8192APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
BUILDING PROJECT IDENTIFICATION
BUILDING -ELECTRICAL -PLUMBING -MECHANICAL
PERMIT NUMBER
��
BUILDINGAPPLICATION&PERMIT
/O��ry
ADDRESS M VY
L
w r -
NAME
CITY. ELECTRIC PERMIT FEE
PLAN CHECK VALIDATION
PHONE
NAME acroRs
OUTLETS-SWITCHES-RECEP 10.00/1.00
LIGHTING FIXTURES 10.00/1.00
L No. /
DATE OF APPLICATION
'Cory Aci Rs'
PDDRESS
HONE
PPLIANCES- RESIDENTIAL 4.00
PANELS 10.Q0
'ARCHITECT
OR
O
PANELS (OVER 200 AMP) 20.00
PLAN CNECK FEE P.C. NO.
ENGINEER
LIC. No.
SIGNS TRANS. 3.00
A DONEss arae.
SPECIAL CIRCUIT 5.0Q
PERMIT VALIDATION
TEMP. METER OR POLE INS. 20.00
Tlp
d' J
APPLICANTS
ADOREss
MOTORS SEE FEE SCH.
SERVICE CHANGE 20.00
LICENSED CONTRACTORS DECLARATION
TEMP. POLE 30.00
1 hereby affirm that I am licensed under provisions of Chapter 9
(commencing with Section 7000) of Division 3 of tic Business and
Professions Code,jqd my license is in full farce nd IT cl
License Cla s Lic. Num
ISSUANCE DATE
SLOG.
ELECT.
❑
PLG. MECH,
❑ ❑
Date Contract
BUILDING PERMIT
INFORMATION
OWNER -BUILDER DP -CL ATION
J
I hereby :dorm that I am exempt from the Contractor's License
Law for the following reason.(Sec. 7031.5, Businessand Professions
Code: Any city or county which reyuiresapermit to construct afteq
improve, demolish, or repair any structure, prior 10 its issuance, also
requires the applicant for such permit to file a signed statement that
he is licensed pursuant to the provisions of the Contractors License
Law (Chapter 9(commencing with Section 7000) of Division 3 ofthe
Business and Professions Code) or that he is exempt therefrom and
MISC. - REFER TO ORD
VALUATION
$/FT.
PERMIT ISSUANCE 10.00
ELEC. CONTR. LIC. NO.
ELEC.OT
TAL
PERMIT TO
SINGLE T�Yyi� J
GTV. PLUMBING PERMIT FEE
STORIES
TYFIE CONSTR.
the basis for [he alleged exemption. Any violation of Section 7031.5
by any applicant for a permit subjects the applicant to a civil penalty
of not more than live hundred dollars (S500).):
9
C7 '�
d
r6/ f/�
V�
ALTER -DRAIN & VENT -WATER (EA.) 5.00
properly, or y employees with wages set
O I, as owner of the pm
their sole compensation, will do the work, and the structure is not
BACK FLOW PROTECT. DEVICE 4.00
RES. UNITS
DRAINS -FLOOR, ROOF, AREA, COND. 5.00
intended or offered for sale (Sec. 7044, Business and 1'rol'cssimTs
Code: The Contractor's License Law does not apply to an owner of
property who builds or Improves thereon, and who docs such work
himself or through his own employees, provided that such improve
menus are not intended or offered for sale. If, however, the building
_ 9
V
j
FIXTURES - PER TRAP 5.00
SO. FT. FLOOR AREA
TOTAL ACREAGE
GAS-EA.SYSTEM-l1NC.40UTLETS 6.00
or improvement is sold within one year of completion, the owner-
-
builder will have the burden of proving that he did not build or inn--
prove for purpose of sale.).INDUSTRIAL
❑ I, as owner of the property, am exclusively contract Ing with
. -..
GAS EASYSTEM OVER 4 IEA) 200
BUILDING USE
RES IND CON PB Omer
Eg/ ❑ ❑ ❑ ❑
WASTE INTER. 30.00
licensed contractors to construct Ore project (Sec. 7044, Business
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- 1 INC 5 V.B. 6.00
ASSESSORS PARCEL NO.
) �
J
LAWN SPRINKLERS - OVER 5 (EA.) 1.00
contracts for such projects with a contractoRsl licensed pursuant to
the Contractor's License Law.
SEWER -SANITARY -STORM EA. 200ft/10.00
NO.
PARCEL NO.
O l am exempt under Sec.-, tin this
/TRACT
`,4U
WATER HEATER W/VENT 6.00
n
rl.U
(O
Owner Date
WATER SYSTEM 5.00
ACC. GATE
ACC. FILE NO.
WATER TREATING EQUIP. 5.00
WORKERS'COMPENSATION DECLARATION
1 hereby affirm that I have u certificate of consent to selGinsure,
ser a certificate of Workers Compensation Insurance, m a cenifieJ
ZONING
ENG. SITE N0.
d
copy thereof (Sec. 3800. Lab C-
Policy No. Company
_
FIRE SPRINK
Y ❑ N ❑
ENERGY T 24
Y ❑ N❑
or
❑ Cenifie yis hereby fL
❑ CeRif d c py is fled ftlt hc city inspeeli n division.
Applicant
MISC. - REFER TO ORD.
.XEMP
CERT ATE OI' Clibl P' )N FROM WORKERS,
PERMIT ISSUANCE 10.00
FLOOD ZONE
A.L.O.C.
PLG. CONTR. sec. NO.
PLG.
TOTAL
IN
(This sec Ion need not be completed if the permit is for one
Y ❑ N❑
Y ❑ N
hundred dollars (S 100) or less, )
I certify that in the performance of the work for which this per-
mit is issued, I shall not employ any person in any manner so as to
GTV. MECHANICAL PERMIT FEE
FEE SUMMARY
BUILDING
sa
I;CU
become subject to the Workers' Compensation Laws of California.
Date Applicant
ALTER OR ADD TO MECH. 5.00
NOTICE "TO APPLICANI It, after making this Certificate of Ex-
APPLIANCE 5.00
PLAN CHECK
vnptiuR, you should become subject to the Workew'Colnpensutiun
provisions of the Labor Code, you most forthwith conOrly with
such provisions or this permit stall be deemed revoked.
FEE
AIR HANDLING UNIT (TO 10SWC.F.M.) 4.00
AIR HANDLING UNIT (OVER 10=C.EM.) 6,00
SEISMIC FEE
/� d 7-
CONSTRUCTION LENDING AGENCY
1 hereby affirm that there ix a construction lending agency for
EXHAUST HOOD (WITH DUCT) 5.00
the pert'onnance of the work for which this permit is issued (Sec.
3097, Civ.C.).
MICROFILM
HEATING UNIT (TO 100,000 B.T.U.) 8.00
HEATING UNIT (OVER 100,000 B.T.U.)9.50
ELECTRIC
Lender's Name
Lender's Address
1 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
ordinances and state laws relating to building construction, and
PLUMBING
BOILER-COMP13 H.P. or 100,000 B.T.U.) 6.00
BOILER -COMP (Over 100,000 BTU) SEE FEE SCH.
MECHANICAL
hereby authorize representatives of this city to enter upon the
above-mentioned property for inspection purposes.
MISC. - REFER TO ORD.
(We) agree to save, Indemnify and keep harmless the City of
Cupertino against liabilities, judgments, costs and expenses which
Fray' -_A
ny way accrue against said City in consequence of the
CONST. TAX
a Ada
PERMIT ISSUANCE 10.00
gra mg (this permitMECH.
CONT. LIC. NO.
MECH.
OT
TOTAL
%?.2 L7
w
fn lApp ca /Con Dat•
INSPECTOR COPY