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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
BUILDING
ADDHESS13274
' 1 /1-
l/•
OWNER'5
PLAN CHECK VALIDATION
NAME �]�aJ
Vr �o PHONEW[-
QTY. ELECTRIC PERMIT FEE
N°AMERACLDRs
UTLETS-SWITCHES-RECEP 10.00/1.00
LIGHTING FIXTURES 10.00/1.00
wi?&Lo LIC. No
-
/DDRESSTORG��L�J1�.l iC-C
PPLIANCES- RESIDENTIAL 4.00
PHONS.3-n-zozo
PANELS 10.00
DATE OF APPLICATION
1OLTITECT
OR
ENGINEER
uc. NO.
PANELS (OVER 200 AMP) 20.00
PLAN CHECK FEE P.C. NO
SIGNS TRANS. 3.00 '
ADDRESS ENG
SPECIAL CIRCUIT 5.00
PERMIT VALIDATION
EMP. METER OR POLE INS. 20.00
' ZIP
1/ �.. ✓ a
`SOW ✓
APPLICA
A
ADDRESS
MOTORS SEE FEE SCH.
SERVICE CHANGE 20.00
/p-
7�La 7 7
LICENSEUCONI'RACTORSDECLARATION
1 hereby affirm that I am licensed under provisions of Chaptcr 9
(commencing with Section 7010) of Division 3 of the Business andprofe
Lice. ions Co it. y license u in (all fur a and e f et
Inn Lic. Number
ISSUANCE DATE
BLDG. ELECT. PLG. MECH.
11El El
Date Contractor
,
OWNER -BUILDER DE RATION
1 hereby allure that 1 am exempt from the iremContractor'sil'fessiom
Lew for the following reason. (Sec. mires 5. OGH tssand Pmfessiom
Code: Any city or county which requitum permit locos suance,
BUILDING PERMIT
INFORMATION
VALUATION S/FT.
MISC.- REFER TO ORD
PERMIT ISSUANCE 10.00
ELEC. CONTR. LIC. N0.
ELEC.
TOTAL
also
improve, demolish, m repair any permit toff prior n Els issuance, alto
requires the applicant t to such revisit to Dk a Signed statement Li that
he is licensed pursuant t° the provisions of the Contractor's License
of t thins 3 ofthe
Law (Chapter 9 (commencingwith Section is exempt
,heroes and Code) or that and
exempt therefrom and
pERMIT
QTY. PLUMBING PERMIT FEE
STORIES
TYPE CONSTR.
he alleged
,he theaora exemption. vi l
nyapfor
tstheapliont to action malty
by any applicant fore permit dollars S5DO).licannoacivil penalty
of not more than five hundred dollars (5500)J:
ALTER-DRAIN-WATER(EA.) 5.00
❑ 1, as owner of the property, or my employees with wages as
their sole compensation, will do the work, and the Stn¢ture Is not
BACK FLOW PROTECT. DEVICE 4.00
C. GROUP
RES. UNITS
DRAINS -FLOOR, ROOF, AREA, COND. 5.00
intended or Offered for Sale (Sec. 7044, Business and Professions
Code: The Contractor's License law doe not apply to an owner of
FIXTURES - PER TRAP 5.00
SD. FT. FLOOR AREA
TOTAL ACREAGE
property who builds or improves thereon, and who does such work
himself or through his own employm, provided that seen improve.
mentsare�nol intended or offered for sale. If, however, the building
GAS-EA.SYSTEM-11NC.40UTLETS 6.00
or improvement is sold within one year of completion, the owner-
builder will have the burden o' proving that he did not build or im-
prove for purpose ofsaie.).
❑ 1, as owner of the property, am exclusively contracting with
GAS - EA. SYSTEM - OVER 4 (EA.) 2.00
BUILDING USE
RES IND Cox PB oma
❑ - ❑ ❑ ❑ ❑
INDUSTRIAL WASTE INTER. 30.00
licensed contractors to construct the project (Sec. 7044, Business
and Professions Code: The Contractor's License Law docs not apply
to an owner of property who builds or improves thereon, and who
LAWN SPRINKLERS - 1 INC 5 V.B. 6.00
LAWN SPRINKLERS - OVER 5 (EA.) 1.00
ASSESSORSPARCELNO.
contracts for such projects with a contractors) licensed pursuant to
the Contractors License Law.
SEWER -SANITARY -STORM EA. 200ft110.00
TRACT NO.
PARCEL NO.
❑ I am exempt under Sec. ,B.&P.C. for this
reason
WATER HEATER W/VENT 6.DO
Owner Date
WATER SYSTEM 5.00
ACC.DATE
ACC. FILE NO.
WATER TREATING EQUIP. 5.00
WORKERS'COMPENSATION DECLARATION
1 hereby affirm that I have a certificate of eunsenl to self-insurr,
or a certificate of Workers Compensation Insurance, or a certified
ZONING
ENG. SITE NO.
copy ther O( Sec 300, Lab.CJ.
PolicyN ` Company�GG.(Dd Ih�
FIRE SPRINK
v ❑ N ❑
ENERGY T 24
v ❑ N❑
Nj Certified copy is hereby famished.
❑- Cent l copy is file vi I he city inspection division.
Appli
IMISC. - REFER TO ORD.
:RTIFICATE OF EXEMPTI FROM WORKERS'
PERMIT ISSUANCE 10.00
FLOOD ZONE
A.L.U.C.
COMPENSATION INSURANCE
(This section need not be completed if the permit is for one
Y ❑ N ❑
Y ❑ N ❑
PLG. CONTR. ❑C. No.
PLG.
TOTAL
hundred dollars (S 100) or les.)
I certify that in the performance of the work for which this per-
mit is issued, I shall not employ any pernon in any manner Mu as to
become Subject to the Workers Compenwtion Laws of California.
Date Applicant
QTY MECHANICALIPEAMIT FEE
-
FEE SUMMARY
BUILDING
ALTER.OR ADD TO FAECH.�175.00
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 most forthwith comply with
Much provisions Or this permit shall ISe deemed revoked.
APPLIANCE •x t` 00
PLAN CHECK
FEE
AIR HANDLING U1JIT �T0110p00pF(Nl) 4.00
AIR HANDLING UNfr(OVERIiQWOCEM.) 6.00
SEISMIC FEE
CONSTRUCT ION LENDING AGENCY
1 hereby affirm that there is a construction lending agency for
EXHAUST HOOD (WITWDUCT) 5.00
the performance of the work for which this pemlit is Laved (Sec.
3097.CJ. 1
MICROFILM
HEATING UNIT (TO 100,000 B.T.U.) 8.00 . UU
Lenders Name
Leader's Address
HEATING UNIT (OVER 100,000 B.T.U.)9.50
ELECTRIC
I certify that 1 have read thisapplication and slate that the above
VENTILATION FAN (SINGLE) 4.00 -p
nformation is correct. I agree to comply with all city and county
ordinances and state laws relating to building construction, and
PLUMBING
Bq LER-CDMP(3 H.P.or 100,000 B.T.U.) 6.00
BOILER-COMP IOver 100,000 BTU) SEE FEE SCH.
MECHANICAL
s.,
3 V `%
`-
hereby authorize representatives of this cit, m enter upon the
albove-mentioned property for inspection purfO S.
(We) agree to save, indemnify and keep harmless the City of
Cupertino against liabilities, judgments• costs and expenses which
any way accrue against said City In cunrequence of the
MISC. - REFER TO ORD.
PERMIT ISSUANCE 10.00 (
O. Vof
CONST. TAX
this permit
MECH. CONT. LIC. NO. MECH.
.I_
r
TOTALL
2I -0D
TOTAL
nalurt of Applicant Coal for Date
OFFICE COPY