9257 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
BUILDING PROJECT I DENTI FICATI ON - - PERMIT NUMBER
f ADDRESS APPLICATION & PERMIT 9257
ADDRESS
(fZ644' CXrFE`,eC BUILDING-ELECTRICAL-PLUMBING-MECHANICAL
1 OWNER'S PLAN CHECK VALIDATION
NAME
• ✓• ELUO7T 2J 7-2_"0 OTY. ELECTRIC PERMIT FEE-
PHONE -F-
CONTRACTORS 7. OUTLETS-SWITCHES-RECEP }6.90!1.00
N ,s �^p
- 1 OSEI� C. E J C.NO. S 90 Cj LIGHTING FIXTURES 19:00/1.00
C"ONTRACTORs `3 pPLIANCES-RESIDENTIAL 4.00
/iV O SS WCIoD PHONE1-7-� S PANELS 10.00 DATE OF APPLICATION
OR
ARCHITECT PANELS (OVER 200 AMP) 20.00 PLAN CHECK FEE P.C.NO.
ENGINEER
LIC NO. SIGNS TRANS. 3.00
ADDREOR SS ENG' SPECIAL CIRCUIT 5,00 ,PERMIT VALIDATION
ZIP TEMP.METER OR POLE INS. 20.00 ^ '
ADDRESSPLICATs
ADDRESS MOTORS SEE FEE SCH.
SERVICE CHANGE 0.00
woo LICENSED CONTRACTORS DECLARATION TEMP.POLE 30.00
<u e I hereby affirm that I um licensed under provisions or'Chapter 9 ISSUANCE DATE
w (commencing with Section 7000)of Division 3 of the Business and - BLDG. ELECT. PLG. MECH.
i Professions Co n�my licenu.is in full fort a c
Z 0 y License
.B.C.
Lic.Number
O w/ Date Contractor City of Cupertin< ,IEl
f "J+ BUILDING PERMIT
rc a OWNER-BUILDER DECLARATION
o w u INFORMATION
X y I hereby affirm that I am exempt from the Contractor's License MISC.- REFER TO ORD
3 u y p VALUATION $/FT.
Foo J Law for the following mason,(Sec.7031.5,Businessand Professions PERMIT ISSUANCE
f ,AAE Code:Any city orcounty which requires a permit to construct,alter,
re ¢¢O improve,demolish,or repair any structure,prior to its issuance,also ELEC.CONTR. LIC.N0, ELEC.
O LL requires the applicant for such permit m file a signed statement that TOTAL PE MIT TO
n w$ he is licensed pursuant to the provisions of the Contractor's License E��"� E h'E�
Fii Law(Chapter 9(commencing with Section 7000)ofDivision 3 oflhe
¢ Business and Professions Code)or that he is exempt therefrom and 9TY" PLUMBING PERMIT FEE
IF _$ the basis for the alleged exemption.Any violation of Section 7031.5 N STORIES TYPE CONSTR.
i; - by any Applicant for a permit subjects the applicant too Civil penalty p ALTER-DRAIN -WATER (EA.)-6AD
of not more than five hundred dollars($500).): 9
❑ I,as owner of the property,or my employees with wages as BACK FLOW PROTECT.DEVICE 4.00 OCC.GROUP RES.UNITS
sole compensation,will du the work,and the structure is not
intended or offered for sale (Sc,, 7044, Business and Professions DRAINS-FLOOR,ROOF,AREA,COND. 5.00
Code:The Contractor's License Law does not apply to an owner of
property who builds Or improves thereon,and who does such work I FIXTURES-PER TRAP 'ELOO 50.FT.FLOOR AREA TOTAL ACREAGE
• himself re through his own employees,Provided that such improve-
hients mself a throughot his or Offered employees,
pe.videdt that
chwlding GAS-EA.SVSTEM-I1NC.40UTLETS 6.00
or improvement is Sold within one year of completion,the owner- GAS-EA.SYSTEM.OVER 4(EA") 2.00
builder will have the burden of proving that he did not build or im- BUILDING USE
prover
for purpose ofsale.).
INDUSTRIAL WASTE INTER. 30.00 RES IND CON PIS Other
❑ as owner of the property,ant exclusively Contracting with El El El111:1licensed
contractors 10 construct the project(Sec.7044,Business LAWN SPRINKLERS- 1 INC 6:00 ASSESSORS PARCEL NO.
and Professions Code:The Contractor's License Law does not apply
to an owner of property who builds or improves thereon,and who LAWN SPRINKLERS-OV .1 1.00
contracts for such projects with a contractor(s)licensed pursuant to
the Contractor's License Law, SEWER-SANITARY-ST M E .20 f[ 10.00
TRACT NO, PARCEL NO.
❑ l am exempt under Sec. ,BAP.C.for this WATER HEATER W/ .00
reason
Owner Date WATER SYSTEM 00 ACC.DATE ACC.FILE NO.
WORKERS'COMPENSATION DECLARATION WATER TREATING_E bdpeffi .00
I hereby affirm that I have a certificate ofconsent to self-insure, ZONING ENG.SITE NO.
or a certificate of Workers'CompensaY1oq Insount,or- crtified
copy thereof(Sec.3- -,Lab.C.). VA,D ,1�yhLT
Policy No. Company
Q O Certified Copy is hereby fumished. FIRESPRINK ENERGY T 24
Z ❑ Certifi% p IS filed with the city inspection division.
0 Applicant {' etlT ��I"Qp MISC.- REFER TO ORD. Y❑ N❑ Y ❑ No
~ asPERMIT ISSUANCE -19:99 FLOOD ZONE A.L.U.C.
CERTIFICATE OF EXEMPTION FROM WORKERS' "�
LU Q COMPENSATION INSURANCE: PLG.CONTR. LIC.NO. To,T.AL �� sAi ❑ ❑N Y❑ '❑.
(This section'need not he completed if the permit is for one Y N
D Z hundred dollars IS 100)Or less)
U O I certify that in the performance of the work for which this per- CITY. MECHANICAL PERMIT FEE FEE SUMMARY
IL 1 mit is issued,1 shall not employ any person in any manner so as to
U become subject to the Workers'Compensation Laws of California.
y Date Applicant ALTER OR ADD TO MECH. .5.00 BUILDING
} 0 NOTICE TO APPLICANT: If,after making this Certificate of Ex.
F- Z emplion,you should become subject to the Workers Compensation APPLIANCE 5.00 PLAN CHECK
provisions of the Labor Code, you must forthwith comply with - FEE
S.0 such provisions or this permit shall be deemed revoked. AIR HANDLING UNIT(TO 1 ) 4.00
CONSTRUCTION LENDING AGENCY AIR HANDLING UNIT(OVER 10J=C.F . , .00 SEISMIC-FEE
I hereby affirm that there is a construction lending agency for EXHAUST HOOD(WI 1 6.00
Ilse performance of the work for which this permit is issued(Sec. MICROFILM
3097,CN.C). HEATING UNIT(TO 100,000 B.T.U.)
Lender's Name HEATING UNIT(OVEFC1 0 ELECTRIC /
Lender's Address
I certify that I have read this application and state that the above VENTILATION FAN (SINGLE) 4,00 ��JJ y(,
information is correct. 1 agree to comply with all city and county PLUMBING "<6Z
ordinances and slate laws relating to building construction, and BOILER-COMP(3 H.P.or 100,000 B.T.U.) 6.00
hereby authorise representatives of this city to enter upon the BOILER-COMP(Over 100,000 BTU)SEE FEE SCH. MECHANICAL
above-mentioned properly for inspection purposes.
(We) agree to save, indemnify unit keep harmless the City of MISC.- REFER TO ORD.
Cupertino age, t liabilities,judgments, costs and expenses which PERMIT ISSUANCE 10.00 Q CONST.TAX
may in a accrue against s "d City in mnaequen of the
Kra of t permit. IMECH.CONT. LIC.NO. MECH.
G II TOTAL �o v TOTAL -�o
Signature of Applicant/Ccntractmr tc /
OFFICE COPY