11296APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
j PBUI LDING PROJECT I DENTI FI ON
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APPLICATION'&P IT' .
BUILDING - ELECTRICAL -PLUMBING -MECHANICAL'
PERMIT NUMBER -
11296
BUILDING
ADDREss
6 SSS o C Ant zp 131 v�b
OWNER'S
NAME
CITY. ELECTRIC PERMIT FEE
PLAN CHECK VALIDATION
�_- 1's'1�T1 I.-..$ PHONE
CONTRACToRs
NAME
OUTLETS -SWITCHES=PIECED 10.00/1.00
LIGHTING FIXTURES 10.00/1.00 ..
L/Mp* li' uc.NO.4/3 902
DATE OF APPLICATION
CONTRACTOR'S Y-
ADDREySS y- I q S .y '
�/ 5,/Ayk0/ PHONE W-0//If
APPLIANCES -RESIDENTIAL 4.00
- PANELS 10.00
ARCHITECT
OR
ENGINEER
LIC. No.
PANELSIOVER 200 AMPI 20,00
PLAN CHECK FEE P.C. NO.
SIGNS TRANS. 3.00
ARCH. SS ENG,
ADDRESS
SPECIAL CIRCUIT 5.00
PERMIT VALIDATION
EMP. METER OR POLE INS. 0.00
- ZIP
nooriessTs
E SC.H.
MOTORS SEE FEE SCH.
SERVICE CHANGE 20.00
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LICENSED CONTRACTORS DECLARATION
I hereby affirm that I am licensed under provisions of Chapter 9
(commencing with Section 7000) of Division 3 of the Business and
Professions Codg, an my license is in full forye unil,aff�9t�
License Class - O Lie. Number YJ 77
ISSUANCE DATE
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BLDG.
❑
ELECT. I
❑
PLG. MECH.
❑
Dat e/2-/b-�'(Tn Contractor Af a A. llTi III
'
BUILDING PERMIT
OWNER -BUILDER DECLARATION
1 hereby affnm that 1 am exempt from the Contractor's License
Law for the following reason. (Sec. 7031.5, Business and Professions
INFORMATION
�
MISC. - REFER TO ORD
VALUATION
$/FT.
PERMIT ISSUANCE 10.00
Code: Any city or county which requires a permit reconstruct, alter,
improve, demolish, or repair any structure, prior to its issuance, also
ELEC. CONTE. LIC. NO.
ELEC.
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
by any applicant for a permit subjects the applicant to a civil penalty
of not more than five hundred dollars (55000.):
TOTAL
PERMIT
/11 -
OTY. PLUMBING PERMIT FEE
STORIES
TYPE CONSTR. I
ALTER -DRAIN & VENT -WATER tEA.) 5.00
❑ 1, 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
BACK FLOW PROTECT. DEVICE 4.00
OCC. GROUP
RES. UNITS
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
F IXTUR ES - PER TRAP 5.00
50, FT, FLOOR AREA
TOTAL ACREAGE
himself or through his own employees, provided that such improve-
ments are not intended or offered for sale. If, however, the building
-
GAS-EA.SYSTEM-11NC.AOUTLETS 6.00
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 for purpose of sale.).
❑ I, 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 Pe Other
❑ ❑ ❑ ❑ ❑
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 (EA.) 1.00
contracts for such projects with a contractorts) licensed pursuant to
the Contractor's License Law.
SEWER -SANITARY -STORM EA. 200ft/10.00
TRACT NO.
PARCEL NO.
❑ lam exempt under Sec.- ,B.&P.C. for this
reason
WATER HEATER_.W/VENT 6.00'
Owner - Date
WATER SYSTEM 5.00
ACC. DATE
ACC. FILE NO. -
WORKERS'COMPENSATIONDECLARATION
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 (Sec. 3800, Lab, C.J?C77D J3 L, I /ND6M
Policy No. Company-,
❑ . Certified Copy is hereby furnished..
IE/Celhj+ c y isB t o city inspection division.
Applicant /�
FIRE SPRINK
Y❑ N❑
ENERGY T 24
Y❑ N❑
MISC.- REFER TO ORD.
rPERMIT
CERTIFICATE OF EXEMPTION FROM WORKERS'
ISSUANCE 10.00
FLOODZONE
A.L.U.C.
PLG.CONTR. LIC. NO.
PLG.
TOTAL
COMPENSATION INSURANCE
section need not be completed if the permit is for one
Y❑ NE]
YE] NE]
CITY MECHANICAL PERMIT FEE
FEE SUMMARY
hundred doll..($100) or less.)
1 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: If, after 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.
ALTER OR ADD TO MECH. 5,00
APPLIANCE - 5.00
AIR HANDLING UNIT (TO 10,000 QF.M.) 4.00 �p
AIR HANDLING UNIT (OVER l0MC.F.M.) 6.00
FFEF
CONSTRUCTION LENDING AGENCY
EXHAUST HOOD (WITH DUCT) 5.00the
I hereby affirm that there is a construction lending agency for
performance of the work for which this permit is issued (Sec.
CN.C.).Lender's
HEATING UNIT (TO 100,000 B.T.U.) 8.003097.
UNIT(OVER 100,000 B.T.U.) 9.50
NameHEATING
Lender's Address
1 certify that I 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
hereby authorize representatives of this city to enter upon the
above-mentioned property for inspection purposes:
VENTILATION FAN (SINGLE) 4.00 1,1 Q�
PLUMBING
'
BOILER-COMP13 H.P. or 100,000 B.T.U.) 6.00
BOILER -COMP (Over 100,000 BTU) SEE FEE SCH.
MECHANICAL
MISC. - REFER TO ORD.
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
PERMIT ISSUANCE' 10.00 /0
MECH, CONT. LIC. NO.
TOTAL O0
��
TOTAL
gran 'ng this permit.
- - Q
Signature of App Ion
van Ctra for Date
OFFICE COPY-