10856 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE'BALL PO ONLY
ONLY
' BU LDING PROJECT I DENTI FICATI ON , - - PERMIT NUMBER
BUILDING APPLICATION & PERMIT
aooREss �- - I BUILDING-ELECTRICAL-_PLUMBING-MECHANICAL
110856
OWNER's - - .,PLAN CHECK VALIDATION
NAME OTY. ELECTRIC PERMIT FEE �t
•� r rPHONE
CON cTDRs, UTLETS-SW ITCHES'-RECEP .10.00/1.00
NA P
f /Y LIGHTING FIXTURES 10,00/1.00
cONTRACTOR's APPLIANCES-RESIDENTIAL 4.00
RE55
PANELS 10,00 DATE OF APPLICATION
ARCHITECT PANELS (OVER 200 AMP) 20.00 PLAN CHECK FEE P.C.. No.
OR
ENGINEER
" Lic.ND.' SIGNSTRANS.- 3.00
AARCH OR
DDRESS ENG: 5 SPECIAL CIRCUIT 5,00 FERMI KION
zhv EMP.METER OR POLE INS. 20.00 - FE
-' e@
• APPLICANTF
'S MOTORS SEE SCH. EB ! 100
ADDRESS. .• •'•1• i.
- SERVICE CHANGE 20.00 ♦ [ '.a
woo LICENSED CONTRACTORS DECLARATION aQ�/TL City CCU PertinO
< U u • I hereby affirm that I am licensed under provisions of Chapter ' ISSUANCE DATE
N Iu (commrncing with Section 7000)of Division 3 of the Business and G BLDG. ELECT. LG. MECH.
r m i
Professionsco ryyJyense is in full forcQn� .
Z o m - License Class C� C-,a V Lic.,Number_V / ❑ ❑ ❑
o r'w Date Conlrucmr
a'N ' - el '` 7 '� BUILDING PERMIT
c s'w OWNER-BUILDER DECLARA IT INFORMATION
E
O n y 1 hereby affirm that I am exempt from the Contractor's License MISC.- REF R ORD
.3 u ',VALUATION $/FT.
F u o j Law for the following reason:(Sec.7031.5,It usiness an d Professions PERMIT ISSUANCE 10.00
,Wy Code:Any city or count y which req Gins o permit to construct,al let,
2 a ¢ 0 improve,demolish,or repair any structure,prior to its issuance,also ELEC.CONTR. LIC.NO. ELEC. Q�
n w m u requires the applicant for such permit to file a signed statement that „ • TOTA F gMIT TO -
he is licensed pursuant to the provisions of the Contractor's License
Law(Chapter 9(commencingwilh Section 7000)of Division 3 ofthe :
¢ Business and Professions Code)or tett he is exempt therefrom and QTY. PLUMBING PERMIT FEE
¢r$ the basis for the alleged exemption.Any violation of Section 7031.5, STOR ES TYPE CONSTR.
ea by any applicant for a permit subjects the applicant to acM]penalty
ALTER-DRAIN&VENT-WATER (EA.) 5.00 e
• of not more lhan five hundred dollars($500).): ' -
❑ I,as owner of the property,or my employees with,wages as BACK FLOW PROTECT.DEVICE 4.00
their sole compensation,will do the work,and the structure is not - OCC.GROUP RES;UNITS
intended or offered for.sale (Sec. 7044; Business and Professions DRAINS-FLOOR;ROOF,AR EA,COND. 5.00
Code:The Contractor's License Law does not apply to an owner of
property who builds or improves thereon,and who does such work . FIXTURE$-PER TRAP 5.00 So.FT.FLOOR AREA TOTAL ACREAGE
• himself orthrough his own employees,provided that such improve
ments are not intended or offered for sale.If,however,the building GAS-EA.SVSTEM•11NC.40UTLET$ 6.00
or improvement is sold within one year of completion,the owner- GAS-EASYSTEM-OVER 4(EA.) 200
builder will have the burden of proving that he did not build or,im-' . . . BUILDING USE
prove for purpose of sale.). INDUSTRIAL WASTE INTER. 30.00 RES ' IND CON PB ower
❑ 1,as owner of the property,am exclusively 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's License Law does not apply '
to on owner of property who builds or improves thereon,and who LAWN SPRINKLERS-OVER 5(EA.) 1.00 ,
contracts Tor such censeprojects with a contructur(xl,licensrd pursuant to SEWER-SANITARY-STORM EA.200ft/10.00 TRACT NO. PARCEL N0.
the Contractor's License Luw. PARCEL
❑ I am exempt under Sec. ,BI&PC.foiling WATER HEATER W/VENT 6.00
reason
Owner .Date WATER SYSTEM - 5.00 ACC.DATE ACC FILE NO.
S'C M NS�n•�[nv D/1,.C;�/A 1ONI WATER TREATING EQUIP. - 5.00
I hKeb a m [hv�l dY•rtfficsCe tfftollSel\t to self-insure,
or a certificate of Workers'Compensation Insurance,or a certified •ZONING ENG.SITE NO
copy I No.-Company
o. lSec. Co Lab.C.).
Policy ere Company.).
Q ❑ Certi"ishereniched. FIRE SPRINK ENERGY T34
ZZ ❑'Cent dh he.c inspect MISC. REFER TO ORD. ❑ , ❑ ❑O Applicant v N v Nw PERMIT ISSUANCE 10.00 FLooD zoNE A.L.u.c.
CC CERPTI ROM WORKERS'
W 1 COMPENSATION I URANCE PLG.CONTR. . LIC.NO. PLG.
LL O (This section nceJ not be complete) if the permit Is (or one TOTAL ❑ N❑ - �.❑ N❑
'Z) Z hundred dollars IS 100)or less)
V O 1 certify that in the performance of the work for which this per- OTY. MECHANICAL PERMIT FEE FEE SUMMARY
LL f- out is issued,I shall not employ any person in any amnner so us to
U become subject to the Workers Compensation Laws of Cali1'ornio.
G. Dam Applicant - ALTER OR ADD TO MECH. 5.00 BUILDING.
to NOTICE TO APPLICANT: If,after making this Certificate of Ex.
F Z
cut
ption,'you should become subject to the Workers'Compensation APPLIANCE 5,00 : PLAN CHECK
prisioos'of the Labor Code, youmustforthwith comply with FEE
C,1 sucovh provisions or this permit shall be deemed revoked. AIR HANDLING UNIT(TO 10=C.F.M.) 4.00
CONSTRUCTION LENDING AGENCY AIR HANDLING UNIT(OVER 10=C.F.M.) 6.00 SEISMIC FEE
I Immlay affirm thm there is construction lending agency for EXHAUST HOOD (WITH DUCT) 5.00
the performance of the wer which this permit is issued(Sec. MICROFILM
3097,Civ HEATING UNIT(TO 100,000 B.T.U.)• 8.00 .
BC 0 �/C _ '
Lender's Name PAS-
Lender's Address HEATING UNIT(OVER 100,000 B.T,U.)9.50 ELECTRIC
'
1 certify that I 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
ordinances•and state laws relating to building construction, and BOILER-COMP(3 H.P.or 100,000 B.T.U.) 6.00
hereby authorize'representatives of this city to enter upon the BOILER-COMP (Over 100,000 BTU)SEE FEE SCH. MECHANICAL.
above-mentioned property for inspection purposes.
(We) agree to save, indemnify and keep harmless the City of MISC.- REFER TO ORD.
Cupertino-ag; st liabilities,judgments, costs and expenses which PERMIT ISSUANCE - 10.00 7 CONST:TAX
m' n cr against tai City in consequence f the 'r
grant hisp �� MECH.CONT. - LIG NO. MECH.
TOTAL TOTAL AD
Signal..ol'Ap cant/Contr or )ate r 1-1