10255APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
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{BUILDING PRONWTIDENTI FICAAs
APPLICATION &PER
BUIL ING-ELECTRICAL-PLUMBING-MECHANICALPLAN
PERMIT NUMBER
10255
CHECK VALIDATION
QTY. ELECTRIC PERMIT FEEPNONE
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UTLETS-SWITCHES-RECEP 10.00/1.00
LIGHTING FIXTURES 10.00/1.00
PPLIANCES-RESIDENTIAL 4.00
PANELS 10.00
vgOry
DATE OF APPLICATION
'ARCHITECT
ENGINEER
LIC. NO,
PANELS (OVER 200 AMP) 20.00
PLAN CHECK FEE P.C. NO.
SIGNS TRANS. 3.00
ADDRESS erva
SPECIALCIRCUIT 5,00
PERMIT AVALIDATION
RM0
EMP. METER OR POLE INS. 20.00
ZIP
A
9$6
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BLDG. .ELECT. PLG. MECH
A Au7s
A
ftVAN4,
MOTORS SEE FEE SCH.
SERVICE CHANGE 20.00
LICENSFD CONI' RACTORS DECLARATION
I hereby affirm that 1 am licensed under provisions of Chapter t
with 1 of Division 3. the B iness a
i. is in full force
Professions CoW1X1R-1Ucle1L'DI7R
TEMP. POLE 30.00
Licens(co�s
License ClassLia Number
❑ ❑ ❑
DamContractor_
BUILDING PERMIT
INFORMATION
DECIA RATIO
I hereby affirm that I am exempt from the Conlrncmr's Licemec
Law for the following reason (Sec. 7031.5, Business and Professions
Code: Any city or county which requires a permit to construct, eller,
MISC. - REFER TO ORD
PERMIT ISSUANCE 10.00
VALUATION
S/FT,
ELEC. CONTR. LIC. NO.
%LEC.
TOTAL
improve, demolish, or repair any structure, prior to its isutance, also
requires the applicant for such permit to file a signed statement that
he is licensed pursuant to the provisions of the Contractor's License
PERMIT TO
Law (Chapter 9 ( commencing with Section 7000) of Division 3 of the
Business and Professions Code) Or that he is exempt therefrom and
QTY. PLUMBING PERMIT FEE
the basis for the alleged exemption. Any violation of Section 7031.5
by any applicant fora permit subjectsapplicant toacivil penalty
of not mom than five hundred dollars ($500).$500), ):
STORIES
TYPE CONSTR.
ALTER-DRAIN-WATER(EA.) 5.00
❑ I, as owner of the property, or my employees with wages as
their sole compensation, will do the work, and the structure is not
BACK F LOW PROTECT. DEVICE 4.00
OCG GROUP
RES. UNITS
intended or offered for sale (Sec. 7044, Business and Professions
Code: 'rhe Contractor's License Law docs not apply to an owner of
DRAINS -FLOOR, ROOF, AREA, COND. 5.00
FIXTURES - PER TRAP 5.00
GAS- EA. SYSTEM -1 INC.4 OUTLETS 6.00
Property who builds or improves thereon, and who does such work
himself or through his own amployces provided that such improve-
ments sere not Intended or otlercd for sale, it, however, the building
Ire, FT. FLOOR AREA
TOTAL ACREAGE
or improvement is sold within one your of completion, the Owner -
builder will have the burden of proving that he did not build or im-
(EA.)
BUILDING USE
prove for purpose of sale.).
0 I, as owner of the property, am exclusively Contracting with
orn
RES IND CON PB DEJ 0 11 ❑
INDUSTRIAL WASTE INTER. 30.00
licensed contractors to construct the project (Sec. 7144, Business
and Professions Code: The Contractor's License Law docs not apply
LAWN SPRINKLERS - 1 INC 5 V.B: 6.00
AgSES RS PARCEL NO.
to an owner of property who builds or improves flacon, and who
LAWN SPRINKLERS - OVER 5 (EA.) 1.00
contracts for such projects with a contractons) li cowd pursuant io
the Contractor's License Law.
❑ lam exempt under See,-, B.&P.C. for this
reason
SEWER -SANITARY -STORM EA. 200ft/10.00
TRACT NO.
PARCEL NO.
WATER HEATER W/VENT 6.00
Owner Date
WATER SYSTEM 5.00
ACG GATE
ACC. FILE NO.
WORKIiRS'COMPENSAT10N DECLARATION
WATER TREATING EQUIP, 5.00
1 hereby affirm that I have a certificate of consent to self -insure,
ZONING
ENG. SITE NO.
or a ceUilicule of Workers' Cumpauation urunec, sera certified
copy IheryLfj L.b.C.).
Policy N uny
❑ ertlfied ropy R eb fqr - ed.
Certif cop - fi d it(the city inspection division.
A Ivan
FIRE SPRINK
v N
ENERGY T 24
v ❑ N�
REFER TO ORD.
PERMIT ISSUANCE 10.00
CE IFICATEOh EXEMPTION FROM WORKERS'
COMPI'NSATION INSURANCE
section need not be completed if the permit is for one
FLOOD ZONE
v N
A. L.U.C.
Y NE]
PLG. CONTR. LIC. NO.
PLG.
TOTAL
hundred dollars ($100) or I..)
I certify that in the performance of the work tot which this per.
mil is issued, I that not employ any person in any manner so as to
QTY MECHANICAL PERMIT FEE
FEE SUMMARY
become subject to the W'orkeri Comperuation laws of California.
ALTER OR ADD TO MECH. 5.00
Dale Applicant
BUILDING
NOTICE TO APPLICANT: IL after making this Certificate of Ex-
APPLIANCE 5.00
AIR HANDLING UNIT (TO 10=12-F.M.) 4.00
PLAN CHECK
FEE
emption. you should become subject to the Workeri Compenmtiun
provisimis of the Labor Code, you most forthwith comply with
such provisions or this permit shall be deemed revoked.
AIR HANDLING UNIT (OVER 10=C.F.M.) 6.00_.aWSMIC
FEE
CONSTRUCTION LENDING AGENCY
1 hereby affirm that there is a constnelion lending agency for
the performance of the work for which this permit is issued (Sec.
3097, Civ.C.L
Lender's Name
EXHAUST HOOD (WITH DUCT) 5.00
HEATING UNIT (TO 100,000 B.T.U.) 8.00
CROFILM
Lender's Address
H EATING UN IT I O V ER 100,000 B.T.U.) 9.50
ELECTRIC
VENTILATION FAN(SINGLE) 4.00
I certify that l have read this application and state that the above
information is correct. I agree to comply with all city and coo
orditnuces and state laws relating to building construction, an
BOILER- COMP (3 H.P. or 100,000 B.T.U.) 6.0
PLUMBING
hereby authorize representatives of this city to enter upon the
above-mentioned property for inspection purposes.
ser ,
BOILER -COMP IO100000 BTU) BEE FEE SCH.
MECHANICAL
(We) agree to save, indemnify and keep hmnol. the City Of
Cupertino agaimt li 'es, judgments, cosh and expenses which
ma ay c against mid City in consequence of the
MISC. - REFER TO ORD.
PERMIT IS ANCE 10.00
ONST. TAX
_ nis/ /1
-V
ME CONT. LIC. NO. ECM.
�7 TOTAL --7�
OL QS
TOTAL
^ �-
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ign to of Am
pplicant/Con ctnr Uule
%OFFICE COPY
IX