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APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
BUILDING PROJECT IDENTIFICATION
APPLICATION & PERMIT
BUILDING - ELECTRICAL- PLUMBING -MECHANICAL
PERMIT NUMBER
-
4769
BUILDING
•poR s I�,�S I,'
NAGQTY.'
PHONE 753-6%
_i.7'- 1' - r -'
r ELECTRIC PERMIT
PLAN CHECK VALIDATION
DATE OF APPLICATION
NDME`�°CTOPs ' `'
Imo' nAX--_' uC.No. q72
OUTLETS - SWITCHES -RECEP 5.00/1.00
LIGHTING FIXTURES 5.00/1.00
CONTIIADORE
`I `C' `LLvNONE 72
PPLIANCES -RESIDENTIAL 4.00
PANELS 5.00
ARCHITECT
SIGNS 6.00
PLAN CHECK FEE P.C. NO.
ENGINEER
L o
SIGNS TRANS. 3.00
PDDREss
SPECIAL CIRCUIT 5.00
PERMIT VALIDATION
TEMP. METER OR POLE INS. 15.00
ZIP
r
J
APPLICANTS
ADDRESS
MOTORS SEE FEE SCH.
SERVICE CHANGE 10.00
,//
LICENSED CONTRACTORS DECLARATION
I hereby affirm that 1 am licensed under provisions of Chapter 9
(commencing with Section 7000) of Division 3 of the Business and
Professions 10r11 Code nd'I I Cosi Is In full f0 n ff-o n ff-y�. Z�
License I s d Lie. Number.0
ISSUANCE DATE
BLDG.
ELECT, I
11
PLG. MEAH.
11 p�J
Dale Contractor
L'DING,P,ERMITCai+t�.
"'( "w*IN FORMATION/ .V_t,
"" "
OWNER -BUILDER DECLARATION
I hereby affirm that 1 am exempt from the Contractor's License
Law for the following mason. (Sec. 7031.5, Business and Professions
Code: Any city or county which requires a permit to construct, alter,
improve, demolish, or repair any structure, prior to its issuance, also
requires the applicant for such permit to Nle 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 fthe•:••?
Business and Professions Cade) .,that he is exempt therefrom and
the basis for the alleged exemption. Any violation of Section 7031.5:
MISC. - REFER TO ORD
VALUATION
5/FT.
PERMIT ISSUANCE 6.00
ELEC. CONTR. LIC. NO. ELEC.
TOTAL
PERMIT TO
v
_
QTY. .`•PLUMBING PERMIT i FEE u
_
STORIES
TYPE CONSTR.
by any applicant for a permit subjects the applicant to a civil penalty
of not more than five hundred dollars (55001.1:
gLTER-DRAIN-WATER (EA.) 4.00
❑ 1, as owner of the property, or my employees with wages Bs
[heir 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
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-
ments are not intended or offered for sale. If, however, the building
FIXTURES - PER TRAP 4.00
So. FT. FLOOR AREA
TOTAL ACREAGE
GAS-EA.SVSTEM-1 q,00
or improvement is sold within one year of completion, the owner-
builder will have the burden of proving that he did not build or im-
prove 1, aso neer of sale.).
❑ L owner of the properly, exclusively contracting with
GAS - EA. SYSTEM •OVER 4 (EA.) 1.00
BUILDING USE
RES IND PB CO.,
❑ ❑ ❑
INDUSTRIALWASTE INTER. 20.00
c he
licensed contractor to construct the project La does, Business
and Professions Code: The who
buildsContractor's improv Law does not apply
to owner of property who builds improves thereon, and who
LAWN SPRINKLERS - 1 INC 5 V.B. 5.00
LAWN SPRINKLERS -OVER 5 (EA.) 1.00
gssESso RCEL NO.
contracts tr
Licenects Lwilha contmetorlsl licensed pursuant to
the Contractor's License Law.
the Contractor's
SEWER -SANITARY -STORM EA. 200ft/8.00
TRACT NO.
PARCEL NO.
❑ lam exempt under Sec. ,B.&P.C. for this
reason
WATER HEATER W/VENT 4.00
Date Owner
WATER SYSTEM 4.00
ACL. DATE
ACC. FILE NO.
WATER TREATING EQUIP. 4.00
WORKF-RS'COMPENSATION DECLARATION
I hereby affirm that 1 have a certificate of consent to self -insure.
or a certificate of Workers' Compensation Insurance, or a cc lifcd
ZONING
ENG. SITE NO.
copy there ( 500, Lah.C.).
a��'���'�
Policy No, Company �MP.PI -5F
FIRE SPRINK
V N
ENERGY T-24
Y 0 N
Cl I ted copy Is hereby famished.
r inspection division.
AVplic.ol--I Ct77 F
MISC- REFER TO ORD.
CERTIFICATE OF EXEMPTION FROM WORKERS'
PERMIT ISSUANCE 6.00
FLOOD ZONE
A.L.U.C.
PLG. CONTR. LIC. No.
PLG,
TOTAL
COMPENSATION INSURANCE
(This section need not be completed if the permit is for one
v� N�
Y� N�
_ ''
QTY. MECHANICAL PERMIT 'S . _ :j FEE' 1
FEE SU'+••Sae; S -fr.,o:
'�,�:iH i..MMARY;,,;�rya_r
- m a ' _
hundred Italian IS 100) or less.);,
I certify that in the performance of the work for which this per,
mil is issued, I shall not employ any person in any manner so as m
BUILDING
becomesubject to the Workers' Compensation Laws of California.
Date Applicant
-
ALTER OR ADD TO MECH. 4.00
NOTICE TO APPLICANT: If, after making this Certificate of Ex-
emption, you should become subject to the Worker' Compensation
APPLIANCE 4.00
PLAN CHECK
provisions of the Labor Code, you must forthwith comply with
such provisions or this permit shall be deemed revoked.
FEE
AIR HANDLING UNIT (TO 10MC.F.M.) 3.00
AIR HANDLING UNIT (OVER 10MC.F.M.) 5.00
SEISMIC FEE
CONSTRUCTION LENDING AGENCY
I hereby affirm that there 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
HEATING UNIT (TO 100,000 B.T.U.) 4.00
HEATING UNIT (OVER 100,000 B.T.U.17.50
ELECTRIC
Lender's Name
Lender's Address
1 certify 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 m building construction, and
PLUMBING
BOILER-COMP(3 H. P. or 100,000 B.T.U.) 4.00
BOILER -COMP (Over 100,000 BTu1SEEFEESCH.
MECHANICAL
O 0
hereby authorize representatives of this city to enter upon the
above-mentioned property for inspection purposes.
NNSC. - REFER TO 0)RD.
-
CONST. TAX
(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 Said City in consequence of the
T I S NCE 0
-
MECH. naONT. LIL. NO.
LWO/%G:.v`•;
ME H. .S
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v'if
gmningOfthispermit A 0-_
Signal of Applicant/C mtr ser ate
OFFICE COPY