11544APPLICANT TO FILL IN INFMMA1h1ON WITHIN RED LINES - USE BALL POINT PEN ONLY
BUILDING PROJECT IDENTIFICATION
APPLICATION PERMIT
PERMIT NUMBER
11544
BUILDING
ADDRESS /lBUILDING-ELECTRICAL-PLUMBING-MECHANICAL
OWNER'S
NAME
QTY . ELECTRIC PERMIT FEE
PLAN CHECK VALIDATION
Pa.✓, �.1Ua'LcanPHDNE
DATE OF APPLICATION
CTOR's
NAME
NAME
6?7
OUTLETS-SWITCHES-RECEP 10.00/1.00
LIGHTING FIXTURES 10.00/1.00
ADDRESS croRs
AooRE
'2//f �• �yP( AiEIONE 17 _107
PPLIANCES- RESIDENTIAL 4.00
PANELS 10.00 .OU
ARCHITECT,
OR
ENGINEER
LIC.. NO.
PANELS IDV ER 200 AMP) 20.00
PLANCHECKFEE P.C. NO.
SIGNS TRANS. 3.00
ARCH, OR ENG.
ADDRESS
ZIP
SPECIAL CIRCUIT 5.00
PERMIT VALIDATION
EMP. METER OR POLE INS. 20.00
APPLICANT'S
ADDRESS
MOTORS S E FEE SCH.
SERVICE CHANGE 20.00
Yo
LICENSED CONTRACTORS DECLARATION
C_
/�
I hereby affirm that I am licensed under provisions of Chapter 9
(commencing with Section 7000) of Division 3 of the Business and
Professions Code, a d m license is in full force p CglLt3
License Class Lie. Number / Y
Date ContractorsT
ISSUANCE DATE
�`
BLDG.
ELECT.
PLG. MECH.
❑ ❑
^ L `
%r
-BUILDING PERMIT
OWNFR-BUILDER DECLARATION -
1 hereby affirm that I am exempt from the Contractor's License
Law for the following reason. (Sec. 7031.5, Business and Professions
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 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 Section 7031.5
INFORMATION
MISC. - O ORD
VALUATION
I PERMIT ISSUANCE 10.00 6P.a 1)
ELEC. CONTR. - LIC. N0. ELEC.
� � �'7 y� TOTA�O -Q I)
PERMIT TO
LGx-i�
QTY. PLUMBING PERMIT FEE
STORIES
TYPE CONSTH.
ALTER-DRAIN&VENT-WATER IEA.) 5.00
by any applicant for a permit subjects the applicant loo civil penalty
of not more than five hundred dollars (5500).):
BACK FLOW PROTECT. DEVICE 4.00
OCC. GROUP
RES. UNITS
❑ 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 for sale (Sec. 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
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 5.00
SQ FT.FLOOR AREA
TOTALACREAGE
GAS-EA.SVSTEM-11NC.40UTLETS 8.00 '
or improvement is sold within one year of completion, the owner-
builder will have the burden of proving that he did not build or am..
prove for purpose ofsale.).
❑ 1, as owner of the property, am exclusively contracting with
licensed contractors to construct the project (Sec. 7044, Business
GAS- EA. SYSTEM - OVER 4 (EA.) 2.00
BUILDING USE
RES IND CON PB Cob.,
11 0 11 0 El
INDUSTRIAL WASTE INTER. 30.00
LAWN SPRINKLERS - 1 INC 5 V.B. 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 -OVER 5 IEA.) 1.00
contracts for such projects with a contracto(s) licensed pursuant to
the Contractors License Law.
❑ lam exempt under Sec. ,B.&P.C. for this
reason
. SEWER -SANITARY -STORM EA. 2008/10.00
TRACT N0.
PARCEL NO.
WATER HEATER W/VENT 6.00
Owner Dale
WATER SYSTEM 5.00
ACL. DATE
ACC, FILE NO.
- WORKERS'COMPENSATION DECLARATION
WATER TREATING EQUIP. 5.00
I hereby affirm that I have a certificate of consent to self -insure,
or a certificate of Workers' Compensation Insurance, or a certified
ZONING
ENG. SITE NO.
copy thereof (Se .j 800, Lab.CJ.
ompany R ra✓G
Policy No. /OG JX/ Company*
❑ Certified copy i5 hereby furnished
�Certified o is file) with he city i spedimu Jiyi on.
Applicant r I��[']�J I��Q PI'N'Y ICS 'TAJCP
-
FIRE SPRINK
v N�
ENERGY T-24
Y ❑ No
MISC.- REFiL
CERTIFICATEOP EXEMPTION FROM WORKERS'
PERMIT ISSUANCE
FLOOD ZONE
A.L.U.C.
PLG. CONTR. LIC. NO.
COMPENSATION INSURANCE
(This section need not be completed if the permit is for one
Y ❑ N
Y C3 N ❑
QTY. MECHANICAL PERMIT FEE
FEE SUMMARY
hundred dollars (S 100) or less.)".
I certify that in the performance of the work for which this per-
nut is issued, 1 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: If, alter making this Certificate of Ex-
emption, you should become subject to the Workers' Compensation
provisions of the Labor Code, you must forthwith comply with
such provisions or this permit shall be deemed revoked.
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 I000C.F.M.) 6.00
SEISMIC FEE
CONSTRUCTION LENDING AGENCY
1 hereby affirm that there is a construction lending agency for
the performance of the work for which this permit is issued (Sec.
3097, Civ.C.). Lender's Name
EXHAUST HOOD (WITH DUCT) 5.00
MICROFILM
HEATING UNIT (TO 100,000 B.T.U.) 8.00
HEATING UNIT (OVER 100,000 B.T.U.)9.50ELECTRIC
'
Q
Lender's Address
Icertify that l have read this application and state that the above
information is correct. I agree to comply with all city and county
ordinances and state laws relating to building construction, and
VENTILATION FAN (SINGLE) 4.001PLUMBING
BOILER-COMP(3 H.P. or 100,000 B.T.U.) 6.00
hereby authorize representatives of this city to enter upon the
above-mentioned properly for inspection purposes.
>\(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 is onsequence of the
BOILER -COMP (Over 10D,D00 BTDISEE FEESCH.
MECHANICAL
MISC. - REFER TO ORD.
CONST. TAX
PERMIT ISSUANCE 10.00
MECH. CONT. LIC. NO. MECH.
TOTAL
TOTAL
,KINBVII, of this permit
I q 717
atureof Applicant/Contractor Ua e
47 UFFIUC COP