10259 APPLICANT TO FILL IN INFORMATION IN RED LINES - USE BALL POINT PEN ONLY
BU LDING PR JECT IDENTIFI PERMITNUMBER
NG APPLIAD
CATION & PE T 10259
DING - ELECTRICAL-PLUMBING-MECHANICAL
OWNrJR'S J PLAN CHECK VALIDATION
NAM OTY. ELECTRIC PERMIT FEE
VXONE
NTR On'S n
NAME -7OUTLETS-SWITCHES,-RECEP 10.00/1.00
LIGHTING FIXTURES 10.00/1.00
ro c Rs
APPLIANCES-RESIDENTIAL 4.00
AOO E
PHO PANELS 10.00 DATE OF APPLICATION
ORCXIi r PANELS (OVER 200 AMP) 20.00 PLAN CHECK FEE P.C.NO.
ENGINEER
•LIC.NO. SIGNS TRANS. 3.00
ARCH,
END -LIC
SPECIAL CIRCUIT 5.00 PERMIT VA
ZIP EMP.METER OR POLE INS. 20.00J A
APP Nrs
A k MOTORS SEE FEE SCH. /1 t 4 1986`
SERVICE CHANGE 20.00
woo LICE. SED CONTRACTORS DECLARATION TEMP.POLE 30.00 CI �f�dPeffln0-
a o I hereby affirm that I um licensed under provisions of Chapter 9 ISSUANCE DATE
E. c E, [commencing wtlh ectioo 7000)of Division 3 of the Business an BLDG. ELECT. PLG. MECH.
m z Professions CoJ• dJn !c NO is in full force a e
z o T- License CI'
him.Number
o z - Uute Contractor _
a Y a BUILDING PERMIT
tc ¢ w ¢ OWN; -B ELDER DECLARATION
u o a v INFORMATION
X g LL y I hereby affirm that I am exempt from the Contractor's License MISC.-. REFER TO ORD
.. o¢ Law for the following mason. 7031.5,Businessand Professions VALUATION $/FT.
H _ PERMIT ISSUANCE 10.00
f 0 Code:Any city or county which requiresa permit to construct,alter,
¢ ¢ ¢ SO improve,demolish,or repair any stmdure,prier 10 its issuance,also ELEC.CONTR. LIG NO. ELEC.
o a requires the applicant for such permit to file a signed statement that - TOTAL
n w m he is licensed pursuant to the provisions of the Contractor's License /PlERMIT TO
H z r
Law(Chapter 9(commencing with Section 7000)of Division 3 ofthe In 'lr
¢ Business and Professions Code)or that he is exempt thorefrmn and DTV. PLUMBING PERMIT FEE
¢ r o the basis for We alleged cxcmptimi.Any violation of Section 7031,5 STORIES TYPE CONS R.
1 ;m by any applicant for a permit subjects the applicant toa civil penalty ALTER-DRAIN&HENT-WATER (EA.) 5.00
of not more than five hundred dollars(5500).):
❑ 1,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 struchve is not OCC.GROUP RES.UMTS
- intetded or offered for sale (Sea 7044, BusincssLand Professions 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 F IXTUR ES-PER TRAP 5.00 so.FT.FLOOR AREA TOTAL ACREAGE
himself or through his own employees,provided that such improve-
mentsarenotintendedorofferedforsale.If,however,the building GAS-EA.SYSTEM-i INC.4 OUTLETS 6.00
or improvement is sold within one year of completion,the owner- ' GAS-EA.SYSTEM OVER 4 IEA) 200
builder will have the burden of proving that h - . .
e did not build or im- BUILDING USE
prove for purpose of sale.). INDUSTRIAL WASTE INTER. 30.00 RE IND CON PB Gone,
0 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 docs not apply '
to an owner of property who builds or improves thereon.and who ILAWN SPRINKLERS-OVER 5(EA.) 1.00
contracts for such projects with a comrnetops)licensed pursuant to
the Contractor's License Law. SEWER-SANITARY-STORM EA.200ft/10.00TRACT NO. PARCEL NO.
❑ 1 am exempt under Sec. ,B.&P.C.I'or this WATER HEATER W/VENT 6.00
reason
Owner Date WATER SYSTEM 5.00ACC.DATE ACC.FILE NO.
WORKERS'COMPF-NSATION DECLARATION WATER TREATING EQUIP. 5.00
1 hereby affirm that 1 have a certificate of consent to self-insum.
or a eertilicate of W rkers Compensation Ins Arae,or a c• tificd ZONING ENG.SITE NO.
COPY there C.1.
policy N r 6t2err
Q jj]] Cer ed copyi crebYfur ed. FIRE SPRINK ENERGY T 24
oA tQ/CenHicd r fled me ;ty inspection division. MISC.- REFER TO ORD, Y ❑ N❑ Y ❑ N❑
m ,�P••{8�1wc-cc CLRTI :BPL FAIPTION PR M WORKCRS' PERMIT ISSUANCE 10.00 FLOOD ZONE A.L.0 C.
LU - Oh1PIiN SATION INSURANCE: PLG.CONTR. LIC.NO. PLG.
Cl_ a This section need out be conmleted if the permit is for one TOTAL V❑ N❑ Y ❑ N❑
- hundred dollars IS 100)or less.)
U O 1 certify that in the performance of the work for which this per- CITY MECHANICAL PERMIT FEE FEE SUMMARY
LL U mit is issued,I shall not employ any person in any manner so as to
become subject to the Workers'Compensation Laws of California.
a Date Applicant ALTER OR ADD TO MECH. 5.00 BUILDING
>_ to 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
provisionsof the labor Code, you must forthwith comply with FEE
U such 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 10.000C.F.M.) 6.00 SEISMIC FEE
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
Lender's Nene
Lender's Address HEATING UN IT(OVER 100,000 B.T.U.)9.50 ELECTRIC
-
I certify that 1 have read this application and state that lire above VENTILATION FAN (SINGLE) 4.00 -
• information is correct. 1 agree to comply with all city and countr PLUMBING
ordinances and slate 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, demnify and keep harmless the C"y of MISC. REFER TO ORD.
Cupertino a t lia t •s,judgments, costs and expenses which CONST.TAX
ma io an ay a r against said City in consequence of the PERMIT ISSUANCE 10.00
a ing tis pe M .CONT. LIC.NO. MECH.
TOTA TOTAL
Ig
d are of pphcant/Contractor J Date ✓',/ '
OFFICE COPY