8150APPLICANT TO FILL.IN INFORMATIONMITHIN RED LINES - USE BALL POINT PEN ONLY
BUILDING PROJECT I DENTI FI N .
APPLICATION & POIT
BUILDING — ELECTRICAL— PLUMBING — MECHANICAL
PERMIT NUMBER
8150
.BUILDING
ADDRESS
O S
NAME ..
"
QTY.
ELECTRIC PERMIT
FEE
PLAN CHECK VALIDATION
DATE OF APPLICATION
/ NAIVE TO
G.
OUTLETS - SWITCHES - RECEP 10.00/1.00
LIGHTING FIXTURES 10.00/1.00
ADDRESS Tarsi -
NE
PPLIANCES - RESIDENTIAL 4.00
PANELS 10.00
nRCRI i -
OR
ENGINEER
LIC. NO.
PANELS (OVER 200 AMP) 20.00
PLAN CHECK FEE P.C. NO.
SIGNS TRANS. 3.00
ARC.. ESS Exc.
' ZIP
SPECIAL CIRCUIT 5.00
PERMIT VALIDATION
ISSUANCE DATE
ITEMP. METER OR POLE INS. 20.00
APPLICANT'S
ADDRESS -
MOTORS SEE FEE SCH.
SERVICE CHANGE 20.00
LICENSED CONTRACTORS DECLARATION •
I hereby affirm that 1 am licensed under provisions of Chapter 9
(commencing with Section 7000) of Division 3 of the Business and
Professions Cody, Amy license is in full forepp,,��mJ efJ }c(.
License Class LIc.Numbc,�x
Date Comtustor'QLS�q_�_
OWNER - BUILDER DECLARATION
1 hereby affirm that I am exempt from Ibc Contractor's License
Law forthe following reason. (Sec. 7031.5, Business and Professions
Code'. Any'city or county which requires permit to construct, alter,
improve, demolish, or repair any structure, prior to its issuance, also
requires the applicant for such permit to file a signed statement that
Ile is licensed pursuant to the provisions of the Contractors License with Section 7000) of Division 3 ofthe
Buslness.and Professions Code) or that he is exempt therefrom. and
the basis for the alleged exemption. Any violation of Seclion;/031.$
bfanyonictha fora permit subjects the applicant toacivil penalty
fact mare than five the prop dollars 1my emp
❑ 11, as owner of the property, or my employees wilt wages as
their sole compensation, will Jo the work, and the structure is not
intended or offered for all (Sea 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 does such work
I himself or through his own employees, provided that such improve.
ments 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 for purpose of sale.).
❑ 1, as owner of the property, am exclusively contracting with
licensed contractors to construct the project (Sec. 7044, Rosiness.
and Professions Code: The Contractor's License Law does not apply to an owner of property who builds or improves thereon. and who
contracts for such projects will, a contract urls) licensed pursuant In
the Contractors License Law.
❑ 1 tin, exempt under Sec. , B. &P.C. for this
reason -
TEMP. POLE 30.00
-
'
BLDG. ELECT.
El 1:1
PLG. MECH.
El
v
BUILDING PERMIT
INFORMATION
MISC. — REFER TO ORD
PERMIT ISSUANCE 10.00
VALUATION.
`
_$/FT..
ELEC. CONTR. LIC. NO.,
ELEC.
TOTAL
PERMIT TO
5 -r GAVE'
QTY.
PLUMBING PERMIT
-
ALTER - DRAIN - WATER(EA.) 5.00
FEE
STORIES
TYPE CONSTR.
BACK FLOW PROTECT. DEVICE 4.00
�- OCC. GROUP
RES. urlrts
DRAINS - FLOOR, ROOF, AREA, CON D. `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 Ome,
INDUSTRIAL WASTE INTER. 30.00
-
LAWN SPRINKLERS- 1 �. 6,00
ASSESSORS PARCEL NO.
LAWN SPRINKLERS -OVER 5 (EA.) 1.00
SEWER - SANITARY - T
A,2 /10.00
.TRACT NO
r
PARCEL NO.
WATER HEATER'W
6.00
Owner Date
• WORKERS'COMPENSATION DECLARATION
I hereby affirm that I have a certificate ofconsent to self: insure.
or a certificate of Workers' Compensation Insurance, or a certified
copy thereof (Sec. 3800, Lab.0 .
Policy No. Company
WATER SYSTEM pB ,00
CUP
ACC. DATE
ACC, FILE NO.
WATER TREATING ERUIP. 5.00
-
ZONING
ENG. SITE NO.
a ',S TDaM /^V�
G
❑ Certified copy is hereby furnished.
Corti Gci copy -•is fileA irh the s 1 inspection division.
Applicant
MISC. - REFER TO ORD.
FIRE SPRINK
v N0
ENERGY T -24
v ❑ rv�
CERT IFICATE OF'EXEMPTI PROM WORKERS'_
COMPIiNSA1'ION INSURANCE
(This section need nut he completed if the permit is lisr one
hundred dollars IS 100) or less.)
I certify that in the performance of the work for which this per-
mil is issued. I shall not employ any person in any manner so as in
become subject to the Workers' Compensation Laws of California.
Date - Applicant
NOTICE TO APPLICANT: If, after making this Certificate of Fx-
elnption, you should become subject to the Workers' Compensa0on
provisions of the Labor Code, you must forthwith comply with
such provisions or this permit shall be deemed revoked.
CONSTRUCTION LENDING AGENCY
I hereby affirm that there is a construction lending agency I'..
the performance of the work for which this permit is issued (Sec
3097, Cie.CJ.
Lender's Name
Lender's Address
I certify that I have read this application and state that the above
information is correct I agree to Comply with all city and county
ordinances and state laws relating to building construction, and
hereby authorize representatives ec this City to enter upon the
all hereby undo ril property for inspection proposes.
(We) agree to save, indemnify and keep harmless the City of
Cupertino against liabilities, judgments, costs and expenses which
may in any way accrue a ainat said City in consequence of the
gr ti IS n( t is per iL
.-
PERMIT ISSUANCE 101001
FLOOD ZONE'
Y N
A. L.0 C.
Y C3 No
PLG. CONTR. LIC. NO.
PLG.f
TOTAL pZOL
QTY.
MECHANICAL PERMIT
'FEE
FEE SUMMARY
BUILDING
ALTER OR ADD TO MECH. .- 5.00
APPLIANCE 600
.
PLAN CHECK'
FEE '
AIR HANDLING UNIT (TO 10=CF.M.) 4.00
AIR HANDLING UNIT(OVER 10=C.RM.) 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.19.50
ELECTRIC r
VENTILATION FAN (SINGLE) ' 4.00
BOILER- COMP(3 H.P. or 100,000 B.T.U.1 6.00
PLUMBING
BOILER -COMP Ova, 100,000 BTU) SEE FEESCH.
MECHANICAL
W
MISC. - REFER TO ORD.
CONST. TAX
PERMIT ISSUANCE - 10.00
MECH. CONT. LIC. NO.
'.
MECH.
TOTAL
TOTAL
N101.1070 of Applicant mr Date
OFFICE COPY