3631APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
BUILDING PROJECT IDENTIFICATION
APPLICATION & PERMIT
BUILDING - ELECTRICAL- PLUMBING - MECHANICAL
P MITNUMEER
631
PLAN CHECK VALIDATION
BUILDING
ADDRESS
sTN (' I
NAME
f PHONE �f �Z
'-y sy .p • - 'T
OTV. ' ELECTRIC PERMIT .. FEE'"
.IOAMERACTORs
UTLETS-SWITCHES-RECEP 5.00/1,00
LIGHTING FIXTURES 5.00/1.00
LIC. No.
CONTRACTOR'S
ADDREu
APPLIANCES 4.00
PANELS 5.00
PHONE
PHONE
DATE OF APPLICATION
ARCHITECTSIGNS
OR
ENGINEER
uc. NO.
6•QQ
PLAN CHECK FEE P.C. NO.
SIGNS TRANS. 3.00
ADDRESS E"O
SPECIAL CIRCUIT 5,0Q
PERMIT VALIDATION
EMP. METER OR POLE INS. 15.00
ZIP
0/.3
APPLICANT',
ADDRESS
IMOTORS SEE FEE SCH.
SERVICE CHANGE 10.00
/ 0i
LICENSED CONTRACTORS DECLARATION
1 hereby affirm that 1 am licensed under provisions Of Chapter 9
(commencing with Section 7000) of Division 3 of the Business and
Professions Code, and my license is in full force and effect.
License Class Lic. Number
ISSUANCE DATE
RL.ELECT.
El❑
PLG. MECH.
11❑
Date Contractor
'G �cBUICDINO QERMIT(jn�,
*•--t�`,._INFORMATIONa•„s;;as-.
OWNER -BUILDER DECLARATION
1 hereby affirm that I am exempt from the Contractor's License
Law for the following reason. (Sec. 7031.5, Busummand Professions
COdel Any city Or County which requires a permit to Construct, alter.
improve, demolish, or repair any structure, prior to its issuance, amELEC.
requires the applicant for such permit to file a signed statement that
he is licensed pursuant to the provisions of the Contractors License
Law (Chapter 9(commencing with Section 7000) of Division 3 of the'1
Bu-iness and Professions Code) or that he is exempt therefrom and
the basis for the alleged exemption. Any violation of Section7031.5
by any applicant to, five permit subjects lheapplican, too Civil penalty
of not more than five hundred dollars (5500).1:
REFER TO ORDr's
ALUATION
I&
I
S/FT:
'
PERMIT ISSUANCE 6.00
ELEC CONTR. LIC. NO.
TOTAL
PERMIT TO
OTV.' y( 1, PLUMBING ,PERMITM, - •;m, + �FEEr;`
e - - .-z.' '.s _'�!,'i',a a
STORIES
rale
PE CONSTR.
ALTER -DRAIN VENT -WATER (EA.) 4.00
❑ 1, 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
OCC. GROUP
BACK FLOW PROTECT. DEVICE 2.00
Ila RES. UNITS
DRAINS -FLOOR, ROOF, AREA, COND. 4.00
Code: The Contract.,', License Law does not apply to an owner of
properly who builds or improves thereon, and who does such work
himself or through his own employees. provided that such improve-
mentsarenot intended or offered for sale. If, however. the building
FIXTURES -PER TRAP 4.00
SO. FT. FLOOR AREA
TOTAL ACREAGE
GAS -EA. SYSTEM -1INC. 4 OUTLETS 4,00
or 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
. ..
GAS - EASYSTEM •OVER 4 IEA) 100
BUILDING USE
RES IND CON PB Other
❑ ❑ ❑ ❑ ❑
.
INDUSTRIAL WASTE INTER20.00
LAWN SPRINKLERS - i INC 5 V.B. 5.00
LAWN SPRINKLERS - OVER 5 (EA.) 1.00
ASSESSORS PARCEL NO.
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
thNradsfor ctor'shcenects Lwilhaconlract.rls) licensed pursuant to
the Contractor's License Law.
SEWER -SANITARY -STORM EA. 200ft/8.00
TRACT NO.
PARCEL NO.
❑ lam exem torr tier sec. .B.&Poco for this
reason
WATER HEATER W/VENT 4.00
Date1114-Owner
WATER SYSTEM 4,00
ACC. DATE
ACC. FILE NO.
WATER TREATING EQUIP. 4.00
WORKERS'COM LN 'ION DECLARATION
1 hereby atrirm that 1 have a certificate of consent to self -insure.
or a certificate of Workers' Compensation Insurance. or a certified
ZONING
ENG, SITE NO.
copy themof(Sec. 3800, Lab,C.L
Policy No. Company
FIRE SPRINK
Y ❑ N❑
ENERGY T-24
Y ❑ N❑
❑ Certified copy is hereby furnished.
❑ Certified copy is riled with the city inspection division.
Applicant
MISC.- REFER TO ORD.
CERTIFICATE OF EXEMPTION FROM WORKERS'
PERMIT ISSUANCE 6.00
FLOOD ZONE
A.L.U.C.
PLG. CONTR. Llc. NO.
PLG.
I TOTAL
COMPENSATION INSURANCE
(This section need not be completed if the permit is for one
Y ❑ N ❑
Y ❑ N ❑
OTV. - t�MECHANICAL PERMIT - FEE-}I=sy,'1FEE'
;: •, a, -^-
^' '"`-"^" '=- •" ` ^•" •�Y'.-i ..: :. S,'••+.'"S.
sum
MARY
hundred dollars(SI00) or less.)
I certify that in the performance .f the work for which this per.
mit is issued, I shall not employ any person in any manner so as to
becomesubjecttotheWorkers'Compermation Laws of California.
Date ApplicantALTER
BUILDING
OR ADD TO MECH. 4.00
NOTICE TO APPLICANT: If, after making this Certificate of Ex-
emption, you should become subject to the Workeri Compensation
APPLIANCE 4.00
PLAN CHECK
provisions of the Labor Code, you must forthwith comply with
such provisions or this permit shall be deemed revoked.
FEE
AIR HANDLING UNIT (TO 10=C.F.M.) 3.00
AIR HANDLING UNIT(OVER 10=C.F.M.)5.00
SEISMIC FEE
�.
CONSTRUCTION LENDING AGENCY
I hereby affirm that there is a construction lending agency for
EXHAUST HOOD (WITH DUCT) 2.00
the performance of the work for which this permit is issued (See.
3097. Ci,,C,).
MICROFILM
HEATING UNIT (TO 100,000 B.T.U.) 4.00
HEATING UNIT (OVER 100,000 B.T.U.)7.50
ELECTRIC
Lender's Name
Lender's Address
I certify that 1 have read this application and state that the above
VENTILATION FAN (SINGLE) 3.00
information is correct. I agree to comply with all city and'"Curly
ordinances and state laws relating to building construction, and
PLUMBING
BOILER-COMPI3 H.P. or 100,000 B.T.U.) 4.00
BOILER -COMP (Over 100,000 BTU) SEE FEE SCH.
MECHANICAL
hereby authorize representatives .f this city to enar upon the
above-mentioned property fCr inspection purposes.
MISC. • REFER TO ORD.
CONST. TAX
(We) agree to vve, indemnify and keep harmless the City of
Cupertino against liabilities, judgments, costs and expenses which
may In way accrue against Id Ily I omCq.,, ,c .1 Nle
gra this permit
-
PERMIT ISSUANCE 3.00
MECH. CONT, LIC. NO.
MECH.
TOTAL
-..•'•If.rv,tyyy{mry
- 'Y
;,,TOTAL -3
Sin ure of Ap an[/C ,actor Date
U OFFICE COPY