6193T
APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY.
BUILDING PROJECT IDENTIFICATION
APPLICATION & PERMIT
PERMIT NUMBER
^
BUILDING
AvoREss
BUILDING - ELECTRICAL- PLUMBING - MECHANICAL
b
Owry ER's
PHONE
QTY. ELECTRIC PERMIT FEE
PLAN CHECK VALIDATION
CONTRACTORS
NAME
&AtOUTLETS - SWITCHES-RECEP 5.00/1.00
FIXTURES 5.00/1.00 6-4 -
( IC. R IMM2,IaLIGHTING
DATE OF APPLICATION
CONTRACTORS
ADDRESSFP;Q43r#f41PPLIANCES-RESIDENTIAL
01/-935 Put,
7D &vh;
4.00
( PANELS 5.00 s
ARCHITECT
OR -
ENGINEER r/CI'
LIC. NO,
SIGNS 6.00
PLAN CHECK FEE P.C. NO.
SIGNS TRANS. 3.00
AR, SS ENc'
ADDDDESSR
SPECIAL CIRCUITS 5.OQ S
PERMIT VALIDATION
EMP. METER OR PO IN 15.00
Zip
��S
ADDRESS
ESS
.ADDRESS
MOTORS S SEE FEE SCH. S
SERVICE CHANGE 10.00
LICENSED CONTRACTORS DECLARATION
PAID
1 hereby affirm that I am licensed under provisions of Chapter 9
(commencing with Section 7000) of Division 3 of the Business and
I'rofessions Cody and my licenx is in full force :
Liana nus_[._/ Lic-Number _ _Z`
Date _/0-/0.= Contractor
ISSUANCE DATE
BLDG.
❑
ELECT.
❑
PLG. MECH.
❑ ❑
BUILDINGPERMITj,'s,;t.
INFORMATION,:'
OWNER -BUILDER DECLARATION
hereby atire ollnn that I am exempt from the Contractor's Ifs License
Law to nycit ll of countywhihrequinng reason. (See sa permitto and tract. aloes
a cure permit m constranc alter,
Code: Any oily or county which structure,
or repair any slnittofi prior n its iatemen, also
improve, he applicant
requires the applic:ml for such penult to file a signed statement that
be 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 t embom and
.L
0 BffIt10
MISC. - EFER TO ORD
VALUATION
$/FT.
PERMIT ISSUANCE 6.00
ELEC. CONTR. LIC. NO.
ELEC. 99�x ^f
TOTAI0( xC
PERMIT TO
C
QTY. PLUMBING PERMIT FEE
STORIES
TYPE CONSTR.
the basis far the alleged exemption. Any violation ofSeclion 7031.5
ALTER -DRAIN & VENT -WATER (EA.) 4.00
by any applicant for a permit subjects the applicant to a civil penalty
of not mor' than five hundred dollars ($500).).
❑ I, is owner of the properly, or my employees with wages as
their sole compensation, will d0 the work, and the structure is not
BACK F LOW PROTECT. DEV ICE 2.00
OCC. GROUP
RES. UNITS
DRAINS- FLOOR, 'ROOF, AR EA, COND. 4.00
intended or offered for sale (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 does such work
FIXTURES - PER TRAP 4.00
So. FT. FLOOR AREA
TOTALACREAGE
himself or through his own employees, provided that such improve-
ments me not intended or offered for sale. If, however, the building
GAS - EA. SYSTEM- 1 INCA OUTLETS 4.00
or improves enl 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 purposenrsale.).
❑ I, as owner of the properly, am exclusively contracting with
licensed contractors to construct the project (See. 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 does not apply
to an owner of property who builds or improves thereon, and who
contracts fur such projects with a comractorts) licensed pursuant to
the Contractor's License Law.
LAWN SPRINKLERS - OV ER 5 (EA.) 1.00
5
SEWER -SANITARY -STORM EA. 200ft/8.00
TRACT NO,
PARCEL NO.
❑ Iumexemptunder Sec. ,B.&P.C.&utlin
reason
WATER HEATER W/VENT 4.00
Owner Dane
WATER SYSTEM 4.00
ACC.OATE
ACC. FILE NO.
WORKERS'COMPENSA'I']ON DELLA RAT ION
WATER TREATING EQUIP. 4.00
I hereby at Firm that 1 have a certificate ofconsenl to sell -insure.
or a Certificate of Workers' Compensation Insurance, or a certified
ZONING
ENG. SITE NO.
4copy the -yy� Scyy,,jj 80 Q.
Policy �,
FIRE SPRINK
v N
❑ ❑
ENERGY T-24
v N
❑ ❑
❑ fwrlilied Copy is hereby furnished.
CeHit, jI .e yRiy flyd, wi ❑ '' y jy1P lint division.
APPlic:u. t-4 lt^ _ S
MISC. - REFER TO ORD.
CENTIFICA1E017 EXEMPNON PROM WORKERS'
PERMIT ISSUANCE 6.00
FLOOD ZONE
A.L.U.C.
PLG. CONTR. LIC. NO.
PLG.
TOTAL
C041.NSAT'ION INSURANCE
(This section need not be Completed if the permit is for one
Y ❑ N
Y ❑ No
QTY. MECHANICAL PERMIT FEE
FEE SUMMARY
hundred dollars (S 100) or less.)
. I certify that in ole performance of the work for which this per-
mit is issued, 1 shall not employ any person inany trimmer so as to
become. subject to the Workers' ConlpunsatlonLaws of California.
Dare Appheant
NOTICE 'TO APPLICANT: If, after making this Certificate of Ex-
emmion, you should become subject to the Workers' Compensation
BUILDING
ALTER OR ADD TO MECH. 4.00
APPLIANCE 4.00
PLAN CHECK
provisions of one Labor Code, you must forthwith comply with
such provisions or this permit shall be deemed revoked.
FEE
AIR HANDLING UNIT (TO 10=C.F.NL) 3.00
AIR HANDLING UNIT (OVER 10=C.F.M.)5.00
SEISMIC FEE
CONSRUCTION LENDING AGENCY
EXHAUST HOOD (WITH DUCT) 2.00
MICROFILM
-
I herehy atfunl that there is or construction lending agency for
the perlonnance of the work for which this permit is issued (Sec.
3097, Civ.C. ).
HEATING UNIT (TO 100,000 B.T.U.) 4.00
H EATI NG UNIT (OVER 100,000 B.T.U.)7.50
ELECTRIC
oZ�a
Lender's Name
Lender; Address
I Certify that I have read this application and slate that the above
intoroution is correct. 1 agree to comply with all City and county
ordinances and state laws relating to building construction, and
VENTILATION FAN (SINGLE) 3.00
PLUMBING
BOILER- COMP (3 H.P. or 100,000 B.T.U.) 4.00
BOILER -COMP (Over 100,000BTUISEE FEESCH.
MECHANICAL
hereby authorize representatives oI'this city to eater upon the
above-onmioned property for inspection purposes.
misc.- REFER TO ORD.
(We) future to Savo, indemnify and keep harmless the City of
Cupertino against liabilities, judgments, costs and expenses which
may,%Ywpap,,ac*mupsI said City in conseyuence of the
CONST. TAX
PERMIT ISSUANCE 3.00.r1im
MECH. CONT. LIC. NO.
MECH.14D-/o TOTAL
TOTAL
Slgnac Date
OFFICECOPV