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APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
AMC-Ak
' ,BUI LD1 NG PROJECT I DENTI F ION
APPLICATION& MIT
BUILDING - ELECTRICAL- PLUMBING - MECHANICAL
PERMIT NUMBER
11566
rBDILD 4aG--
aoDREss
D'- IPOL
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OWNER'S
N U1fi
QTY. ELECTRIC PERMIT FEE
PLAN CHECK VALIDATION
v � .ONE
CONTRACTORS
ME /�/y
UTLETS-SWITCHES -RECEP 10.00/1.00
LIGHTING FIXTURES 10.00/1.00
L.No. Hyl lo/
roNTRAcioes SS
OREAC
APPLIANCES - RESIDENTIAL 4.00
PANELS 10.00
ell SSAPHONE
DATE OF APPLICATION
ARCHITECT j]�� ,/(.1\1
ENGINEE
DR klVf'6 {�'{ /V Llc. No.
PANELS (OVER 200 AMP) 20.00
PLAN CHECK FEE P.C. NO.
SIGNS TRANS. 3.00 3 "
AARCH. OR DDRESS ENG,
SPECIAL CIRCUIT 5.00
PERMIT VALIDATION
TEMP. METER OR POLE INS. 20.00
zip
APPLICANT'S
ADDRESS
MOTORS SEE FEE SCH.
SERVICE CHANGE Fix WII20-00/%Li
kfA
LICEN SED CONTRACTORS DECLARATION
I hereby affirm that I am licensed under provisions of Chapter 9
ISSUANCE DATE
(commencing with Section 7000) of Divisio 3 �By(r�sjand
Professions s It!;&1 license is N" full fs>�1y,Pi{y
License Class E••� t Lic Hauler_ LLx••A` L_
BLDG. ELECT.
❑ K
PLG. MECH.
❑ ❑
Date Conlmctor
,y
CupOrtin
BUILDING PERMIT
p Of
City
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 permit to construct, alter,
improve. demolish, or repair any structure, prior to its issuance, also
INFORMATION
MISC. - REFER TO ORD
VALUATION
$/FT.
PERMIT ISSUANCE 10.00 Id'
ELEC. CONTR. LIC. NO.
ELEC, s
requires the applicant for such permit to file a signed statement that
he is licensed pursuant to the provisions of the Contractor's License&Z
Law(Chapter 9(commencing with Section 7000) of Division 3 of the
Business and Professions Code) or that he is exempt therefrom and
the basis for the alleged exemption. Any violation orSeclion 703 L5
TOTAL
PERMIT TO
i$,7
QTY. PLUMBING PERMIT FEE
1
STORIES
TYPE CONSTR.
gLTER-DRAIN &VENT -WATER (EA.) 5.00
by any applicant for a permit subjects the applicant to a civil penalty
of mat more than five hundred dollars ($500).):
❑ I, as owner of the property, or my employees with wages as
sale 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
OCe. -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 thescon, and who does such work
FIXTURES - PER TRAP 5.00
SD. 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-l1NC.40UTLETS 6.00
OF improvement is sold within one year of completion, the owner-
builder will have the burden of proving that Ise 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.
and Professions Code. The Contractor's License Law does not apply
to an owner of property who builds or improves thereon, and who
GAS - EA. SYSTEM - OVER 4 (EA.) 2.00
BUILDING USE
RES IND CON PB Omer
El El ❑ El El
INDUSTRIAL WASTE INTER. 30.00
LAWN SPRINKLERS- 1 INC 5 V.B. 6.00
tLAWN SPRINKLERS - OVER 5 (EA.) 1.00
ASSESSORS PARCEL NO.
contracts for such projects with a contractor(s) licensed pursuant to
Ilse Contractor's License Law.
SEWER -SANITARY -STORM EA. 200tt110.00
TRACT NO.
PARCEL NO.
❑ Ium exempt antler Sec. .B.&P.C. fur this
reason
WATER HEATER W/VENT 6.00
Owner Date
WATER SYSTEM 5.00
ACC. DATE
ACC. FILE NO,
WORKF:RS'COMPENSATION�1f'CLARATION
WATER TREATING EQUIP. 5.00
1 hereby nfrirm that 1 e u certil'i tyuf consent to sel6insure,
or a certificate of Work en i II Imuran e, or a certified
ZONING
ENG, SITE NO.
copy thereof( -.380
Policy No. Ont
❑ Certified cop Is Is for ted.
❑ Certified c is s he city in division.
Applicant
FIRESPRINK
Y ❑ N ❑
ENERGY T-24
v ❑ N❑
MISC.- REFER TO ORD.
PERMIT ISSUANCE 10.00
FL000 zoNE
A.L.u.c.
CERTI EXEMPTION FROM WO
PLG. CONTE. LIC. NO.
PLG.
TOTAL
PIiN$ATION IN SURANCC
(This section eed not be completed if the permit is fur one
V❑ N❑
Y❑ N❑
QTY. MECHANICAL PERMIT FEE
FEE SUMMARY
hundred dollars ($100) or less.)
I certify that in the performance of the work for which this per-
mit is issued, 1 shall not employ uny person in any manner so as to
become suhject to the Workers' Compensation Laws of California.
Date Applicant
NOTICE TO APPLICANT: 1(, after making this Certificate of Ex-
emption, you should hecome subject to the Workers' Compensation
BUILDING
ALTER OR ADD TO MECH. 5.00
APPLIANCE 5.00
PLAN CHECK
provisions of the Labor Code, you must forthwith comply with
such provisions or this permit shall be decined revoked.
FEE
AIR HANDLING UNIT (TO 10,000C.F.M.) 4.00
AIR HANDLING UNIT(OVER 10=C.EM.) 6.00
SEISMIC FEE
CONSTRUCTION LENDING AGENCY
I hereby affirm that there is a construction lending agency for
lhe,perforniance of the work for which this permit is issued (Sec.
3097, Civ.C.).
Lenders 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.)9.50
ELECTRIC
Lender's Address -
VENTILATION FAN (SINGLE) 4.00
PLUMBING
I 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 slate laws relating to buil g construction, and
BOILER-COMPI3 H.P. Or 100,000 B.T.U.) 6.00
BOILER -COMP (Over 100,000 BTU) SEE FEE SCH.
MECHANICAL
hereby authorize representatives of Ihis ty to enter upon the
above-mentioned property rinspe b urpoms.
(We) agree to save, e a keep harmless the City of
Cupertino against Iia 1 m ls, costs and expenses which
may. in any nst id City in consequence oft e
granting Orth, pe I
MISC. - REFER TO ORD.
CONST. TAX
PERMIT ISSUANCE 10.00 -
MECH. CONT. LIC. NO. MECH.
TOTAL
TOTAL
Signature of c ntmclor Date
L� OFFICE COPY