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APPLICANT TO FILL IN INFORMATION WITHIN RED LINES -USE BALL POINT PEN ONLY
BUILDING PROJECT I DENTI FICA'
APPLICATION&PEK T
BUILDING - ELECTRICAL- PLUMBING - MECHANICAL
PERIVIT. . R
1525
a,r,LO,NG
DDRESS
/
,/:? l /%�iili. L' c°'
OwNER'S
NAME _
%rt m,'�r%�/•'dei/,'v.. �RONE.�.S>%73�
QTY. ELECTRIC PERMIT FEE
PLAN CHECK VALIDATION
CONTRACTORS
.S OUTLETS -SWITCHES -RECEP 5.00/1.00 S�
LIGHTING FIXTURES 5.00/1.00 j C^
CONTRACTORS
A DDRESs
PPLIANCES-RESIDENTIAL 4,00
PANELS 5.00
_
S r�.HI PHONE
DATE OF APPLICATION
ARCHITECT
On
ENGINEER
LIC. No.
SIGNS 600
PLAN CHECK FEE
P.C. NO.
/
SIGNS TRANS. 3.00
ARCH. OR ENG,
ADDRESS
SPECIAL CIRCUIT S.QQ
PERMIT VALIDATION
TEMP. METER OR POLE INS. 15.00
ZIP
APPLICANTS
AODRESs
�=tyZ. .-.
MOTORS SEE FEE SCH.
SERVICE CHANGE 10.00
LICENSED CONTRACTORS DECLARATION
Or CUPCRTI
r
1 hereby affirm that I am licensed under provisions of Chapter 9
r yry`•
ISSUANCE DATE
(commencing with Section 7000) of Division 3 of the Business and
DLOG.
ELECT.
PLG. MECH.
Professions Code, and my license is in full force unJ of feet.
Class Lin. Number
L_ Contractor
D 'JJ
B 9
❑
I
❑ ElL"erre
BUILDING PERMIT
OWNER -BUILDER DECLARATION
I hereby affirm that I am exempt from the Contractor's License
Professions
Law forthefollowing reasonntyw.ch c. requ03 ires a permit to construct,
Code: Any mulish county any structure p riot t oConstruct.alter,
structure. prior n its issuance, also
improve, demolish, or repair any permit that
requires for such permit to file a signet atm
INFORMATION
MISC.- TO ORD
VALUATION
i! �
PERMIT ISSUANCE
ELEC. CONTR. LIC. N0.
ELEC.
TOTAL
PERMIT TO
is Li
he is licensed pursuant to the provisions of the Convector's License
nedp pursuant
Law (Chapter 9 (commencing with Section 7000)Of Division 3 ol'the
Business and Professions Code) or that he is exempt therefrom and
the basis for the alleged exemption. Any violation of Section 7031.5
by any applicant for a permit subjects the applicant toe civil penalty
of not more than five hundred dollars (5500).1:
DTV. PLUMBING PERMIT FEE
STORIES
TYPE CONSTR.
ALTER -DRAIN & VENT -WATER (EA.) 4.00
BACK F LOW PROTECT. DEVICE 2.00
OCC. GROUP
�-�
RES. UNITS
❑ h 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
DRAINS -FLOOR, ROOF, AR EA, COND. 4.00
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 orthrough his own employees. provided that such improve
are not intended or offered for sale. If. however, the budding
FIXTURES - PER TRAP 4.00
50, FT. FLOOR AREA
OPO
TOTAL ACREAGE
GAS - EA. SYSTEM -11NC.40UTLETS 4.00
or improvement is sold within one year of completion, the owner-
builder will have the burden of proving that he did not haild or iso-
for purpose of sale. 1.
❑ I, as owner of the properly, am exclusively contracting with
licensed Contractors to construct the project (Sec. 7044. Business
GAS - EA. SYSTEM - OVER 4 (EA.) 1.00
BUILDING USE
RES INDC PB Oil.,prove
❑ ❑ ❑ ❑
INDUSTRIAL WASTE INTER. 20.00
LAWN SPRINKLERS - 1 INC 5 V.B. 5.00
ASSESSORS PARCEL NO.
and Professions Code: The Contracwr's License Law does not apply
to an owner of property who builds or improves thereon. and who
LAWN SPRINKLERS - OVER 5 MA.) 1.00
contracts for such projects with a convactons) licensed pursuant to
Ile, Contractor's License Law.
❑ I am exempt under Sec... B &P C. for this
SEWER -SAN ITAR V -STORM EA. 200f1/8.00
TRACT NO.
PARCEL NO.
WATER HEATER W/VENT 4.00
reason
Date OwnerWATER
SYSTEM 4.00
ACC. DATE
ACC. FILE NO,
WORK ERS'COMPENSATION DECLARATION
WATER TREATING EQUIP. 4.00
1 hereby allirm that I have a certificate of consent to elf -insure.
or a Certificate of W'orkeri Compensation Insurance, or a Certified
ZONING
ENG, SITE NO.
copy thereof (Sec. 3800. Lab CA
Policy No. mpany (uy
❑ Certif Ted co 6he�ebrnrshed.
�❑ Certified p is file with tl ci Spection divis' n.
pPlicant
FIRE SPRINK
Y ❑ N
ENERGY T44
Y L] N[_
MISC. - REFER TO ORD.
CERTIFICATE OF EXEMPTION FROM WORKE
PERMIT ISSUANCE 6.00
FLOOD ZONE
A.L.u.0
PLG. CONTR. sec. NO.
PLG,
TOTAL
COMPENSATION INSURANCE
(This section need not be Completed if the permit is for one
v ❑ NE]
Y C:] N ❑
GTV. MECHANICAL PERMIT FEE
FEE SUMMARY
hundred dollars (S 1001 or less.)
I certify that in the performance of the work for which this per-
mit is issued. I shall not employ any person in any manner so as to
become subject to the Workers'Compensation Laws of California.
Date Applicant
NOTICE TO APPLICANT: IC after making this Certificate of Ex-
emption. you should become subject to the Workers'Compensation
provisions of the Labor Code• you must forthwith comply withFEE
such provisions or this permit shall be deemed revoked.
CONSTRUCTION LENDING AGENCY
BUILDING�-
L' ( ---
ALTER OR ADD TO MECH. 4.00
APPLIANCE 4.00
PLAN CHECK
-.
!.
AIR HANDLING UNIT (TO 10p00 C.F.M.) 3.00
AIR HANDLING UNIT (OVER 10=C.F.M.) 5.00
SEISMIC FEE
EXHAUST HOOD [WITH DUCT) 2.00
MICROFILM
I hereby 'affirm that there is a construction lending agency for
the performance of the work for which this permit is issued (Sec
3092 C's.C. I
Nom /NwrH
Lender's Name �/
HEATING UNIT (TO 100,000 B.T.U.) 4.00
HEATING LINIT (OVER 100,000 B.T.U.)7.50
VENTILATION FAN (SINGLE) 3.00
ELECTRIC
`G
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 countyPLUMBING
ordinances and state laws relating to building construction, and
hereby authorize representatives of this city to enter upon the
BOILER-COMp13 H.P. or 100,000 B.T.U.) 4.00
BOILER -COMP (Over 100,000 BTU) SEE FEE SCM.
MECHANICAL
✓ ^
above mentioned property for inspection purposes.
(We) agree to save, indemnify and keep harmless the City of
Cupertino - inst liabilities, judgments, costs and expenses which
may in way accrue against said fitY in consequence of the
g,.mm !!Anparmll.
MISC. - REFER TO ORD.
CONST. TAX
PERMIT ISSUANCE 3.00 �.'-c--
MECH. CONT. LIC. NO.MECH.
TOTAL/-
G
TOTAL''
Ign urciof AppllCllnt, Ont, Clnr Da1C
OFFICE COPY