8642'APPLICANT TO FILL IN INFORMATION WITHIN RED LINES- USE BALL POINT PEN ONLY
. BUILDING PROJECT IDENTI
" APPLICATION & PERMIT
BUILDING -'ELECTRICAL- PLUMBING - MECHANICAL
PERMIT NUMBER,iFICATION
19642
E , ooa
ADDRESS
10201 -Torre Ave.
OWNER'S
PLAN CHECK VALIDATION
NAME
QTY. ELECTRIC PERMIT FEE
Haldane ONE
NAM>ERAcroas
UTLETS-SWITCHES-RECEP 10.00/1.00
uc. No.
'
DATE OF APPLICATION
LIGHTING FIXTURES 10.00/1.00
DITEss cos
COCONTRAC pp
IpED_
APPLIANCES - RESIDENTIAL 4.00
PANELS 10.00
Aa Cr
OR
ENGINEER y
' uc. Na.
PANELS (OVER 200 AMP) 20.00
PLAN CHECK FEE P.C. NO.
SIGNS TRANS. 3.00
AARCH. 08
DDRESS ENG.
SPECIAL CIRCUIT 5.00
PERMIT VALIDATION
rrEMP. METER OR POLE INS. 20.00
ZIP
APPLICANT 5
ADDDRESSDRESSMOTORS
SEE FEE SCH.
SERVICE CHANGE 20.00
LICENSED CONT RACFORS DECLARATION
TEMP. POLE 30.00
-I hereby aIlito, that I an, licensed mid, rprovision s of Chapter 9
(commencing Willi Section 7000) of Division 3 of the Business and
Professions Code, and my license is in full force and effect
License Class x- - I& Lie. Number 2�sZw�n-
ISSUANCE DATE
BLDG. ELECT.
❑
PLG. '• MECH.
❑
Date Court.".,
BUILDING PERMIT
INFORMATION
OWNER -BUILDER DECLARATION
I hereby affirm that 1 am exempt from the Contractors License
Law for the following reason. (Sec. 7031.5. Business and Professions
Code: Any city orcounty which requires a permit to construct, alter,
improve, demolish, or repair any structure, prior to its issuance, also
requires the applicant for such permit to file it signed stalcmcnt that
he is licensed pursuant to the provisions of the Contractor's License
M ISC.- REFER TO ORD
VALUATION
S/FT.
PERMIT ISSUANCE 10.00
ELEC. CONTR. LIC. NO.
ELEC.
TOTAL
PERMIT TO
'
OTY. PLUMBING PERMIT FEE
Law (Chapter 9 (commencing with Section 7000) of Division 3 of the
Business and Professions Code) or that he is exempt therefrom and
TNMERq
the basis for the alleged exemption. Any violation of Section 7031.$
STORIES TYPE CONSTR.
by any applicant for a permit subjects the applicant to a civil penalty
of noinure nure than live hundred dollars (S500)J:
ALTER -DRAIN -WATER (EA.) 5.003
Cl I, as owner of the properly, or my employees wiucth wages as
their sole compensation, will do the work, and the strture is not
BACK FLOW 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 docs not apply to an owner of
property who builds or improves thereon, and who docs such work
himself or through his own employees, provided that such improve-
ments annot intended oroffered for sale, If, however, the building
FIXTURES - PER TRAP 5.00 '
SD. IT,FLOORAREA
TOTALACREAGE
GAS - EA. SYSTEM -1 INC.4 OUTLETS 6.00
or improvement is Sold within one year of completion, the owner-
builder will have the burden of proving that he did not build or an
prove for purpose of sale.).
❑ 1, as owner of the properly, am exclusively contracting with❑
. ..
GAS - EASYSTEM -OVER 4 (EA.) 200
BUILDING USE
.RES IND CON PB Omer
❑ ❑ ❑ ❑
INDUSTRIAL WASTE INTER. 30.00
licensed contractors to construct Ore 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
LAWN SPRINKLERS - OVER 5 (EA.) 1.00
ASSESSORS PARCEL NO.
contracts I'm meb projects wilh a conluetorts) licensed puranum to
the Contractor's License Law.
SEWER -SANITARY -STORM EA, 200ft/10.00
TRACT NO.
PARCELNO.
❑ lain exempt under Sec.-, B.&P.C. for this
WATER HEATER W/VENT 6.00
reason
Owner Oaw.:
t r
WATER SYSTEM 5.00
ACG DATE
ACC. FILE NO.
WATER TREATING EQUIP. 5.00
WORKERS'CONIPENSATION DECLARATION. '
1 hereby affirm that I have a certificate otconsent W sell -insure,
or a certificate of Workers' Compensation Insurance, or a certified
ZONING
ENG. SITE NO.
copy thereof ( Sec 3800, Lab C.).
Policy No621zwy&xny
FIRE SPRINK
ENERGY T 24
Cl Certnfm opy is hereby furnished.F�yc
fE' Cer ified copy is filed With the city inspection` {{�Y
TO
Applicant
MISC.- REFER ORD.
Y❑ N❑
v❑ N❑
CERTIFICATE OF I XEMPTION' FROM WORKERS'
PERMIT ISSUANCE 10.00
FLOOD ZONE
A.L.uc.
PLG. CONTR. LIC. N0.
PLG.
COO, INSURANCE:
('Phis seclioo need nod In, completed it the permit is for one
TOTAL
Y ❑ N ❑
V E] N❑
hundred dollars ($100) or less,)
I certify that in the performance of 0m work for which this per.
DTV. MECHANICAL PERMIT FEE
FEE SUMMARY
mit is issued, I shall not employ any person in any manner so as to
become subject to the Workers' Compensation laws of California.
ALTER OR ADD TO MECH. 5.00
Dow Applicant -
BUILDING
147 ;n
NOI'IC1i 1'0 AITLICANT: If, after making this Certificate of Ex-
emption, you should become subject to the Workers'Compensation
APPLIANCE 5.00
PLAN CHECK
provisions of the Labor Code, you must forthwith comply with
FEE
21.13
AIR HANDLING UNIT (TO 10)000C.F.M.) 4.00
such Provisions or this permit shall b, deemed revoked.
AIR HANDLING UNIT(OVER 10=C.F.M.) 6.00
If
SEISMIC FEE
'
CONSTRUCTION LENDING AGENCY
1 hereby afl'irnn 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
HEATING UNIT (TO 100,000 B.T.U.) 8.00
3097, Civ.C.).
Lender's Name
HEATING UNIT (OVER 100,000 B.T.U.) 9.50
ELECTRIC
en Address
Lender's
1 certify that I have read this application and state that the above
VENTILATION FAN (SINGLE) 4.00
intonation is correct. I agree to comply with all city and county
PLUMBING
ordinances and state laws relating to building construction, and
BOILER-COMP(3 H.P. or 100,000 B.T.U.) 6.00
BOILER
hereby aulhori/e representatives of this city to enter upon the
above-mentioned property for inspection purposes.
-COMP (Over 100,000 BTU) SEE FEE SCH.
MECHANICAL
MISC. - REFER TO ORD.
(We) agree to save, indemnify and keep harmless the City of
Cupertino against liabilities, judgments, costs and expenses which
CONST. TAX
mayin ny w a roe against said City in consequence of the
PERMIT ISSUANCE 10.00
gremlin flhi ermL
MECH. CONT. LIC. NO.
MECH.
TOTALaAe
TOTAL
54.13
Sign ne of Applcanl/ onlr for
V U