8591LICANT TO FILL IN INFORMATION WITHIN RED LINES -USE BALL POINT PEN ONLY 40djl N
BUILDING PROJECT IDENTIFICATION
APPLICATION & PERMIT
BUILDING - ELECTRICAL- PLUMBING - MECHANICAL
I
PERMIT NUMBER
8
BUILDING
FDDRESS
102
• 10201 Torre AVE.
-57
NAME
NAMES/�K44 328-8051CITY
/��
PHONE
ELECTRIC PERMIT FEE
PLAN CHECK VALIDATION
DATE OF APPLICATION
NAME
NAME CONTRACTORS 449414
CLINTON HEATING LIC. NO1jMng
UTLETS-SWITCHES -RECEP 10.00/1.00
LIGHTING FIXTURES 10.00/1.00
CONTRACTOR
ADDRESS
2162 Prune Ave. PRONE657-682
APPLIANCES- RESIDENTIAL 4.00
PANELS 10.00
ARCHITECT
OR
ENGINEER
LIC.mO.
PANELS (OVER 200 AMP) 20.00
PLAN CHECK FEE P.C. NO.
SIGNS TRANS. 3.00
ADDRESS ENG'
nv
SPECIAL CIRCUIT 5.OQ
PERMIT VALIDATION
f% /
a3/�3.
ISSUANCE DATE
EMP. METER OR POLE INS. 20.00APPLICANT
S
ADDRESS
MOTORS SEE FEE SCH.
SERVICE CHANGE 20.00
LICENSED CONTRACTORS DECLARATION
1 hereby ullirm that I am licensed under provisions of Chapter 9
(commencing with Section 7000) of Division 3 of the Business at
Professions Cod , and my'license is in fulLfmce d f ct
it License Class Con Number
Dale Contractor
O NER-BUILDER DECLARATION
I hereby al firm That I am oxempt from the Contractor's License
Law for the following reason. (Sec. 7031,5. Business and Professions
Code: Any city or county which requires a permit to construct, alter,
improve-delool1sh, or repair any structure, prior to Its Issuance, also
requires the applicant such permit to file a signed statement that
he is licensed pursuant to the provisions of the Contractor's License
Law (Chapter 9(commencing with Section 7000) of Division 3 of the
Business and Professions Code) or that he is exempt therefrom and
The basis for the alleged exemption. Any violation of Seelimh 7031.5
by any applicant for a permit subjects the applicant to a civilpenully
of not more than five hundred dollar, ($500).)'
❑ I, 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 fir 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-
meets 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 the did not build or ire-
prove for purpose ofsale.).
❑ I, as owner of the property, am exclusively' contracting with
licensed cummetors 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 suet' projects with a contractor(s) licensed pursuant to
the Contractors License Law.
❑ 1 am exanpt under Sec. ,B.&P.C. for This
reason
TEMP. POLE 30.00
BLDG.
ELECT.
❑
PLG. MECH.
0 []j
LX,
BUILDING PERMIT
INFORMATION
MISC.- REFER TO ORD
PERMIT ISSUANCE 10.00
VALUAnON
ELEC. CONTE. LIC. NO.
ELEC.
TOTAL
PERMIT TO
.
OTV. PLUMBING PERMIT FEE
ALTER-DRAIN&VENT-WATER (EA.) 5.00
STORIES
TYPE CONSTR.
BACK FLOW PROTECT. DEVICE 4.00
ocC. GROUP
RES. UNITS
DRAINS -FLOOR, ROOF, AREA, CONO. 5.00
FIXTURES - PER TRAP 5.00
SD. FT, FLOOR AREA
x
TOTAL ACREAGE
GAS - EA. SYSTEM -1 INC.4 OUTLETS 6.00
GAS - EA. SYSTEM -OVER 4 IEA.) 2.00
BUILDING USE
RES IND CON PB Other
El El
INDUSTRIALWASTE 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
`?W°`r Date
WATER SYSTEM 5.00
WORKERS'COMPENSATION DECLARATION
I lwmby allinn Ihul I hove u certificate of consent to svilinsure.
or v c'crlilicele of Workor Compensation Insurance, or a certified
copy thereof(Sce. 3800, Lah.C.).
Policy No. Conhpany
ACC.DATE
Ace FILE No.
WATER TREATING EQUIP. 5.00
ZONING
'ENG. SITE NO.
❑ Ce i py is hereby s%-
❑', tlilied c y is lilt h ' inspection /vision.
Applin t
CE 'IFI A'IEOF ..'ILMP ON FROM WORKERS'
COAIPISN$A'1'10 INSURANCE
(Thi sect n need not be completed if the permit is for one
hundfc d ars (5100) or IessJ
1 cert' y that in the performance of the work for which this per
mit is iisned, 1 shall not employ any person in any manner so as to
beconu.•.sdbjnet to the Workers' Compensation Laws of California.
Dale °T AppliAPPLICANT:
NOTICE TO APPLICANT: If. after making this Certificate of lix-
I
emption, you should beconhn subject to the Workers'C ompensation
Provisions (if'the labor Code, you must forthwith conhply with
such prgvisions or this permit shall be deemed revoked.
I '
CONS 'TRUCI']ON LENDING AGENCY
I hereby(afl'irin that there is a construction lending agency for
Oho performance of the work for which this permit is issued (Sec.
3097, Civ CJ.
Lende,'s Name
FIRE SPRINK
v� N�
ENERGY T-24
y� N[
MISC.- REFER TO ORD.
PERMIT ISSUANCE 10.00
FLOOD ZONE
V NE
A.L.U.C.
V _ NEI
PLG. CONTR, LIC. NO.
pLG
TOTAL
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=C.F.M.) 4.00
AIR HANDLING UNIT (OVER 1g000QEM.16.00 p,
SEISMIC FEE
,
EXHAUST HOOD (WITH DUCT) 5.00
MICROFILM
HEATING UNIT (TO 100,000
Lender's Address
I certify that 1 have read this application and state that the above
i nfon'iution is correct. 1 agree to comply with all city and county
ordinance's and Hato laws relating to building construction. and
'those! authorid reperty Ionicsec this city to enter upon the
ubove�menlioned property for inspection purposes.
(We) agree to save, indemnify and keep harmless the City of
Cupertino' against f�abilities, jud menu, costs and expenses which
phdYTrh a Y gsy�accru .,tyP�i "fit sr, Gly it consequence of the
granting o ¢ pcnmj
/
nt Contr cto D.re`
HEATI NG UNIT (OVER 100,000 B.T.U.)9.50
ELECTRIC
VENTILATION FAN (SINGLE) 4.00
BOILER- COMP (3 H.P. or 100,000 B.T.U.) 6.00
PLUMBING
BOILER-COMP(Over 100,000 BTU) SEE FEE SCH.
MECHANICAL
MISC. - REFER TO Ofl D.
PERMIT1 $UAN �7Q
_,CONST. TAX
ECH. CONT.' L G 0.
�3 7�
MECH.
OTAL 7
TOTAL
INSPECTOR COPY