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APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALLPOINT PEN ONLY
BUILDING PROJECT IDENTIFICATION
APPLICATION & PERMIT
BUILDING - ELECTRICAL- PLUMBING - MECHANICAL
PERMIT NUMBER
6191
arnLGIND
AuoRESs
�O F, 'a C, r.A rV
J V� l�
OWNER'S
Na E I . • ,(JE'
CUFM `- PHONE
OTY. - ELECTRIC PERMIT' FEE
PLAN CHECK VALIDATION
NATE of APPLICATION
GO ry a c OR's
NAME t / CL 0A �7�-
1 1 uc. N.44IN-�So1
UTLETS- SWITCHES -RECEP 5.00/1.00
LIGHTING FIXTURES 5.00/1.00
CONTRACTORS
ADDRESS M1
1 I -(51, 11-
,HONE
APPLIANCES - RESIDENTIAL 4.00
PANELS 5.00
ARCRITECT
OR
ENGINEER LIC.
c. No.
SIGN$ 6.00
PLAN CHECK FEE P.C. NO.
SIGNS TRANS.
ARCH. OR ENG.SPECIAL
ADDRESS
ZIP
CIRCUIT 6,QQ
PERMIT VALIDATION
S
EMP. METER OR POLE INS. 15.00
ADDRESS
APPLICANT'SMOTORSIC
SEE FEE SCH.
SERV E CHANGE 10.00
LICI?NSED CONTRACTORS DECLARATION
1 hereby affirm that I am licensed under provisions of Chapter 9
(en h Inane ng with S,,Ii.R 7000) of Division 3 ol'the Business and
Professions Cod -, anEd� my liccnsc is in full for y zd�eIt
liccnsc Class CT _ Lic. Number. U
ISSUANCE DATE
BLDG.
❑
ELECT.
❑
PLG. MECH.
❑
-
Iltd c'_kQ. _ .Contractor_
BUILDING PERMIT
OWNIiR-BUILDIiR DFCLARA 'I
I hereby .11 -on, that I am exempt from the Contractor, License
Law for the following reason, (Sec. 7031.5, Bosinessand Professions
Code: Any city or county which requires a permit to construct. alter.
improve, demolish, or repair any slmcture, prior 10 its issuance, also
INFORMATION
MISCREFER TO ORD
. -
VALUATION
S/FT.
PERMIT ISSUANCE 6.00
ELEC. CONTE. LIC. NO.
ELEC.
requires lire applicant for such permit to file a signed statement that
tic Is licensed pursuant to the provlslo x DI the Contractors License
L.. (Chapter 9(commencing`with Section 7000) of Division 3 ofthe
Business and Professions Code) or that he is exempt therefrom and
the basis I'or the alleged exemption. Any violation of Section 703 t.5
TOTAL
PEflMT O
,�
/V1
/"/0 ,
OTY. PLUMBING PERMIT FEE
STORIES
TYPE CONSTR.
ALTER -DRAIN -WATER IEA.14.00
by any applicant for a permit subjects the applicant to a civil penalty
of not more than five hundred dollars ($500).):
BACK FLOW PROTECT. DEVICE 2.00
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, AR EA, COND. 4.00
C(de: The Contractor's License Law does not apply to an owner of
properly Who builds or Improves thereon, and who does such Work
FIXTURES - PER TRAP 4.00
SO. FT. FLOOR AREA
TOTAL ACREAGE
hinhsell' or through his own employees, provided that such inmrove-
ntents are not intended or offered for sale. If, however, the building
GAS - EA. SYSTEM -1 INC.4 OUTLETS 4.00
r 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.) 1.00
BUILDING USE
RES IND CON PB Omer
INDUSTRIAL WASTE INTER. 20.00
LAWN SPRINKLERS- 1 INC 5 V.B. 5.00
ASSESSORS PARCEL NO.
and Professions Code: The Contractor's License Law docs not apply
torn owner of property who builds or improves thereon. and who
LAWN SPRINKLERS - OVER 5 IEA.) 1.00
amtrvaslctor'shceProject, Lwithucuntractngs) licensed pursuant to
the C.nlracmr's License Law.
SEWER -SANITARY -STORM EA. 200ft/8.00
TIT ACTNO.
PARCEL NO.
WATER HEATER W/VENT 4.00
❑ I am exempt under See . B.&CC. for this
on,
Owner Dale
WATER SYSTEM 4.00
ACC. DATE
ACO. FILE NO.
WORKERS'COMPFNSATION DI'CI.ARA'f ION
WATER TREATING EQUIP. 4.00
I hereby :dfirm that 1 have a cerliticatc of consent tosell'-insure.
or a certificate of Workers' Conipensal ion Insure '•rtificd
copy tire, See 38 0, 1�C g,
-
ZONING
ENG. SITE NO.
I'nlic oti,§>-1 iyalt �s.-
CcrtireTTTT'opynherebyfumaheJ.
FIRE BPRINK
ENERGY 24
Cl Certified copy o filed with the airy inspection division.
Applicant
Y ❑ NE]
Y C] N�
MISC. - REFER TO ORD.
CERTIFICATE OF EXEMPTION FROM WORKERS.
PERMIT ISSUANCE 6.00
FLOOD ZONE
a. L.u.c.
PLG, CONTR. LIC. NO.
PLG.
TOTAL
COMPENSATION INSURANCE
1'1'his section need not be completed if the permit is for one
Y E] N
Y N�
F-PAII Li
pTy MECHANICAL PERMIT FEE
-lL'
l
FEE SUMMARY
hundned dollars IS 100) or IessJ
I 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
licence subject to the W .,kers' Compensat ion Laws of California.
Dam Applicant
BUILDING
ALTER OR ADD TO 4.00
NOIICIi 'I'O APPLICANT: 11', after making this Certificate of 1°x-
Cmptior, you should becomC subject to the Workers' Compensation
provisions of the Labor Code, you First InHhwilh comply withFEE
such provisions or this permit shall be deemed revoked
APPLIANCE 4.00
PLAN CHECK
AIR HANDLING UNIT ( 0 -00
AIR HANDLING UNIT (OVER IO,OODC.F.M.) 5.00
SEISMIC FEE
CONSTRUCTION LENDING AG17NCY
EXHAUST HOOD (WITH DUCT) 2.00 -'
MICROFILM
I hereby affirm that there is a construction lending agency for
III performance of the work for which this permit is issued (Sec.
3097, Civ.CT.
HEATING UNIT (TO 100,000 B.T.U.) 4.00
HEATING UNIT (OVER 100,000 B.T.U.17.50
ELECTRIC
-
LName
Lender's Addressender's
I certify that I have read this application and state that the above
information is correct. 1 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
abuvomentioned property for inspection purposes.
[
V ENT a ON N ( ING E) 3.00 p
PLUMBING
BOILER- 13 P. Or 10 00 B.T.U.) 4.00 a-
'a BOILER -COMP fOver100pOOeTU1SEE FEE SCH.
of
MECHANICAL
-�
MISC. - REFER TO ORD.
CONST. TAX
(We) agree to save, indemnify and keep harmless the City' of
Cupertino against liabilities, judgments, costs lid expenses which
may i any way accrue against said Cit in sequence of the
gran of this PC, IT. rr
u 1i/U{_\ 1� IO-� IU-
r
PERMIT ISSUANCE 3.00 1 J
MCH. CONT. LIG NO,
`�
MECH.
or"L S �f 0 °
%
TOTAL
t roof Applicant/Contractor Date
OFFICE COPY