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APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
BU LDI NG PROJECT 1 DENT[ FICATI ON
APPLICATION &PERMIT
BUILDING — ELECTRICAL— PLUMBING — MECHANICAL
PERMIT NUMBER
L1LU1NG
r �^�
/
P11nonE55
a
O.NTE.'S
NAME
C / l O PHONE L/ O
DTV. ELECTRIC PERMIT FEE
T PLAN CHECK VALIDATION
'
NAMERAcaoRs
OUTLETS-SWITCHES-RECEP 5.00/1.00
4A7'K _ m. ND. y06Li 5
DATE OF APPLICATION
LIGHTING FIXTURES 5.00/1.00
CONTRACTOR'S "-z
ADDRESS I/� Jam'. /�� �/�
Q -o-8 �J1'x221 NE / �-ClI
PPLIANCES- RESIDENTIAL 4.00
PANELS 5.00
ARCHITECTSIGNS
OR
ENGINEER
Llc. No.
6.00
PLAN CHECK FEE P.C. NO.
SIGNS TRANS. 3.00
ADDRESS erre.
SPECIAL CIRCUIT 5,00
PERMIT VALIDATION
EMP. METER OR POLE INS. 15.00
2,P
AS
ADDR
ADDRESS
MOTORS SEE FEE SCH.
SERVICE CHANGE 10.00//
'
33� 7/�
LICENSLD CONTRACTORS DECLARATION
1 hereby atfinn that 1 ;un licensed under provisions Of Cha"Icr 9
ISSUANCE DATE
(cont...... ring with Section 7000) of Division 3 of the Business and
Profrssi mo CoQ .yn n s in full found 4ffr�-L
License Class C G.. JqL��. Number ilU1
DaleCdntraclor ��
OWNFR-BUILDIiR DECLARATION
hereby affirm Ilial I son exempt 0o.5 the Con Naot Dr's License
Law :Anythe ity or cong n.tywhchn. c. requires
Any y y quires'a Alt to conslruet, alteq
a permit to construct,
Code An cit or count'wh icy re pen
improve, demolish, or repair any Structure, prior lD its issuance, x150
BLDG.
El
ELECT.
El I
PLG. MECH.
El
BUILDING PERMIT
INFORMATION
MISC.— REFER TO ORD
PERMIT ISSUANCE } -6.00
VALUATION
$/FT.
ELEC. CONTE. LIC. NO.
EOTA
for such permit ID file a signed statement i that
requiresisic the dp pursuant
he is licensed pursuant to the provisions of the) Contractor's License
the
Law (Chapter (commencing ,,Section is exempt
xemf Dtheren3 air(]
Business wWhe.legedeCode)or that heisexemptectio.ora mA
TOTAL
PERMIT TO
Y
QTY. PLUMBING PERMIT FEE
STORIES
TYPE CONSTR.
basis For the allegedexemption. Any
tto action malty
by any applicant fore permit subjects theapplicam loacivil penalty
by applicant
of not more than five hundred dollars (5500)J:
1„
ALTER-DRAIN-WATER(EA.)4.00
❑ 1, as owner of the property or my employees with wages as
their sole compensation, will do the work, and the structure is not
BACK FLOW PROTECT. DEVICE' 2.00
OCC. GROUP
RES. UNITS
DRAINS -FLOOR, ROOF, AR EA, COND. 4.00,
intended or offered for sale (Sec. 7044, Business and Professions
Cede: The Contractor's License Law does not apply In mn owner of
FIXTURES - PER TRAP 4.00
SO. FT. FLOOR AREA
TOTALACREAGE
properly who builds or improves thereon, and who does such work
himself or through his own employees, provided that such improve-
mentsarenotinlended or offered for Sala If, however, the building
GAS - EA. SYSTEM -1INC. 4 OUTLETS 4.00
or improvement is sold within one year of completion, the owner-
builder will have (he burden of proving that h e (lid not build or am-
prove lbr purpose of s:dal'
of
1, is owner the property, am exclusively contracting with
. ..
GAS - EASYSTEM -OVER 4 IEA) 100
BUILDING USE
RES IND CON PR Omer
El ❑ El El 1:1❑
INDUSTRIAL WASTE INTER. 20.00
licensed contractors to construct the project (Sec. 7844, Business
VProfessions Code: The Contractor's License law docs not apply
an owner of properly who builds or improves thereon. and who
LAWN SPRINKLERS- 1 INC 5 V.B. 5.00
r
LAWN SPRINKLERS - OVER 5 (EA.) 1.00
ASSESSORS PARCEL NO.
contracts for such projects with a contractors) licensed pursuant to
the Contractor's License law.
SEWER-SANI ARV -STORM EA. 200ft/8.00
TRACT NO.
PARCEL NO.
❑ I ane exempt under Sec.—, B.&P.C. far this
reason
ACC. DATE
ACC. FILE NO.
WATER HEATER W/VENT 4.00
Owner Date
WATER SYSTEM 4.00 q
WORK ERS'COMPENSATION DECLARATION
WATER TREATING EQUIP. 4.00
I hereby affirm that l have a cenifica0.' ofconsenl hr w1binsure'
or a certificate of Workers Compensation Insurance, o certified
ZONING
ENG. SITE NO.
copy there W; .
Policy Lwapatay S uq sq &�)C/A
FIRE SPRINK
Y❑ N❑
ENERGY T"24
Y❑ N❑
❑ Certified copy is hereby furnished.
A pvc,im. fed c� t IiId1 with Wa.ci nspedinn division
MISC.- REFER TO ORD.
PERMIT ISSUANCE 6.00
CIiRI'IF AI'1!flE liXi: NPROM WORKERS'
FLOOD ZONE
c.
AL.ULC
PLG. CONTE. LIC. NO.PLG.
TOTAL
COWENSATION INSURANCE
(This section need not be completed if the permit is for one
❑ N❑
v [:] N❑
hundred dollars (S 100) nr less.)
I certify that in the performance of the work for which this per-
mil is issued, 1 shall not employ any person in any manner m as to
OTY. MECHANICAL PERMIT FEE
FEE SUMMARY
BUILDING
become subject to the Workers Compensation Laws of California -
Date ApplicantALTER
OR ADD TO MECH. q,QQ
NO1ICli '1'O APPLICANT: If, atter making this Certificate of Ex-
APPLIANCE- 4.00
PLAN•CHECK
emption, you should become subject to 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-) 3.00
AIR HANDLING UNIT (OVER 10A000.F.M.) 5.00
SEISMIC FEE
St.
CONSTRUCI' ION LENDING AGENCY
I hereby affirm that Iherc is a construction lending agency for
EXHAUST HOOD (WITH DUCT) 2.00
the performance of the work for which this permit is issued (Sec.
3097, Civ.C.).
MICROFILM
n
HEATING UNIT TO 100,000 B.T.U.) 4.00
HEATING UNIT (OVER 100,000 B.T.U.)7.50
ELECTRIC
Lender's Name
L,ml 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 countyPLUMBING
ordinances and state laws relating to building construction, and
VENTILATION FAN (SINGLE) 3.00
BOILER-COMP(3 H. P. or 100,000 B.T.U.1 4.00
BOILER -COMP (Over 100,000BTUISEE FEESCH.
MECHANICAL
hereby authorize representatives o1' this city to enter upon the
above-Inenlioned properly for inspection purposes.
MISC. - REFER TO ORD.
(We) agree to save, indemnify and keep harmless the City of
Cupertino against liabilities, judgments, costs and expenses which
may in any way accrue against id City in consequence of the
CONST. TAX
PERMIT ISSUANCE 3.00
granting of this permit,
S
MECH. CONT. LIC. NO.
MECH.
TOTAL
TOTAL
l0� i
ign are of Ap R Detractor Date
INSPECTOR COPY