09543APPLICANT TO FILL IN INFORMATION WITHIN RED LINES- USE BALL POINT PEN ONLY
BU LDI NG PROJECT I DENTI FICATI ON
APPLICATION &PERMIT
PERMIT NUMBER
aDILrING
ADDRESS
L
•/
BUILDING - ELECTRICAL- PLUMBING -MECHANICAL
4
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NER'a C^�
NAME O [
.)r y GXONE ,67I-/ Q I
CITY. ELECTRIC PERMIT FEE
PLAN CHECK VALIDATION
c NTnacrons
NAME
UTLETS-SWITCHES -RECEP 10.00/1.00
LIGHTING FIXTURES 10.00/1.00
.No.
PEA
ACT Rs
ADDRESS
APPLIANCES- RESIDENTIAL 4.00
PANELS 10.00
PHONE
DATE OF APPLICATION
ARCHITECT
O
OR
ENGINEER
LIC. No.
PANELS (OVER 200 AMP) 20.00
PLAN CHECK FEE P.C. NO.
SIGNS TRANS. 3.00
ADDRESS E.G,
CIRCUIT 5.00
PERMIT
PERMIT VALIDATION
TEMP. METER OR POLE INS. 20.00
ZIP
P41a
APPLICANTS
A OORESs
MOTORS SEE FEE SCR.
SERVICE CHANGE 20.00Aurx
rx9
UU ('r rd �Q,Q�
LICENSED CONTRACTORS DECLARATION
TEMP. POLE 30.00
1 berehy affirm that I am licensed under provisions of Chapter 9
-ISSUANCE DATE
(commencing with Section 7000) of Divi.aiou 3 of the Business and
Pro fessm Code, ul n)y license is in full liuce and effect.
License CP ss Lie. Number 's1h
BLDUry
❑
UVL
P
PL MECH.
rt,
Dote Comractor
BUILDING PERMIT
OWNER -BUILDER DECLARATION
I hereby uollo that I am exempt frons the Contractor's License
Law for lhcity or countywhich reouire, a emBUSit to lmdl'mfcsaions
Code Any city or county which sequiture permit to construct , .1,0
improve, demolish, or repair any structure, prior signed its issuance, also
regUlRS[Iled mrstntt t the permlles file ofta Contactor' Li that
he IS licensed to the Secti Of[he(.'ml License
ION
INFORMATION
MISC.- REFER TO ORD
PERMIT ISSUANCE 10.00
VALUATION
$/FT.
ELEC. CONTR. LIC. NO.
ELEC.
TOTAL
pE I TO
CITY. PLUMBING PERMIT FEE
9( roomt
Law (Chapter r(commencingwith Section 7000)of D ivision3 of the
Division
Business unA Professions Code) or thin he is exempt therefrom and
Ir
TVP CONSTR,
the basis for the alleged exemption. Any violation of Section 7031.5
byuny apphcant for a permit subjects lire applicant to a Civil penalty
Of not more than five hundred dollars (5500).):
ALTER -DRAIN -WATER IEA.) 5.00
❑ 1, as owner of the property, or my employees with wages as
their sole compensation, will do the work, and the structure is not
BACK FLOW PROTECT. DEVICE 4.00
OCC. GROUP
RIES. UNITS
DRAINS -FLOOR, ROOF, AR EA, GOND. 5.00
intended or offered for sale (Sec. 7044, Business and Professions
Code: The Contractor's License Law does not apply to an owner of
property who builds or improves thereon, and who does such work
himisclf or through his own employees, prsvidcd Bwl such improve-
mentsarenotlntended uraffe..0 for sale. If. however, the building
SO, FT. FLOOR AREA
TOTAL ACREAGE
� )
F IXTUR ES - PER TRAP 5.00 Uy
GAS-EA.SYSTEM-1 INCA 0UTLET$ 6.00
or impmvement is sold within one year of completion, the owner-
builder will have the burden of proving (hut lie did not build or im-
prove for purpose of,rIc'.INDUSTRIAL
❑ I, as owner, of the property, an i exclusively contracting with
GAS - EA. SYSTEM -OVER 4 IEA.) 2.00
BUILDING USE
s IND CON PB Other
❑ ❑ ❑ ❑
WASTE INTER3000
. .
licensed contractors to construct the project iSce 7044, Business
and P,ofcssi ons Code:' I' lie Contractor's License Low does not apply
to an owner of property who builds or improves thereon, and who
LAWN SPRINKLERS - 1 INC 5 V.B. 6.00
LAWN SPRINKLERS - OVER 5 (EA.) 1.00
ASSESSORS PARCEL NO.
contracts forsuch projects with a contractor(,) licensed pursuant to
the Contractor's License Law.
SEWER -SANITARY -STORM EA. 200ft/10.00 00
TRACT NO.
PARCEL NO.
❑ I am exempt under Sec.-, B.&P.C. for this
WATER HEATER W/VENT 6.00 00
reason
Owner Date
WATER SYSTEM 5.00 r CV
ACC. DATE
ACC. FILE NO.
WATER TREATING EQUIP. 5.00
WORK ERS'COMPEN$ATION DECLARATION
I hereby affirm that I have a certificate ofconsent to self -insure.
or a certificate of Workers' Compensation Insurance, or a certified
ZONING
ENG. SITE NO.
Copy thereof (Sec. 3800, Lab.C.L
Policy No. Company
FIRE SPRINK
v❑ N❑
ENERGY T 24
Y❑ N❑
❑ C,Nifi,d copy is hereby fulnohed.
Certified o i' Bled with the city inspection division.
Apph'anl� rr'/h[ r-•
MISC.- REFER TO ORD.
CERTIFICATE OP EXEMPTION I'ROM WORKERS.
PERMIT ISSUANCE 10.00 d0
FLOOD ZONE
A.L.UC.
PLG. CONTH. LIC. NO.
PLG.
TOTAL
COMPENSATION INSURANCE
(This section need not be completed if the permit is for one
Y ❑ N❑
Y ❑ N❑
hundred doll... ( $100) nr ICFs.)
I certify that in the serfurmane, of the work for which this per-
mit is issued. I shall not employ any person in any manner so as to
OTV. MECHANICAL PERMIT FEE
FEE SUMMARY
BUILDING
become subject to the Workets Compensation Laws of California.
Date Applicant
NOTICE TO APPLICANT: If, after making this Certificate of Ex-
ALTER OR ADD TO MECH. 5.00
APPLIANCE 5.00
PLAN CHECK
emption, you should become subject to the Workers' Cornpeasutlon
provisions of the Lubar Code, you must forthwith cnmiply with
such provisions or this permit shall be deemed revoked.
FEE
AIR HANDLING UNIT (TO 10MC.F.M.) 4.00
AIRHANDLING UNIT(OVER IOMC.F.M.) 6.00
SEISMIC FEE
"
CONSTRUCT ION LENDING AGENCY
I hereby affirm that there is a construction lending agency for
EXHAUST HOOD (WITH DUCT) 5.00
theperformance of the work for which this permit is issued (Sec.
MICROFILM
HEATING UNIT (TO 100,000 B.T.U.) 8.00
H EATI NG U N IT (OVER 100,000 B.T.U.) 9.50
ELECTRIC
Lender's Name
Lender's Address
I certify that I have read this application and state that the above
information is correct 1 agree to comply with all city and county
ordinances and state laws relating to building construction, and
VENTILATION FAN (SINGLE) 4.00
PLUMBING
00
BOILER-OOMP13 H.P. Dr 100,000 B.T.U.) 6.00
BOILER -COMP (Over 100,000 BTU) SEE FEE SCR.
MECHANICAL
hereby authoris representatives of this city to enter upon the
,hove -mentioned property for inspection purposes.
MISC. - REFER TO ORD.
(We) agree to save, indenmify and keep harmless the City of
Cupertino against liabilities, judgments, costs and expenses which
may in any way accrue a ins[ said City in consequence of the
gmn)ng ftry� permit /
CONST. TAX
PERMIT ISSUANCE 10.00
MECH. CONT. LIC. NO.
_i 12 "" , Q �J r�Q'r
TOTAL
TOTAL
Siyfn�rc p cmmtl o t n� DatL
INSPECTOR COPY