10256APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
i3U1 LDI NG PROT I DENTI FICA
APPLICATION & PART10256
BUILDING — ELECTRICAL— PLUMBING — MECHANICAL
PERMIT NUMBER
aDIL
OWN
NAM
PNONE
OTY. ELECTRIC PERMIT FEE
PLAN CHECK VALIDATION
-
DATE OF APPLICATION
NT
rc+ACO's .y syn
No.
UTLETS-SWITCHES-RECEP 10.00/1.00
LIGHTING FIXTURES 10.00/1.00
1,0 TR
ADOR
On
PPLIANCES- RESIDENTIAL 4.00
PANELS 10.00
OR RITECT
ENGINEER
LIC. NO.
PANELS (OVER 200 AMP) 20.00
PLAN CHECK FEE .C. NO.
ISIGNS TRANS. 3.00
AACHOR
ADDRESS ENG.
ZIP
SPECIAL CIRCUIT 5.00
PERMyjyr�+ON
iiillJ
il/l AI A �(�pC
JRIV '3 986
City of Cupertino
ISSUANCE DATE
BLDG. ELECT. PLG. MECH
❑ ❑ ❑
EMP. METER OR POLE INS. 20.00
A unrs
MOTORS SEE FEE SCH.
SERVICE CHANGE 20,00
LICENSED CONTRACTORS DECLARATION
I hereby affirm that I ore licensed under provisions of Chapter 9
(commencing with Section 7000) of Division 3 of the Busin and
Professions Code Iiccnsa ,s in lull fore"
License Class_ Lie Number
Dale Contractor
OWN- -B.exe pt fro theC N
I hereby affirm that I am exempt from the Contractor s License
Law for the following mason.(Sec. 7031,5. Businnsand Professions
Code: Any city or county which requires a Permit to construct, alter,
improve, demolish, or repair any structure, prior to its i tuunce, also
requires the applicant for such permit to the a signed statement that
he is licensed pursuant to the provisions of the Contractor's License
Law (Chapter 9 (commencing with Sect ion 7000) of Division 3 of the
Business and Professions Code) or that he is exempt therefrom and
the basis for the alleged exemption. Any violation of Sect ion 7031.5
by any appbcanl for a permit subjects theapplicant toa civil Penally
of not mom than five hundred dollars (55(0).):
❑ 1, as owner of the property, or my emptoyms with wages as
their sole compensation, will Jo the work, and the structure is not
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 does such work
himself or through his own employees, provided that such improve-
ments are not intended oroffered for sale.. If, however, the building
or improvement is sold within one year of completion, the owner-
builder will have the burden of proving that he did not build or im-
prove for purpose of sale J'
❑ I, as owner of the property, am exclusively contracting with
licensed contractors to construct the project (Sec. 7044, Business
and Professions Code: The Contractor's License Lew does not apply
to an owner of property who builds Or improves thereon, and who
contracts for such projects with a cofn uctods) licensed pursuant to
the Contractors License Law,
❑ I am exempt under See. ,B.&P.C. for this
reason
TEMP. POLE 30.00
BUILDING PERMIT
INFORMATION
MISC. — REFER TO ORD
PERMIT ISSUANCEVALUATION
10'00
$/FT.
ELEC. CONTR. LIC. NO.
ELEC
TOTA.L
PE IT TO
OTY. PLUMBING PERMIT FEE
STORIES
TYPE CONSTR,
ALTER -DRAIN & VENT -WATER (EA.) 5.00
BACK FLOW PROTECT. DEVICE 4.00
OCC. GROUP
RES. UNITS
DRAINS -FLOOR, ROOF, AREA COND. 5.00
FIXTURES - PER TRAP 5.00
GAS-EA.SYSTEM-11NC.4OUTLETS 6.00
SO. FT. FLOOR AREA
TOTAL ACREAGE
GAS - EA. SYSTEM -OVER 4 IEA.) 2.00
BUILDING USE
RIND CON PB Omer
Es 11 ❑ ❑ ❑
INDUSTRIAL WASTE INTER'. 30,00
LAWN SPRINKLERS - 1 INC 5 V.B. 6.00
LAWN SPRINKLERS - OVER 5 (EA.) 1.00
ASs SSORg PARCEL NO.
SEWER -SANITARY -STORM EA. 200ft/10.00
TRACT NO,
PARCEL NO.
WATER HEATER WNENT 6.00.
Owner Date
WORKS RS'COMPENSATION DECLARATION
1 hereby affirm that I have a certificate of consent to self -insure,
or a certificate Df Workers' Com Pensation umnce, or geertifed
COPY thcr 0� C.1. (/.��
Policy /�ry
VA -t. coPY IS hereby furnished
Certifrcd <o file h t of inspection division.
AP sent
WATER SYSTEM 5.00
ACC. DATE
ACC. FILE NO.
WATER TREATING EQUIP. 5.00
ZONING
ENG. SITE NO.
FIRE SPRINK
V N
�
ENERGY T -Z4
V NE]
�
MISC.- REFER TO ORD.
CERT ICA F.OF Ex1 AFT' FROM WORKERS'
COMPENSATION INSURANCE
(This section need not he completed if the permit is for one
hundred dollars ($ 100) or Icss. )
1 certify that in the performance of the work for which this per-
mit is issued, 1 shall not employ any person in any manner an as or,
become subject to the Worked Compensation Laws of California.
Dale Applicant
PERMIT ISSUANCE 10.00
FLOOD ZONE
Y [] N�
I A.L.U.c.
V NE]
PLO CENTS, LIC. NO.
PLG.
TOTAL
QTY MECHANICAL PERMIT FEE
FEE SUMMARY
BUILDING
ALTER OR ADD TO MECH. 5.00
NO'r1Cli TO APPLICANT: If, after making this Certificate of Ex-
emption, you should become subject to the Workeri Compensation
provisions of the Labor Code, you must forthwith comply with
such provisions or this Permit shall he deemed revoked.
CONSTRUCTION LENDING AGENCY
I hereby affirm that there is a construction lending agency for
the paformenro of the work for which this purrnit is issued (Sec.OFILM
3097, Civ.C.).
Lender's
APPLIANCE 5.00
AIR HANDLING UNIT (TO 10)000C.F.M) 4.00
PLAN CHECK
FEE
AIR HANDLING UNIT(OVER 10)=C.F.M.)6.00
SEISMIC FEE
EXHAUST HOOD (WITH DUCT) 5.90
HEATING UNIT (TO 100,000 B.T.U.) 8.00
Name
Lender's Address
HEATING UN IT (OVER 100,000 B.T.U.)9.50
ELECTRIC
I certify that l have read this application and state that the ahoy
information is correct. I agree to comply with sell city and count
ordinances and state laws relating to building construction, and
hereby authorize representatives of this city to enter upon the
above-mentioned property for ins ec I purpuus.
(We) agree to inde Ify nil keep hamrlL-ss the City of
Cupertino again a ilic , jud its, costs and expenses which
may ve true again said City in consequence of the
Pg [h x,
[vIe AppIrs" n {Coractor am
VENTILATION FAN (SINGLE) 4,00
BOILER -COMP 13 H.P. Or 100,000 B.T.U.) 6.00
PLUMBING
BOILER -COMP (Oxer 100,000 BTU) SEE FEE SCH.
MECHANICAL
MISC. - REFER TO ORD.
CONST. TAX
ERMIT I LANCE 10.091
ME ENT. LI . N0.
MECH.
TOT
TOTAL
OFFICE COPY