correct. I agree to comply with all city and county PLUMBING
Ordinances and stale laws relating to building construction,and BOILER-COMP(3H.P.or 100,000B.T.U.) 6.00
hereby enioneauthorize representatives for ins inspection
this city to enter upon the BOILER-COMP(Over 100,000 BTU)SEE FEE SCH. MECHANICAL
above-mentioned property tativsp of
purposes.
(We) agree to save, indemnify and keep harmless tine City of MISC.- REFER TO ORD.
Cupertino against liabilities,judgments, costs and expenses which PERMIT ISSUANCE 10.00 CONST.TAX
may iA any way accrue against said City in consequence Of the
granting Of this permit. MECH.CONT. LIC.NO. MECH.
i
TOTAL
/ Igna� cant/Contractor pai4� TOTAL