C6157APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
BU LOI NG PROJECT I DENT[ FI CATION
APPLICATION & PERMIT
PERMIT NUMBER
BDILDING
ADORES.
C
BUILDING - ELECTRICAL- PLUMBING -MECHANICAL
b 15"7
6
GwNEH'S
PLAN ECK VALIDATION
NAMEOTY]
ELECTRIC PERMIT FEE
EA Soni PHDNE 2
DATE OF APPLICATION
CONTRACTOR s
NAM
N /'
TIC No.
L yf U
UTLETS- SWITCHES -RECEP 5.00/1.00
LIGHTING FIXTURES 5.00/1.00
ADDRACaoRs --
aDDY.AC-��a"��.�y.va��l /A/�A
l.�kl'RN[
PPLIANCES- RESIDENTIAL 4.00
PANELS 5.00
AOR ITECT
ENGINEER
LIC . NO.
SIGNS 6.00 ,A
PLAN CHECK FEE P.C. NO.
T '
SIGNS TRANS. 3.00 I
ADDRESS esa.
SPECIAL CIRCUIT 5.00
PERMIT VALIDATION
TEMP. METER OR POLE INS. 15.00
Zap
'
APPLICANT'S
ADDRESS ,n
CJSCW�ASERVICE
MOTORS SEE FEE SCH.
CHANGE 10.00
LICENSED CONTRACTORS DECLARATION
I hereby affirm Ihat I am licensed under provisions of Chapter 9
(commencing with Section 7000) of Division 3 of the Business and
Professions Code, d my license is in lull for, e and rff
License CI ss Lie Number
ISSUANCE DATE
BLDG.
ELECT.
❑
PLG. MECH.
❑ ❑
Date Contractor
BUILDING PERMIT
OWC�
OWNIi R -B IIILDIiR DECLAIVIs')'ION
I hereby .Hien that 1 ant exempt fnnn McCort ... I.C, LicemC
Law for 0m following ...m. (See r 7031.5, Businrsamd Prdrsslons
Code: Any city or county which requires. permit to construct, alter,
improve, demolish, or repair any Structure, prior to its issuance, also
requires the applicant for such permit to Gln a signed statement that
he is licensed pursuant to the provisions (It the Contractor's License
Law (Chapter 9 (commencing with Section 70000of Division 3 of the
Business and Professions Code) or that he is exempt therefrom and
INFORMATION
MISC. - REFER TO ORD
VALUATION
� /
$/FT.
PERMIT ISSUANCE 6'00
ELEC.CONTE. LIC. NO.
ELEC.
TOTAL
PERMIT TO
L/�
�
OTY. PLUMBING PERMIT FEE
STORIES
TYPF/CO STR.
the basis for the alleged exemption. Any violation of Section 7031.5
by any applicant for a permit subjects the applicant tea civil penalty
HI nnl mom tlmn five hundred doll...I S500).):
ALTER -DRAIN & VENT -WATER (EA.) 4.00
/
❑ 1, as owner III the property, or my employees with wages as
sole eonlpenmtion, will do the work, and the structure is not
BACK FLOW PROTECT. DEVICE 2.00
OCC. GROUP
EES. UNITS
DRAINS -FLOOR, ROOF, AR EA, GOND. 4.00
intended or offered for sale (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 does such work
FIXTURES - PER TRAP 4.00
SO. FT, FLOOR AREA
TOTAL ACREAGE
himself or through his own employees, provided that such improve.
Tentsarenotintendedoroffered 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 an.
prove bi,mrposc it .alert.
❑ 1, as owner tit the properly, am exclusively contracting with
`-
GAS - EA. SYSTEM -11 NC.4 OUTLETS 4.00
GAS - EA. SYSTEM -OVER 4 (EA.) 1.00
BUILDING USE A'
RS IND CON PB Ont,,
❑ ❑ ❑ ❑
INDUSTRIAL WASTE INTER. 20.00
LAWN SPRINKLERS- 1 INC 5 V.B. 5.00
LAWN SPRINKLERS - OVER 5 (EA.) 1.00
ASSESSORS PARCEL NO.
licensed contractors to constmct the project (Sec. 7144, Business
and Professions Code :'I'lie Contractors Licenu Law does not apply
It, an owner of property who builds or improves thereon. and who
contracts for such projects with a.ontractods) licensed pursuant to
tlreContmctor'sLicense Law.
SEWER -SANITARY -STORM EA. 200ft/8.00
TRACT NO.
-
PARCEL NOf
❑ Iamexenlplunder Sec .B.&P.C. for this
reason
WATER HEATER WNENT 4.00
Owner Date
WATER SYSTEM /14.00
ACC.DATE
ACC. FILE NO,
WATER TREATING EQUIP. 4.00
WORKERS'COMPENSAIION DECLARA11ON
'
I hereby uffirn that I have a certificate of consent to self -insure,
or a certificate I Workers' Compensation Insurance, or a certified
Copy lheraof I. c. 3fl
PolicyN'o C t1:+L A Q.S
ZONING
ENG: SITE NO�
-
IJr4b�s
11p�n31' -A 1O-In-I-ItF
"I Ie copy ereby (u iinheiL . 1
❑ Certil' I 'S r .c i �1 'it 'nspection division.
Applicant
_��
CERT ICA'IF OP L'XRMPTION FROM WORM RS'
/
/
MISC. - REFER TO ORD.
FIRE SPRINK
v ❑ N ❑
ENERGY T 24
v ❑ N❑
PERMIT ISSUANCE 6.00
FLOOD ZONE
A.L.U.C.
PLO. CONTR. LIC. NO.
PLG.
TOTAL
C04FNSAT10N INSLJRANC17
I'I'ILs se ion need not be completed i( the permit is for one
v ❑ N ❑
Y ❑ N ❑
GTY. MECHANICAL PERMIT FEE
FEE SUMMARY
hundred doll... t S 100) or Iess.)
1 certify that in the performance DI lire work for which this per.
mil is issued, I shut[ not employ any person in any manner so as to
become subject to the Worker,' Compensation Laws of California.
Date Applicant
NOTICI, "f0 APPLICANT: If, after nmking this Certificate of E.
s'aption, you should become subject to tire Workers' Compensation
BUILDING
(-�
��f
ALTER OR ADD TO MECH. 4.00
APPLIANCE 1 4.00
PLAN CHECK
provisions of the Labor Code, you must Blrlhwilh comply with
such provisions o. this permit shall be drented revoked.
FEE
-
AIR HANDLING UNIT (TO 10p000.F.M.) 3.00
AIR HANDLING UNIT (OVER 10= C. P.M.) 5.00
SEISMIC FEE
r ,`Q
CONSfRUCI'IONLENDINGAGENCY
1 hereby affirm that (here is a construction lending agency for
EXHAUST HOOD (WITH DUCT) 2.00
the performance of the work for which this permit is essual (Sec.
3097, Civ.CJ.
MICROFILM
I HEATING UNIT ITO 100,000 B.T.U.) 4.00
HEATING UNIT (OV ER 100,000 B.T.U.)7.50
ELECTRIC
Lender's Name
Lender's Address
I certlly that I have read this application and state that the above
VENTILATION FAN (SINGLE) 3.00
information is correct. I agree to comply with all city and county
ordinances and state laws relating to building construction, and
PLUMBING
BOILER -COMP (3 H.P. or 100,000 B.T.U.) 4.00
BOILER -COMP (Over 100,000BTU)SEE FEE SCH.
MECHANICAL
hereby authorize representatives of this city to enter upon the
above-mentioned Property for inspection purposes.
MISC. - REFER TO ORD.
(We) agree to Save, indemnify and keep harmless the City of
Cupertino agai M Iiabilitilk, judgments, costs and expenses which
may in any y accrue Sgamet Said Cily in ponsc pence of the
CONST. TAX
PERMIT ISSUANCE 3 W
..
MECH, CONT. LIC. NO. MECH.
TOTAL
TOTAL
gm i' Irm
VVV
Sign re 'Applicddt ContmClor le
V INSPECTOR COPY