8413w:APPLICANT TO FILL IN INFORMATION WITHIN
REDLINES - USE BALL POINT PEN ONLY
" BUILDING PROJECT IDENTIFICATION
APPLICATION & PERMIT
BUILDING -ELECTRICAL- PLUMBING - MECHANICAL
PERMIT NUMBER
g 413
pDHEss
.BUILDING 4uw_
�..
NER'S
NAME Fj LG
P.Y ELECTRIC PERMIT FEE
PLAN CHECK VALIDATION
ONE
NAMER
UTLETS-SWITCHES-RECEP 10.00/1.00
LIGHTING FIXTURES10.00/1.00
uc. No.
HAS os 4/S
ADDRESS
APPLIANCES -RESIDENTIAL 4.00
PANELS '- 10.00
ONE
DATE OF APPLICATION
OOPCHIi EC
PANELS (OVER 200 AMP) 20.00
PLAN CHECK FEE P.C. N0.
ENGINEER
I.C. No.
SIGNS TRANS. 3.00
ARCH
Ess era
SPECIAL CIRCUIT 5.00
PERMIT VALIDATION
TEMP. METER OR POLE INS. 20.00
IP 9VAI 4
APPucANis
ADDRESS
MOTORS SEE FEE SCH.
SERVICE CHANGE 20.00
41 DA 14
'`//
-14a
LICENSED CONTRACTORS DECLARATION
TEMP. POLE 30.00
I hereby affirm that I an, licensed under provisions of Chapter 9
(commencing with Section 7000) of Division 3 of the Business anti
Profen, ons Code, and my license is in full force and effect.
License Class L1c.Nurnber /-;+rEl
Date Contractor �w�'�'�
ISSUANCE DATE
BLDG,
ELECT.
PLG. MECH.
11
❑
BUILDING PERMIT
INFORMATION
OWNER -BUILDER DECLARATION
1 hereby affirm that I wn exempt &con the Contractors License
Law forAny tile c. requi3ss perminess andt town Professions
Code: Any city or wumy which requires a permit m construct, alter,
improve, demolish, or repair any structure, prior to its issuance, also
requires the applicant for such permit to filo a signed statement that
he is licensed pursuant to tine provisions of the Contractor's License
MISC. - REFER TO ORD
PERMIT ISSUANCE 10.00
VALUATION _
'
$/FT.
ELEC. CONTE. LIC. NO. ELEC,
TOTAL
,
PERMIT TO
Law (Chapter 9 (commencing with Section 70001 of Division 3 of the
Business olid Professions Code) or that he is exempt therefrom and
QTY. PLUMBING PERMIT FEE
STORIES
Tv TR
the basis for the alleged exemption. Any violotion ofSection 7031.5
by any applicant fora permit subjects the applicant to a civil penalty
of not there than five hundred dollms ($500).):
ALTER -DRAIN -WATER (EA:) 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
DGG. GROUP
RES. UNITS
DRAINS -FLOOR, ROOF, AREA, CONDE 5.00
intended or offered Tor sale (Sec. 7044, Business and Professions
Code: 'fhe Contractor's License Law does not apply to an owner of
property who builds or improves (hereon, and who does Such work
hiorsclf or through his own employees, provided that such improve
ments are not intended or offered for sale, If. however, the building
FIXTURES - PER TRAP •Y 5.00
SO. FT. FLOOR AREA
TOTAL ACREAGE
.GAS-EA.SYSTEM-1 6.00
or improvement is sold within one year of completion, tine owner-
builder will have the burden of proving that he did not huild or im-
prove for purpose of sale.).INDUSTRIAL
❑ I, as owner of the property, am exclusively contracting will(
GAS - EA. SYSTEM - OVER 4''(EA.) 2.00
BUILDING USE
RES IND PB Omer
❑ ❑ ❑ ❑
WASTE INTER. 30.00
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
LAWN SPRINKLERS - 1 INC 5 V.B. 6.00
ASSESSOR A CEL NO.
'
LAWN SPRINKLERS;'OVER 5 (EA.) �, 1.00
contracts for such projects with a contractor(s) licensed pursuant to
the Contractor's License Law.
❑ I am exempt Linder See - ,B.&P:C. for this
re ... 11
SEWER -SANITARY -STORM EA. 200ft/10.00
TRACT NO.
PARCEL NO.
WATER HEATER W/VENT 6`.00
Owner _ Date
WATER SYSTEM 5.00
ACC. DATE
ACC. FILE NO.
WATER TREATING EQUIP. 5.00
WORKERS'COMPENSATION DECLARATION
1 herehy affirm that I have a certificate of emexent to sell -insure, or
or a certificate of Workers' Compensation Insurance, or a certified
WC
ENG. SITE si
copy thereof 1 Sec. 3800, Lab.CJ.
Policy No. Company
FIRE SPRINK
v❑ NE]
ENERGY T 24
Y❑ N[]CERTIFICATE
❑ Certified copy is hereby furnished.
❑ Certified copy is fled with the city inspection.divisio'
Applicant -'•
- .
MISC.REFER TO ORD
OF EXEMPTION FROM WORKERS'
PERMIT ISSUANCE 10.00
FLOOD ZONE
A.L.U.C.
COMPENSATION INSURANCE
(This section need not be completed if the permit is for one
Y ❑ N ❑
y ❑ IN
PLG. CONTR. LIC, NO.
PLG.
TOTAL
hundred dollars ($100) or less.)
I certify that in the performance of the work for which this per-
mit is issued, 1 shall not employ any person in any Inspect so as 10
QTY. MECHANICAL PERMIT FEE
FEE SUMMARY
BUILDING
become subject to the Workers'Compensation taws of California
Date ApplicantALTER
X5.00
OR ADD TO MECH.
NOTICETO APPLICANT: If, aftermakingnhis Ccrtificatc of Ex-
emption, you should become subject to the Workers' Compensation
provisions of the Labor Code, you must forlhwhh�coinply with
such provisions or this permit shall be deemed revoked.
APPLIANCE 5.00
PLAN CHECK
FEE
AIR HANDLING UNIT (TO 10=CF.M.) 4.00
AIR HANDLING UNIT (OVER 10PMC.EM.) 6.00
SEISMIC FEE
CONSTRUCTION L17NDING AGENCY
I hereby affirm that there is a construction lending agency for
EXHAUST HOOD (WITH DUCT) 5.00
tile performance of the work for which this permit is issued (Sec.
3097,Civ.C.),
MICROFILM
HEATING UNIT (TO 100,000 B.T.U.) 8.00
me
Lender's Aide
Lender's Address
H EATING UNIT (OV ER 100,000 B.T.U.)9.50
ELECTRIC
I certify that I have read this application and state tlwt the above
VENTILATION FAN (SINGLE) 4.00
information is correct. 1 agree to comply with all city and county
ordinances and state laws relating to building conanuchon, and
PLUMBING
BOILER-COMP(3 H.P. or 100,000 B.T.U.) 6.00
BOILER -COMP (Over 1000o0BTU1 SEE FEESCH,
MECHANICAL
hereby authorize representatives of this city to enter upon the
above-mentioned property for inspection purpose
MISC. - REFER TO ORD. `
CONST. TAX
(We) agree to save, indemnify and keep har.mless the City of
Cupertino against liabilities, judgments, cost, and expenses which
may in ny way accrue against said City in consequence of the
PERMIT ISSUANCE 10.00
gr: rtln of this nniL r r
MECH. CONT. LIG NO.
MECH.
TOTAL
TOTAL
igna aM APpircrrhRC6n1rBuih5r D
INSPECTOR -COPY