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APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
BUILDING PROJECT IDENTIFICATION
APPLICATION & PERMIT
BUILDING - ELECTRICAL-PLUMBING-MECHANICAL
PERMIT NUMBER
8 9
8 5
UVJ
all'LOING
ADDRESS / �-
OWNER'S
NAME .CITY.
ELECTRIC PERMIT FEE
PLAN CHECK VALIDATION
ON
' '
CONTRACTORS
NA E '' �O
CO uc. No. 770
OUTLETS - SWITCHES -RECEP 10.00/1.00
LIGHTING FIXTURES 10.00/1.00'
CONTRACTORS �, 1./Tl-
ADDRESS YY'��'�
PPLIANCES- RESIDENTIAL 4.00
PANELS 10,00
vHONG377-a,
DATE OF APPLICATION
ARCHITECT-
OR
PANELS (OVER 200 AMP), 20.00
PLAN CHECK FEE P.C. No.
ENGINEER
LIC, No.
SIGNS TRANS. 3.00
OR ENG.
ADDRESS
' SPECIAL CIRCUIT 5.O
PERMIT VALIDATION
TEMP. METER OR POLE INS. 20.00
- ZIP
APPLICANT
ADDRESS
ss o� ./b
MOTORS SEE FEE SCH.
SERVICE CHANGE 20.00
LICENSED CONTRACTORS DECLARATION
- -
I hereby affirm that I am licensed under provisions of Chapter 9
ISSUANCE DATE
(commencing with. Section 7000) of Division 3 of the Business and
Professions Coit nit by liceme le in full rorce and IT
License Class , � S LIc. Namb
BLDG.
❑
ELECT.
PLG. MECH.
❑ ❑
Dalein=>� Contm.... 4442 41
BUILDING PERMIT
INFORMATION
.
OWNER -BUILDER DECLARATION U
I hereby alfinn that I am exempt the Contractor's License
Law for the following reason. (Sec. 7031.5, Business and Professions
Code. Any city or county whichrequiresapermit toconstrucl,alter,
improve, demolish, or repair any structure, prior to its issuance, 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
MISC.- REFERTOORD
VALUATION
$/FT.
PERMIT ISSUANCE 10.0
ELEC. CONTR. LIC. NO.
ELEC.n
TOTAL (j� 011111-
PERMIT TO
DTV. PLUMBING PERMIT FEE
Law(Chapler 9(commencing with Section 7000) of Division 3 of the
Business and Professions Code) or that he is exempt therefrom and
'
STORIES
TYPE CONSTR.
the basis for the alleged exemption. Any violation of5eclion 7031.5
by any applicant for a permit subjects the applicant to a civil penalty
of not more than five hundred dollars($500).):
ALTER -DRAIN St VENT -WATER (EA.) 5.00
❑ 1, as owner of the properly, or my employees with wages as
their sole compensation, will do the work, and the structure is nut
BACK FLOW PROTECT. DEVICE 4.00
OCC.GROUP
RES. UNITS
DRAINS -FLOOR, ROOF, AREA, COND. 5.00
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 Ihrough his own employees, provided that such improve-
.Cutsare not intended or offered for sale If, however, the building
FIXTURES - PER TRAP 5.00
SO. FT. FLOOR AREA
TOTAL ACREAGE
GAS - EA. SYSTEM -1 INC.4 OUTLETS 6.00
orimprement is Sold within one year of completion, the owner
buildov
er will have the burden of proving that hdid not build or am-
prowfor purpose of sale.).RES
❑ I, as owner of the property, am exclusively Contracting with
GAS - EA. SYSTEM -OVER 4 IEA.) 2.00e
BUILDING USE
IND CON PB Other
El E 1:1 ❑
INDUSTRIAL WASTE INTER. 30.00
INDUSTRIAL
licensed contractors to construct the project (Sec. 7044, Business
and Professions Cade: The Contractor's License Law does not apply
to an owner of property who builds or improves thereon, and who
LAWN SPRINKLERS - 1 INC 5 V.B. 6.00
ASSESSORS PARCEL NO.
,.
LAWN SPRINKLERS - OVER 5 (EA.) 1.00
contracts for such projects with a comoietor(s) licensed pursuant to
theContractor'sLicenseLaw.
-
SEWER -SANITARY -STORM EA. 200ft/10.00'
TRACT NO.
PARCEL NO.
❑ lam exempt under Sec.-, B.&P.C. for this
ason
�%�'®
gTER HEATER W/VENT 6.00
Owner Date
E T 5.00
PCL. DATE
ACC. FILE NO.
-
WORK ERS'COMPFNSA'I'ION DECLARATIONR
EA, 5.00
CT 27
I hereby affirm that 1 have a certificate of consent to self -insure,
or a certificate of Workers' Compensation Insurance, or a certified
copy thereof(Sec.3800, Lab.C.).
r
^ I,I
ZONING
Y OF (.UFetnI
ENG. SITE NO.
Iw
s-✓ a
Policy No. Company
Certified copy is hereby furnished.
Certified copy is riled with the city inspection h0sum.
Applicant
MISC.- REFER OORD.
FIRE SPRINK
- YE] N ❑
ENERGY T-24❑
Y ❑ N❑.
CERTIFICATE OF EXEMPTION FROM WORKERS'
PERMIT ISSUANCE 10.00
FLOOD ZONE
A.L.U.C.
PLG. CONTR. LIC. NO.
PLG.
TOTAL
COMPENSATION INSURANCE
(This section need not be completed if the penmil is for one
Y�N�
Y[ N❑
hundred dollars IS 100) or less.)
I certify that in the performance of the work for which this per-
mit is issued, 1 shall not employ any person in any intoner So as to
CITY. MECHANICAL PERMIT FEE
FEE SUMMARY
BUILDING
become subject to the Workers' Compensation Laws of California.
Date Applicant -
NOTICE TO APPLICANT: If, after making this Certificate of Ex-
ALTER OR ADD TO MECH. 5.00
APPLIANCE 5.00
PLAN CHECK
emption, you should become subject m the Workers' Compensation
provisions of the Labor Code, you must forthwith comply with
such provisions or this permit shall be deemed revoked.
FEE
-
AIR HANDLING UNIT (TO 10,000CF.M.) 4.00
AIR HANDLING UNIT (OVER 10=C.F.M.) 6.00
SEISMIC FEE'
CONSTRUCTION LENDING AGENCY
1 hereby affirm that there is a construction Imhding agency for
EXHAUST HOOD (WITH DUCT) 5.00
ormance of the work for which this permit is issued (Sec.
the performance
MICROFILM
HEATING UNIT (TO 100,000 B.T.U.) B.00
HEATING UNIT (OVER 100,000 B.T.U.) 9.50
ELECTRIC
Lender's Name
Lender's Address
I certify that I have read this application and stale that the above
information is correct. I agree to comply with all city and county
Ordinances and state laws relating to building construction, and
VENTILATION FAN (SINGLE) 4.00
PLUMBING
BOILER- COMP (3 H.P. or 100,000 B.T.U.) 6.00
BOILER -COMP (Over 100,000 BTU) SEE FEE SCH.
MECHANICAL
hereby authorize representatives of this city to Cold upon the
above-mentioned property for inspection purposes. '
MISC. - REFER TO ORD.
(We) agree to save, indemnify and keep harp ss the City of
Cupertino against liabilities, judgments, costsxpenses which
may in any waY accrue man st said City i co se uence of the
CONST. TAX
PERMIT ISSUANCE 10.00
ming of t 'o -P rmit.
��
MECH. CONT. LIC. NO.
MECH.
TOTAL
TOTA
S' a raData
X vv OFFICE COPY