8396r P R. tl
APPLICANT TO FILL IN INFORMATION WITHIN RED LINES S- USE BALL POINT PEN ONLY
..BUILDING PROJECT - IDENTI FI N
APPLICATION & P IT-
BUILDING - ELECTRICAL - PLUMBING - MECHANICAL
PERMITNUMBER
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ELECTRIC PERMIT
FEE
PLAN CHECK VALIDATION
DATE OF APPLICATION
CONTRACTOR S
L `U uc NO. Q
WITCHES - RECEP 10.00/1.00
'
GTTG
L TURES 10.00/1.00
TO s
ADDRESS
�� PRONE �7
PPLIANCES- RESIDENTIAL 4.00
PANELS 10.00
0gcnrtSCT
ENGINEER
L)C. NO.
PANELS (OVER 200 AMP) 20.60
PLAN CHECK FEE P. C. NO.
'
SIGNS TRANS. 3.00
ADORES$ ENG.
t zap
SPECIAL CIRCUIT 5.06
PERMIT VALIDATION
(}
J
6
-
ISSUANCE DATE
BLDG. ELECT. PLG. MECH.
❑ ❑ ❑
TEMP. METER OR POLE INS. 20.00
APPLICANT'S
ADDRESS
-
MOTORS SEE FEE SCH.
SERVICE CHANGE 20.00
LICENSED CONTRACTORS DECLARATION
. 1 hereby affirm that I am licensed under provisions of Chapter 9
Icommencing with Section 7000) of Division 3 of the Business and
Professions Code d y 'tense isN full forey'�' 1 •ff
License Class Lie Number y
Date Contractor
TEMP. POLE 30,00
- '
-
OWNFR- BUILDER DLCLARATI
P
1 hereby oolr wing 1 am exempt from the Coss andP oLicense
Law for ycitylorcounty whihrequireSo po USittocodProfessions
Code: e, demolish, [y county n pair any structur e p riort to consianc alter,
improve,happicant for siranystructure,
,fileaorm itsiatemen, also
ter wires the applicant for such revisit to,fi e a signet) statement Li use
he is licensed 9 (Commencing m to the provisions o 700 ) of Division License
Business (Chapter and Prof ..ions de) with Suction is exempt theref o oUbe
Business and essions Code) or that he is exempt therefrom and
the basis for the alleged exemption. Any violation of Section 7031.5
by any applicant fora permit subjects the applicant loacivil pinalty
of Rol more than five hundred dollars ($500).): -
❑ 1, as owner of 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 owner of
property who builds Or improves thereon, and who does such work
himself or through his own employees, provided that such improve-
` .cuts 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 on-
prove for purpose of xaleJ. -
❑ 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 Law does not apply
to an owner of property who builds or improves thereon,: and who
contracts for such projects with a contractors) licensed pursuant to
the Contractor's License Law,
❑ I am ex em pt under Sec. , BAP.C. I'nr this
reason
BUILDING,PERMIT„ ,
INFORMATION
MISC. _ REFER TO ORD
PERMIT ISSUANCE
VALUATION
$ /FT.
ELEC. CONTR. LIC. NO.
-
C.
ELEC.
TOTAL.
PERMITTO
„S� i
r O'er
O
PLUMBING PERMIT
'FEE
STORIES
TYPE CONSTR.
ALTER - DRAIN - WATER(EA.) 5.00
.
BACK FLOW PROTECT. DEVICE 4.00
OCC. GROUP
RES. UNITS
DRAINS- FLOOR, ROOF; AR EA,COND. 5.00
FIXTURES - PER TRAP 5.66
GAS- EA.SYSTEM -A INC.4OUTLETS 6,00
6
dl
SO. FT. FLOOR AREA
TOTAL ACREAGE
GAS - EA. SYSTEM -OVER 4 (EA.) 2.00
BUILDING USE
RES IND- CON PS Other
❑ ❑ ❑ ' ❑ ❑
INDUSTRIAL WASTE INTER 30.00
.
LAWN SPRINKLERS - 1 INC 5 V.B. 6.00
LAWN SPRINKLERS - OVER 5 (EA.) , 1.00
g55es5oRS PARCEL ND.
_
•�
S EWER -SAN ITARV -STORM EA. 200ft /10.00
`
TRACT NO.'
PARCEL NO,
WATER HEATERW /VENT 6.00
Owner Darn
-
WORK ERS'COMPENSA'I ION 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, Lab. C.) {{--
Policy No. Company hKu (/ILOilnra.a
WATER SYSTEM 5.00
ACC. DATE
ACC. FILE NO. -
i
WATER TR ATING,EQUIP.1riJ 5.00
ZONING
P '
ENG. SITE NO.
❑ Certified copy is hereby furnished.
r ❑. Certified cop is Ne with thy city inspection division.
Applicant
MISC. - REFER TO ORD.
-FIRE SPRINK
Y ❑ N❑
ENERGY T -24
Y ❑ N❑
CIi RTI FICA'1'1 :OF 1: X 17 M PITON 1 WORKERS'
_ COMPENSAI' ION INSURANCE
(This section need not be completed if the permit is for one
hundred dDllatr 1$100) or less.)
,nI certify that in the performance of the work for which this per-
it is issued, I shall not employ any person in any manner so as to'
becmne subject in the Workers' Compensation Laws of California.
Date Applicant
NO "I'ICE '1'O APPLICANT': 11, after making this Certificate of Ex-
emption, you should become subject to the Workers Compensation
provisions of the Labor Code, you most 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 For
the performance of the work for which this permit is issued (Sec.
3097, Civ.C.).
PERMIT ISSUANCE . 19160
' ""
FLOOD ZONE
Y ❑ N❑
A.LU.C.
N
'Y ❑ ❑
PLG.CONTR. LOC. NO.
TOTAL O d-
OTV.
'. MECHANICAL PERMIT
FEE
FEE SUMMARY '
BUILDING
ALTER OR ADD TO MECH. 5,00
APPLIANCE 5.00
PLAN CHECK
FEE
AIR HANDLING UNIT (TO 10=12-F.M.) 4.00
AIR HANDLING UNIT(OVER 10MC.EM.) 6.00
SEISMIC FEE
EXHAUST HOOD (WITH DUCT) - 5.00
-
MICROFILM
'
HEATING UNIT (TO 100,000 B.T.U.) 8.00
Lender's Name
Lender's Address
I certify that I have read this application and store that the above
,,in tinformation is correct. I agree to comply with all city and county,
o and stale laws relating to building construction, and
aendby authorize
hereby authorize representatives ec this. city es enter upon th°
property forinsp of this
purposes.
(We) agree to save, indemnify and keep harmless the City of
Cupertino against liabilities, judgments, costs and expenses which
may in any way acct a against said City in consequence of the
granting of this permit
_
HEATING UNIT (OVER 100,000 B.T.U.)9.50
ELECTRIC
VENTILATION FAN (SINGLE) 4.00
PLUMBING
�rs7i
BOILER- COMP(3 H.P. or 100,000 B.T.U.) 6.00
BOILER -COMP (Over 100,000 BTU) SEE FEE SCH.
MECHANICAL
MISC.- REFER TO ORD.
PERMIT ISSUANCE 10.00
CONST. TAX.
MECH. CONT, LIC, N0.
MECH..
TOTAL
'
TOTAL
[ureof APPlicant/Conlacror )ate
OFFICE COPY