8711APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
BU LDI NG PROJECT I DENTI FICATI ON
APPLICATION & PERMIT
PERMIT NUMBER
BUILDING
ADDRESS
512
BUILDING - ELECTRICAL- PLUMBING - MECHANICAL
11
OWNERS
NAME
CITY. ELECTRIC PERMIT FEE
PLAN CHECK VALIDATION
ONE
NAMERCTORS
\�'
OUTLETS-SWITCHES-RECEP 10.00/1.00
LIGHTING FIXTURES 10.00/1.00
uc. rvo.
'
r. DRESS 's
ADOREss eoj/I%1E«
PPLIANCES-RESIDENTIAL 4.00
PANELS 10.00
-vor 6 PHONEq _
DATE OF APPLICATION
AORRCHITECi
PANELS (OVER 200 AMP) 20.00
PLAN CHECK FEE P.C. NO.
ENGINEER
LIc, No,
`
SIGNS TRANS. 3.00
ARCH ESS siva
SPECIALCIRCUIT 5.00 ��
, PERMIT VALIDATION
TEMP. METER OR POLE INS. 20.00
ZIP
1
J
�'j/a ✓���
T
A
ADDPPLICARESS
-_
MOTORS 3 SEE FEE SCH.
SERVICEC A GE � 20.00
LICENSED CONTRACTORS DECLARATION
TEMP. POLE,.e 30.00
I hereby affirm that I am licensed under Provisions of Chapter 9
(commencing with Section 7000) of Division 3 of lire Business and
Professions Code. and my license is in full force and effect
License Clan �{e Lic. Number
Date Gs�_ V Contractor
ISSUANCE DATE
SLOG. ELECT. PLG. MECH.
\ ❑ E]
BUILDING PERMIT
INFORMATION
OWNER-BUILDKR DEC A!rLv'n'v
1 hereby affirm thin I am exempt fr, m th
Law lin the following mason. (Sec, 7031.5, dusinessand Profession,
Code: Any city or county which requiresu permit to construct, alter,
M ISC.- REFER TO ORD
PERMIT ISSUANCE 7QJIO ✓'C'
VALUATION
$/FT.
ELEC. CONTR. UC. NO.
TOTAL /
Improve, demolish, Or repair any structure, prior to Its Issuance, ab,
requires the applicant for such permit to file a signed statement that
he is licensed pursuant to the provisions of the Contractors License
PERMIT TO
OTV. PLUMBING PERMIT FEE
Law (Chapter 9 (commencing with Section 7000) of Division 3 at the
Business and Professions Code) or that he is exempt therefrom and
STORIES
TYPE CONSTR.
the basis for the alleged exemption. Any violation o(Section 7031.5
by any applicant for a permit subjects the applicant to a civil penalty
of not more than five hundred dollars (S500)J:
ALTER -DRAIN (EA.) 5.00
❑ 1, as owner of the property, or my employees with wages as
sole compensation, will do the work, and the structure is not
BACK FLOW PROTECT. DEVICE 4.00
OCC. GROUP
RES. UNITS
DRAINS -FLOOR, ROOF, AREA, CONE. 5.00
intended or offered for sale (Sec. 7044, Business and Professions
(fide: I lie Contractors License Law does not apply to an owner of
property who builds or improves thereon, and who does such work
himself or Borough his own employees, provided that such impro4c-
menlsare not intended oroffered for sale. If, however, the building
FIXTURES - PER TRAP 5.00
SOFT, FLOORAREA
TOTAL ACREAGE
GAS - EA. SYSTEM - 1 1 NC. 4 OUTLETS 6.00
or improvement is sold within one year of completion, lire owner-
builder will have the burden of proving that he did not build or im.
prove lot purpose ofsale.).
❑ I, as owner of the property, am exclusively contracting with
GAS - EA. SYSTEM - OVER 4 (EA.) 2.00
BUILDING USE
RES IND CON PB Omer
❑ ❑ ❑ ❑ ❑
INDUSTRIAL WASTE INTER3000
. .
licensed contractors to construct the project (Sec. 7044, Business
and Professions Code The Contractor's License Law does not apply
to an owner of properly 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 for such projects with a contractors) licensed pursuant to
the Contractor', License Law.
SEWER -SANITARY -STORM EA. 200ft/10.00
TRACT NO.
PARCEL NO.
❑ I ani exempt order See ,B.&P.C. for this
WATER HEATER W/VENT 6.00
reason
Owner Date
WATER SYSTEM 5.00
ACC,DATE
ACC. FILE NO,
WATER TREATING EQUIP. 5.00
WORKERS'COMPF-NSATION DECLARATION
I hereby affirm that I have a certificate of crosenl to self -insure,
or A Certificate of Workers' Compensation Insurance, or a certified
ZONING
ENG. SITE N0.
copy thereof (Sec 3800 Lab C.)
l
Paucy n'a ny 4J� JFFA,Q !
❑ Cctlil is coP /s mr (lyra nl 1hed.
y Certified C Is Aad winh the city 'rsnvnion division.
A p'cant
FIRE SPR INK
Y❑ N❑
ENERGY T 24
Y❑ N❑
MISC.- REFER TO ORD.
Ch G1'E OF IiXEMP110 -R01f WORKERS,
PERMIT ISSUANCE 10.00
FLOOD ZONE
iAL.0 c.
COMPIiNSA'I'ION IN URANCIi
TThis section need not be completed it the permit is for one
PLG CONTR. LIC. No.
PLOY
TOTAL
Y ❑ N❑
/ Y ❑ NEI
I u ndred dollars IS 100) ar lass.)
I certify that in the performance of the work for which this per-
mit is issued, I shall not employ airy person in any manner so as to
OTY. MECHANICAL PERMIT FEE
FEE SUMMARY
BUILDING
become subject to the Workers' Compensation Laws of California.
Date Applicant
ALTER OR ADD TO MECH. 5.00
NOTICE TO APPLICANT: If, after making this Certificate of Ex-
emption, you should become subject to the Workeri Compensation
APPLIANCE 5.00
PLAN CHECK
--
Provisions of the Labor Code, you must forthwith comply with
such provisions or this permit shall be deemed revoked.
AIR HANDLING UNIT (TO 10=C.F.M.) 4.00
FEE
AIR HANDLING UNIT(OVER 10,0MC.EM.) 6.00
SEISMIC FEE
CONS'TRUCT'ION LENDING AGENCY
I hereby affirm Iliat there is a construction lending agency for
EXHAUST HOOD (WITH DUCT) 5.00
the performance of the work for which this permit is issued (Sce.
3097, Civ.C.).
MICROFILM
HEATING UNIT (TO 100,000 B.T.U.) 8.00
Lender's Name
Lender's Address
HEATI NG UNIT (OVER 100,000 B.T.U.)9.50
ELECTRIC
h
VENTILATION FAN (SINGLE) 4.00
I certify that I have read this application and state that the above
information is correct. I agree to comply with all city and County
ordinances end state laws relating to building construction, and
PLUMBING
BOILER-COMP(3 H.P. or 100,000 B.T.U.) 6.00
BOILER -COMP (Over 100,000 BTWSEE FEE SCM.
MECHANICAL
hereby authorize representatives of this city to enter upon the
above-mentioned property for inspection purposes.
MISC. - REFER TO ORD.
-
CONST. TAX
(We) agree to save, indemnify and keep harmless the City of
Cupertino agai t liabilities, judgments, costs and expenses which
may in any ayr ac' a ugninst said City i consequence of the
PERMIT ISSUANCE 10.00
granlingof 11 pe
H,
MECH. CONT. LIC. NO. MECH.
Of _
TOTAL
TOTAL
of pphcam/ omructor Due
/ INSPECTOR COPY