09930APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
BUI LDI NG PROJECT I DENTI FICATI ON
APPLICATION & PERMIT
BUILDING — ELECTRICAL— PLUMBING — MECHANICAL
PERMIT NUMBER
^ ^ O
O 9 y
BUILDING
ADDRESS J�
NA E / jJ
T H t.HDNE U/�I//
OTY. ELECTRIC PERMIT FEE
PLAN CHECK VALIDATION -
NAME ACTORS
UTLETS-SWITCHES-RECEP 10.00/1.00
LIGHTING FIXTURES 10.00/1.00
- LIC.No.
CONTRACTORS
ADDRESS
APPLIANCES -RESIDENTIAL 4.00
PANELS 10.00
PHONE
DATE OF APPLICATION
ARCHITECT
ENGINEER
LIC. No.
PANELS (OVER 200 AMP) 20,00
PLAN CHECK FEE P.C. NO.
SIGNS TRANS. 3.00
AARCDDRESS ENG.
SPECIAL CIRCUIT S.00
PERMIT VALIDATION
TEMP. METER OR POLE INS. 20.00
ZIP
APPLICANTS
ADDRESS
MOTORS SEE FEE SCH.
SERVICE CHANGE 20.00A_
OCT 2 �4 ��,�5
ISSUA ATE
LICENSED CON TRACTORS DECLARATION
1 hereby affirm that 1 am licensed under provisions of Chapter 9
(comme neing with Section 7000) of Division 3 of the Business and
Professions Code, and my license is in full force and effect.
License Class Number
TEMP, POLE 30.00
BL G. ELECT. PLG. MECH.
0 Cho WE]Lac.
C ❑
Date Contractor
_
- 13UILDING PERMIT
INFORMATION
OWNER -BUILDER DECLARATION,
1 hereby affirm 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 requiresapermit to construct, alter,
improve, demolish, or repair my structure, prior to its issuance, also
requires the applicant for such permit to file a signed statement that
he is licensed pursuant to the provisions of the Contractor's License
MISC.— REFER TO ORD
-
.
PERMIT ISSUANCE 1000
VALUATION
O
S/FT.
ELEC. CONTR. LIC. NO.
ELEC.
OT
TAL
PERMIT TO
DTV: PLUMBING PERMIT FEE
Law (Chapter 9 (commencing with Section of Division 3 of the
Business and Professions Code) or that he is exempt therefrom and
is exempt
STORIES
TYPE CONSTR.
the basis for the alleged exemption. Any violation 0l Section 7031.5
by any applicant for a permit subjects the applicant to a civil penalty
of not more than five hundred dollars (5500).):
ALTER -DRAIN & VENT -WATER (EA.) 5.00
❑ I, as owner of the property, or my employees with wages as
their sole compensation, will tlo the work, and the structure is not
BACK F LOW PROTECT. DEVICE 4.00
OCC. GROUP
RES. UNITS
- DRAINS -FLOOR, ROOF, AREA, COND. 5.00
intended or offered for sale (Sec. 7044, Business and Professions
Code: The Contractor's License Law does not apply to ao owner of
property who builds or improves thereon, and who does such work
himself or through his own employees, provided that such improve-
mprove-mentsarenotintendedoroffered for sale. If, however, the building
ments are not intended or offered
F IXTURES - PER TRAP 5.00
SO. FT. FLOOR AREA
TOTALACREAGE
GAS - EA. SYSTEM -11 NC. 4 OUTLETS 6.00
or improvement is sold within one year of completion, the owner-
builder will have the burden of proving that h e did not build or im-
prove for purpose of sale.).
as owner of the property, um exclusively contracting with
- . ..
GAS EASYSTEM -OVER 4 IEA) 200
BUILDING USE
IND CON PB Omer
.INDUSTRIAL WASTE INTER. 3000
.
LAWN SPRINKLERS - 1 INC 5 V.B. 6.00
LAWN SPRINKLERS - OVER 5 (EA.) 1.00
licensed contractors to construct the 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
ASSESSORS PARCEL NO.
commas forsu LicenecLwithacontractods)licensed pursuant
rof a Law.
' contractstire or is h projects
SEWER -SANITARY -STORM EA. 200ft/10.00
TRACT NO.
PARCEL NO,
❑ lam exempt underec. .B.&P.C. I'or this
,
WATER HEATER W/VENT 6.00
on _
Owne ale
WATER SYSTEM 5.00
ACC. DATE
ACC. FILE NO.
WATER TREATING EQUIP. '5.00 `
WORK ERS'COM PENSATION DECLARATION
I hereby affirm that I have a cetlillcate o(consenl [o sell -insure.
or a certificate of Workers' Compensation Insurance, or a certified
ZONING
ENG. SITE NO.
copy thereof (Sec. 3800, Lab C.).
Policy No. Company
FIRE SPRINK
N
ENERGY T-24
Y ❑ N�
❑ Cetlified copy is hereby furnished.
❑ Certified copy is filed with the city inspection division.
ApplicantY
MISC.- REFER TO ORD.
CERTIFICATE OF EXEMPTION FROM WORKERS'
PERMIT ISSUANCE 10.00
FLOOD ZONE
A, L.U.D.
PLG.CONTR. -LIC. NO.
PLG.
TOTAL
COMPENSATION INSURANCE
(This section need not be completed if the permit is for one
Y 0 NEl
Y ❑ NE]
hundred dollars (S 100) or Icss.l
1 certify that in the perlonnence o1tire work I... which this Per-
mit is issued, I shall not employ any persori m any manner so as to
OTY MECHANICAL PERMIT FEE
FEE SUMMARY
BUILDING
become subject to the Workers' Compensation laws of California.
Date Applicant
NOTICE TO APPLICANT: II, after making thus Certificate of Ex-
ALTER OR ADD TO MECH. 5.00
APPLIANCE 5.00
PLAN CHECK
emption, you should become subject to the Workers' Compensation
provisions of the Labor Code, you must forthwith comply with
such provisions or this permit shall be deemed revoked.
FEE
AIR HANDLING UNIT (TO 10SMC.F.M.) 4.00
AIR HANDLING UNIT (OVER IQOWQEM.) 6.00
SEISMIC FEE
r
CONSTRUCTION LENDING AGENCY
I hereby affirm that if.... is a construction lending agency for
EXHAUST HOOD (WITH DUCT) 5.00
the performance of the work for which this permit is issued (Sec.
30 .
MICROFILM
HEATING,UNIT (TO 100,000 B.T.U.) 8.00
HEATING UNIT (OVER 100,000 B.T.U.)9.50
ELECTRIC
Lender'snder's Name e
Lender's Aedress
I 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
ordinances and stale laws relating to building construction, and
PLUMBING
BOILER-COMP13 H. P, or 100,000 B.T.U.) 6.00
BOILER -COMP (Over t00,0008TU)5EE 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 I0 save, indemnify and keep harmless the City of
Cupertino against liabilities, judgments, costs and expenses which
may in any way ac a against said City in consequence of the
CONST. TAX
PERMIT ISSUANCE 10.00
gra g0(lhis
j0 -
MECH. CONT. LIC. NO.
MECH.
OTAL
-
TOTAL
Signature LT licant/Contractor etc -
OFFICE COPY