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APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALI- POINT PEN ONLY
BU LDI NG PROJECT I DENTI FICATI ON
APPLICATION & PERMIT
BUILDING -ELECTRICAL- PLUMBING -MECHANICAL
PERMIT NUMBER
0620
BUILDING,
ADOR
OW ER'S
N ME ��' �g
CITY. ELECTRIC PERMIT FEE
PLAN CHECK VALIDATION
HON �
NAME c oRs
NAME
S UTLETS- SWITCHES -RECEP 5.00/1.00 3
13 LIGHTING FIXTURES 5.00/1.00
LIC. .O.
DATE OF APPLICATION
,CONTRACTORS
ITY°Q} CUPERTINO
vHDrvE
PPLIANCES- RESIDENTIAL 4.00
�/}��
PANELS 5.00 J-"-
AfFCH(I'•TECT /��{1
198
SIGNS 6•.00
PLAN CHECK FEE P.C. NO.
�faCIN EEY e
LSC. NO,
SIGNS TRANS. 3.00
ARCH. OR ENO.
ADOR
AID' ZIP
SPECIAL CIRCUIT 5.00 _
PERMIT VALIDATION
TEMP. METER OR POLE INS. 15.00
APPLICANTS
ADDRESS
MOTORS SEE FEE SCH.
SERVICE CHANGE 10.00 /0 OV
LICENSED CONTRACTORS DECLARATION
..i aU
I hereby affirm that I am licensed under provisions of Chapter 9..3
(commencing with Section 7000) of Division 3 of the Rusintss and
Professions Code, and my license is in full force and effect.
License Class Lic. Number
ISSUANCE DATE
OG ELECT,
❑
PLG. MECH.
❑ ❑
Date Contractor
OWNER -BUILDER DECLARATION
I hereby affirm that 1 am exempt from the Contractor's License
Law for the following reason. (Sec. 7031.5. Business and Professions
Code: Any city or county which requires a permit to construct, alter,
improve, demolish. Or repair any structure, prior 10 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 he is exempt therefrom and
BUILDING PERMIT.
INFORMATION
MISC. REFER TO ORD
-
VALUATION
`moo
J
PERMIT ISSUANCE 6.00
ELEC. CONTR. LIC. NO.
ELEC. //
TOTAL �W
PERMIT TO
of�11
DTV. PLUMBING PERMIT FEE'
STORIES
TYPE CONSTR.
the basis for the alleged exemption. Any violation of Section 7031.5
by any applicant fora permit subjects $5000licant toacivil penalty
of not more than five hundred dollars the ap.
ALTER-DRAIN & VENT -WATER (EA.)4.001'.
❑ 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 ProfessionsDRAINS-FLOOR,
BACK FLOW PROTECT. DEVICE 200
,
OCC. GROUP.
RES.UNITS
/
ROOF, AREA, COND. 4.00
Code: The Contractor's License Law does not apply to an owner of
property who builds or improves thereon, and who does such work
himself or through his own employees, provided that such improve-
ments are not intended or offered for sale. If, however, the building
,1
0 FIXTURES - PER TRAP 4.00 o
SD. FT. FLOOR AREA
TOTAL ACREAGE
GAS-EA.SVSTEM-11NC.40UTLETS q.00 Uo
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.).
❑ h as owner of the property, am exclusively contracting with
GAS - EA. SYSTEM -OVER 4 (EA.) 1,00
BUILDING USE
E IND CON PB Omar
❑ ❑ ❑ ❑
INDUSTRIAL WASTE INTER. 20.00
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
LAWN SPRINKLERS - 1 INC 5 V.B. 5.00
LAWN SPRINKLERS - OVER 5 (EA.) 1.00
ASSESSORS PARCEL NO.
contracts for such projects with a conrractods) licensed pursuant to
the Contractor's License Law.
SEWER -SANITARY -STORM EA. 200ft/8.00
TRACT NO.
PARCEL NO.
❑ I am exempt under Sec .B.&PC forthis
reason WN A.. V%
WATER HEATER W/VENT 4.00
Date Owner
WATER SYSTEM 4.00
ACC. DATE
ACC. FILE NO,
WORKERS'COMPF.NSATION DECLARATION
WATER TREATING EQUIP. 4.00
I hereby affirm that I have a certificate ofconsent to self -insure.
or a certificate of Workers' Compensation Insurance, or a certified
ZONING
ENG. SITE NO.
copy thereof (Sec. 3800, LaDCA
Policy No. Company
FIRE SPRINK
Y ❑ IN El
ENERGY T 24
Y ❑ NO
❑ Certified copy is hereby furnished
❑ Certified copy is filed 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. LIC. NO.
PLG.
TOTAL d
COMPENSATION INSURANCE
(This Section need not be completed if the permit is for one
Y ❑ N❑
Y ❑ IN
hundred dollars IS 100) or less.)
1 certify that in the performance of the work for which this per.
mit is issued, 1 shall not employ any person in any manner so as to
CITY.MECHANICAL PERMIT FEE
FEESUMMARY-
BUILDING
d�s�
become subject to the Workers' Compensation Laws of California.
Dam ApplicantALTER
'
OR ADD TO MECH. 4.00
NOTICE TO APPLICANT: IL after making this Certificate of Ex-
emption, you should become subject to the Workers' 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.
AIR HANDLING UNIT ITO 10.000GF.M.) 3.00
FEE
AIR HANDLING UNITIOVER 10MC.F.M.)5.00
SEISMIC FEE
..
CONSTRUCTION LENDING AGENCY
1 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 (Sec.
3097. Civ.C.).
MICROFILM
HEATING UNIT ITO 100,000 B.T.U.) 4.00
HEATING UNIT (OVER 100,000 B.T.U.)7.50
ELECTRIC
7G 0, C)
,/��
Lender's Name iV
Lender's Address
I certify that I have read this application and state that the above
information is correct. I agree to comply with all city and county
ordinances and state laws relating to building construction, and
VENTILATION FAN (SINGLE) 3.00 PO
PLUMBING
_
per)
O -
BOILER -COMP QH.P.or100,000B.T.U.) 4.00
BOILER -COMP (Over 100,000 BTU) SEE FEE SCH.
MECHANICAL
4
0.2-
hereby authorize representatives of This oily to enter upon the
y
above-mentioned property for inspection purposes.
MISC. - REFER TO ORD.
PERMIT ISSUANCE 3.00 ..�
CONST. TAX
(We) agree to save, indemnify and keep harmless the City of
Cupertino against liabilities, judgments, costs and expenses which
ainat said City in consequence of the
ng
may in a"f_-II
MECH. CONT. LIC. NO.
MECH.Tj/V roTALTOTAL
377
nature Date
OFFICE COPY