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APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY -
BUI LD1 NG PROJECT.I DENTI FICATION
APPLICATION & PERMIT
BUILDING - ELECTRICA- PLUMBING - MECHANICAL
L
PERMIT NUMBER
6295
AOGRESG
OWNER'S
NAME`/
PHONE
__ -
QTY. ELECTRIC PERMIT FEE
PLAN CHECK VALIDATION
DATE OF APPLICATION
CONTRACTOH'r
NA FI
T- /V2: O LIC -NO. LJI%x'L
OUTLETS - SWITCHES=RECEP 5.00/1.00
LIGHTING FIXTURES'" 5.00/1.00
CONTRACTOR'S 0PPLIANCES
ADDRESS
`7�/D fes✓ PHONE 2
- RESIDENTIAL 4.00
PANELS 5.00
OR
ENGINEER
LIG, No,
SIGNS 6.00
"PLAN CHECK FEE P.C. NO.
SIGNS TRANS. 3.00
moo eOR ENG.
zm
SPECIALCIRCUIT 5.00
PERMIT VALI DATION
+
l
ISSUANCE DATE
BLD ELECT. PLG. MECH.
❑ ❑ ❑
TEMP. METER OR POLE INS. 15.00
ADDRESNT's
ADDRESS
MOTORS SEE FEE SCH.
SERVICE CHANGE 10.00
LICENSED CONTRACTORS DECLARATION
1 hereby affirm that I am licensed under provisions of Chapter9
(.U.lmeneing with Section 7000) Of Division 3 of the Business and
I'rofcssions Cndc, J n I''-nsc is in lull furck and Of c�
I;ate - Class Loc. Number L
Dated C7�Contractor ?--'�
OWNER -BUILDER DECLARATION
I hereby affirm that I am exempt from the Contractors 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 be 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(S500)J:
❑ 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
Code: The Contractor's License Law does not apply to an owner or
property Who builds or Improves thereon, and who does such work
himself or through his own employees, provided that such int prove.
ments are not intended or offered for sale. If, however, the building
or improvement is sold within one year of completion, the owner -
builder will have the harden of proving that he did not build or im-
prove for purpose of sale.).
❑ L as owner of property, um exclusively contracting with
rs
licensed contracto: 1. constrctth
u e project (Sec. 7044,Business
and Professions Code The Contractor's License Law Joos not apply
to ownar nl property who builds tl improves thereon. and who
contrtr each acts for ch projeccts with a cmrtractor(s) licensed pursuant to
Binorielaw.
Imuv
O um exemptpIruenmder Sec ,B &P.C. far this
reason
AIG
y -
- �7
0 � 3- p
•l,C-
BUILDING PERMIT
INFORMATION
MISC. - REFER TO 011D
PERMIT ISSUANCEVALUATION
6.00
/
SIFT.
ELEC. CONTR. LIC. NO.
ELEC.
TOTAL
PER
'
OTY. PLUMBING PERMIT FEE
TO
C
TYP CONSTR,
RES. ONITS
ALTER -DRAIN & VENT -WATER (EA.) 4.00
BACK FLOW PROTECT. DEVICE 2.00
DRAINS -FLOOR, ROOF, AREA,COND. 4.00
FIXTURES - PER TRAP 4.00
GAS - EA. SYSTEM - 1 INC.4 OUTLETS 4.00
SO. FT. FLOOR AREA
TOTAL ACREAGE
GAS - EA. SYSTEM - OVER 4 (EA.) 1.00
BUILDING USE
PB O
❑ N ❑
ASSESSORS PARCEL NO.
INDUSTRIAL WASTE INTER. 20.00IND
.
LAWN SPRINKLERS -1 INC5 VB. 5.00
LAWN SPRINKLERS -OVER 5 (EA.) 1.00
SEWER -SANITARY -STORM EA. 200ft/8.00
TRACT NO.
PARCEL NO.
WATER HEATER.W/VENT 4.00
UwncrDate
WATER SYSTEM 4.00
WORKERS'COMPHNSAI ION DECLARATION
1 hereby affirm that I have a certificate ofconsont to wU-insure,
or is certificate of Workers' Compensation �Insurance, or a certified
cupy Ihereol(Set. 3800, Lab.C.). / / ♦ /tom
IYdiCY ''. Company L✓ [
ACC. -DATE
ACC. FILE NO.
WATER TREATING EQUIP. 4.00
ZONING
ENG. SITE NO.
urfilled Copy is hereby fumlhcd.
Cent opY fie with a city inspection division.
Applicant �.�
FIRE SPRINK
Y NE]
ENERGYT]4
Y ❑ No
MISC. - REFER TO ORD.
CER1'IEICATIi OlrEXEMPI'JUN FROM WORKERS'
COMPENSATION INSURANCE
(This section need not be completed if the permit is for one
hundred dollars ( S 100) or Iess.)
I certily that in file performance of the work, for which this per-
mit is issued, 1 shall not employ any person in any manner so as to
become subject to the Workers Compensation Laws of Califomia.
Date Applicant
PERMIT ISSUANCE 6.00
FLOOD ZONE
Y ❑ N
A. L. u.c.
Y [-] No
PLG.CONTR. LIC. NO.
PLG.
TOTAL
-
CITY. MECHANICAL PERMIT FEE
FEE SUMMARY
BUILDING
ALTER OR ADD TO MECH. 4,00
N(1TICE "10 APPLICANT: If, after making this Certificate of Ex-
emption, you should become subject to the Workers' Compensation
provisions of the Labor Code, you most forthwith comply with
,net, stivisioro or this permit shall be devoted revoked.
CONSTRUCTION LENDING AGENCY
I hereby affirm that there is a construction lending agency for
the performance of O le work for which this permit is issued (SeC.
3097, Civ.C.).
Lender's Name
App LI ANCE 4.00
AIR HANDLING UNIT (TO 10=C.F.N1') 3.00
PLAN CHECK
FEE
AIR HANDLING UNIT(OVERIQOOOC.F.M.) 5.00
SEISMIC FEE'
EXHAUST HOOD (WITH DUCT) 200
.
MICROFILM
'
HEATING UNIT (TO 100,000 B.T.U.) 4.00
Lender's Address
1 certify that I have read this application and state that the above
inl'000ation 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.
(We) agree 10 save, indemnify uGO keep harmless the City of
Cupertino against liabilities, judgments, costs and expenses which
may in any way accrue against said City in consequent of the
granting oft Ip e i1. /f
CL lr �Y
HEATING UNIT (OVER 100,000 B.T.U.)7.50
ELECTRIC
VENTILATION FAN (SINGLE) 3.00
BOILER-CONP(3H.P.cr 100,000B.T.U.) 4.00
PLUMBING
BOILER -COMP IOser 100,000 BTU) SEE FEE SCH,
MECHANICAL
MISC. - REFER TO ORD.
PERMIT ISSUANCE 3.00
CONST. TAX
MECH. CONT. LIG NO. MECH.
TOTAL
'
TOTAL
Signature of Apphcant/Contractor ' Dat r^
OFFICE COPY