8520APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
BU LDI NG PROJECT I DENTI FICATI ON
APPLICATION & PERMIT
BUILDING - ELECTRICAL- PLUMBING - MECHANICAL
PERMIT NUMBER
�. ADDRESS
0
AME ,
ONE
OTY. ELECTRIC PERMIT FEE
PLAN CHECK VALIDATION
DATE OF APPLICATION
Name acro s
LIC. No.
UTLETS-SWITCHES -RECEP 10.00/1.00
LIGHTING FIXTURES 10.00/1.00
ADDRESS rov's
PHONE
PPLIANCES- RESIDENTIAL 4.00
PANELS 10,00
OR
ENGINEER
LIC. NO.
PANELS
PANELS (OVER 200 AMP) 20,00
PLAN CHECK FEE P.C. NO.
/ SIGNS TRANS. 3.00 +ti
ARCH.OR ENG.
ADDRESS
ZIP
SPECIAL CIRCUIT 5.00
PERMIT VALIDATION
JU/p s
ISSUANCE DATE
EMP. METER OR POLE INS. 2000.
APPLICANT'S
AOOREss
MOTORS SEE FEE SCH.
SERVICE CHANGE 20.00
LICENSED CON'T'RACTORS DECLARATION
I hereby affirm that I am licensed under provisions of Clhapter9
(commencing with Section 7000) of Division 3 of the Business and
Prnfessions Code, and my license is in full force and effect.
.License Class Lic.Number
Date Contractor
TEMP. POLE 30.00
SLOG.
ELECT.
PLG. MECH.
OWNER -BUILDER DECLARATION
I hereby affirm that I am exempt from the Contractor's License
Law for the lollowing reason. (Sec. 7031.5, Busincssare I'rnfex1mrs
Cprove.y<ityor coo npair any structure perminoconslR¢Laatq
improve, demolish, or repair any structure, prior n its issuance, also
requires the applicant for such permit to ole o signed stuteme i that
License
he is licensed pursuant to the provisions of the ) of Division the
Law (Chapter and professions
Business and Professions Code) or that he is exempt therefrom and
Codeng with Section 7s excui t theron 3 and
the basany
tile alleged a ermit subjects
1plin tSection malty
applicant is the applicant
by lotetha furspermitsubjectsthc04.)macivil penalty
ul' not more than five hundred dollars ($5004.):
❑ I, az owner at the property, or my employees with wages as
their sole compensation, will do the work, and the structure is not
intended or offered for sale (Sec. 7044, Business and Professions
Code: The Contractor's License Law does not apply to an reviler of
properly who builds or Improves thereat, and who does such work
himself or through his own employees, provided that such impmoc-
mtnts are not intended or offered 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 1, a, own,,ose of (lie .
pp d as owner of the property; um exclusively contracting with
lnd Pro contractors In construct the project (Sec 7044, Business
and Profusions Code: The Contractor's License Law does nut apply
to tr owner of property who builds tr improves thereon. and who
let such projects with a anHructor(9 licensed pursuant m
the Contractor's
the Contractor's Licenu Law.
❑ 1 am exempt under Sec. , B.&P.C. for this
rcazon
BUILDING PERMIT
INFORMATION
MISC.- REFER TO ORD
PERMIT ISSUANCE 111,Q0 / C/1.
VALUATION
S
O U
ELEC. CONTR. LIC. NO.
ELEC.
TOTAL 9
PERMIT TO
DTV. PLUMBING PERMIT FEE
ALTER -DRAIN -WATER IEA.) 5.00'
STORIES
TYPE CONSTR.
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 -1 INC.4 OUTLETS 6.00
GAS - EA. SYSTEM -OVER 4 (EA.) 2.00
SO, FT. FLOOR AREA
TOTAL ACREAGE
BUILDING USE
RES IND CON PB other
13 ❑ El D ❑
INDUSTRIAL WASTE INTER. 30.00
LAWN SPRINKLERS- 1 INC 5 V.B. 6.00
ASSESSORS PARCEL NO.
,
_
LAWN SPRINKLERS -OVER 5 (EA.) 1.00
SEWER -SANITARY -STORM EA, 200ft/10.00
TRACT NO.
PARCEL NO.
WATER HEATER W/VENT 6.00
t�K01r bale
s'cOhu1NsnT10N DECLARATION
1 hereby affirm that I have a certificate of consent to self -insure.
or a certificate of Workers' Compensation Insurance, or a certified
copy thereof (Sec. 3800, Lall,C).
Policy No. Company
WATER SYSTEM 5'00
ACC.DATE
ACC. FILE N0;
WATER TREATING EQUIP. 5.00
20NING
-
ENG. SITE NO.
MISC. - REFER TO ORD.
❑ Certified copy' is hereby fumislued.
Certified copy is fled with the city inspection division.
Applicant
fIRE SPRINK
Y E] N�
ENERGY T-24❑
Y 0 NE]
CERTIFICATE OP EXEMPTION FROM WORKERS
COMPENSATION' INSURANCE
This section need not be completed if the permit is for one
hundred dollars ($ 100) or less)
I ccrtity that in the perromonce of the work for which this per-
mit is issued, 1 shall not employ any person in any manner so to
becomesubject
ct to the Workers' Compensation Laws of California.s
Dam Applicant
NOTICE TO shout burn If, after making this Certificate of ion
provision you should Code,me oct to the forthwith comply with
provisions io the Labor Code, you must forthwith comply wish
such provisions or this permit shall be deemed revoked.
CONSTRUCT ION LENDING AGIiNCY
I hereby affimh that them is a construction lending agency for
the performance of the work for which this permit is issued (Sec.
3097, Civ.C.T
Lender's Name
Lender's Address
I certify that I have read this application and state that tire above
information is correct. 1 agree to comply with all city and County
ordinances and state laws relating to building construction, and
hereby authorize representatives of this city t0 enter upon the
abuvc-mentioned property for inspection purposes.
(We) agree to save, indemnify and keep harmless the City of
Cupertino a�$Juruue 4 b+4{ Les, judgments. costs and expenses which
may in anyway accrue'J�ams, said City' in conseghlll}}}nc of the
gran ing of th • -rmit. f• O[
r
PERMIT ISSUANCE 10.00
FLOOD ZONE
v ❑ NE]
A.L.U.C.
v ❑ N
PLG. CONTR. LIC. NO.
PLG.
TOTAL y
DTV. MECHANICAL PERMIT FEE
FEE SUMMARY
BUILDING
/i� f Z/
T'
ALTER OR ADD TO MECH. 5.00
APPLIANCE 5.00
AIR HANDLING UNIT (TO 10,000GF.M.) 4.00
PLAN CHECK
FEE
( 1
oZ O
AIR HANDLING UNIT (OVER 10)DWC.F.M.) 6.00
SEISMIC FEE
EXHAUST HOOD (WITH DUCT) 5.00
MICROFILM
HEATING UNIT (TO 100,000 B.T.U.1 8.00
HEATING UN IT (OVER 100,000 B.T.U.) 9.50
ELECTRIC
C%V
VENTILATION FAN (SINGLE) 4.00
BOILER-COMP(3H.P.Or1OO,000B.T.U.1 6.00
PLUMBING
BOILER -COMP (Ovo, 100,000 BTU) SEE FEE SCH.
MECHANICAL
MISC. - REFER TO ORD.
PERMIT ISSUANCE 10.00
CONST. TAX
MECH. CONT. LIC. NO.
MECN.
TOTAL
TOTAL
Signature of pplicant b Date
INSPECTUH COPY