13083APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
BUILDING PROJECT IDENTIFICATION
APPLICATION&PERMIT
BUILDING —ELECTRICAL— PLUMBING —MECHANICAL
PERMIT NUMBER
13083
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aD,REss
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OWNER'S
IME c � OSD
DTV. ELECTRIC PERMIT FEE
PLAN CHECK VALIDATION
DATE OF APPLICATION
C RACT 5
AME
CT .J4ALIE. No.
UTLETS -SWITCHES-RECEP 70.0011.00
LIGHTING FIXTURES 10.00/1.00
CONTRAS
ADDRESSTOR's
'3PHONE / 9(�OJ✓
APPLIANCES - RESIDENTIAL 4.00
PANELS 10.00
AR ITECT
OR
ENGINEER
LICNO.
PANELS IOVER 200 AMP) 20.00
PLAN CHECK FEE P.C. NO.
SIGNS TRANS. 3.00
ADDRESS END'
SPECIALCIRCUIT 5,00,
PERMIT VALIDATION
TEMP. METER OR POLE INS. 20.00
ZIP
n _
APPLICANT'S
AOORESa
MOTORS SEE FEE SCH.ov
SERVICE CHANGE 20.00
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LICENSED CONTRACTORS DECLARATION
1 hereby affirm that I am licensed under provisions of Chapter 9
ISSUANCE DATE
(commencing with Section 7000) of Division 3 of the Business and
Professions Code, ivAmy license Is In full fore �t •' y�
Livens C/j
S}n"s-y- _Lie. NumhcrO"�
Data /j Contractor
BLDG. ELECT.
PLG. MECH.
❑
x-
BUILDING PERMIT
/OWNER-BUILDL'R
DECLARATION
I hereby affirm that I am exempt from the Contractor's Ors License
Law forAldi the followingmason.whcheq iresu BusPermittO CI and Protestors
Code: Any city or county which structure permitmmnsuanLalter,
improve, demolish, or repair any structure, prior to its issuance, also
requires ns applicant for such permit to file n signed statement i That
he is licensed pursuant to the provisions of the ) ofTivloo s License
the
Law (Chapter 9 (commencing with Section is exempt the therefrom
Business and or that he is exempt therefrom and
INFORMATION
MISC. — REFER TO ORD
VALUATION
/O 0-�.-.�
PERMIT ISSUANCE 10.00 ,�
ELEC. DONTR, LIC. NO,
ELEC. L� 1l99 ,I
TOTAL V� `
PERMIT TO
'
DTV. PLUMBING PERMIT FEE
STORIES
TYPE CONSTR.
the basis for the alleged exemption. Any violation of Section 7031.S
he alleged exemption.
by any applicant for a permit subjects the applicant toa civil penally
more than five hundred dollars ($500).).
ALTER -DRAIN & VENT -WATER (EA.) 5.00
I, as owner of the property, or my employees with wages as
t n sole compensation, will do the work, and the MruClure is not
oxt
BACK FLOW PROTECT. DEVICE 4.00
OCC. GROUP
RES. UNITS
DRAINS -FLOOR, ROOF, AREA, COND. 5.00
intended or offered for sale (Sec. 7044, Business and Professions
Code: The Contractors License Law does not apply to an owner of
property who builds or improves thereon, and who does such work
FIXTURES - PER TRAP 5.00
SG. FT. FLOOR AREA
TOTAL ACREAGE
himself or through his own employees, provided that such improve-
mentsarenotintendedorofferedforsale. If, however. the building
GAS-EA.SVSTEM-11NC.40UTLETS 6.00
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.).
❑ 1, as owner of the property, am exclusively contracting with
GAS - EASYSTEM -OVER 4 (EA) 200
. . .
BUILDING USE
RES IND CON PB Omer
❑ ❑ ❑ ❑ ❑
.
INDUSTRIAL WASTE INTER30,00
licensed cnnlmocna to construct the project (Sec. 7044, Business
and Professions Code: The Contractor's License Law doua not upply
to an owner ulproperty who builds or improves therCon. and who
LAWN SPRINKLERS - 1 INC 5 V.B. 6.00
LAWN SPRINKLERS - OVER 5 (EA.) 1,00
ASSESSORS PARCEL NO.
contracts for such projects with a contractor(s) licensed pursuant to
the Contractor's License Law.
SEWER -SANITARY -STORM EA. 2001t/10.00 U
TRACT NO.
PARCEL NO.
❑ lam exempt under Sec.., BAP.C. forth)
reason
WATER HEATER W/VENT 6.00
Owner -
WATER SYSTEM 5.00ACC.
DATE
ACC. FILE NO,
WATER TREATING EQUIP. 5.00
WURK ERSCOMPENSATION UECLA RA N
I hereby uIl'um that 1 have a cerlilicate ol'eonsent to sell' -insure,
or a certificate of Workers' CompeaSthou Insurance, or a certified
ZONING
ENG. SITE NO.
Q Q
copy thereof(Sce. 3800, Lah.C.).
Policy NcE Company
FIRE SPRINK
y F] 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.
CER'TIFIC'ATE OF EXEMPTION FROM WORKERS'
PERMIT ISSUANCE 10.00 Id
FLOODZONE
A.L.U.C.
PLG. CONTE. LIC. NO.
TOTAL d-� A
COMPENSATION INSURANCE
(This section need not be completed if the permit Is for one
v ❑ N ❑
v ❑ N ❑
hundred 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
DTY. MECHANICAL PERMIT FEE
FEE SUMMARY
BUILDING
�' .
become subject to the Workers' Com pensut ion Laws of California.
Dale Applicant
NOTICE, TO APPLICANT: If, after making this Cetlil'icste of Ex-
ALTER OR ADD TO MECH. 5.00
APPLIANCE 5,00
PLAN CHECK
emption, you should become subject to the Workers' Compensation
provisions of the Labor Code, you must forthwith comply with
such provisions or this permit shall be deemed revoked.
FEE
AIR HANDLING UNIT (TO 10MCF.M.) 4,00
AIR HANDLING UNIT (OVER 10XIC.F.M.) 6.00
SEISMIC FEE
70
CONSTRUCTION LENDING AGENCY
1 hereby affirm that there is a construction lending agency for
EXHAUST HOOD (WITH DUCT) 5.00
the performance of the work for which this permit is issued (Sec.
3097, Civ.C.).
MICROFILM
HEATING UNIT (TO 100,000 B.T.U.) 8.00
HEATING UNIT (OVER 100,000 B.T.U.)9.50
ELECTRIC
50 ��
Lender's Name
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 slate laws relating to building construction, and
VENTILATION FAN (SINGLE) 4.00
PLUMBING
PO
Q �—
BOILER -COMP I3H.P.or t00,000B.T.U.) 6.00
BOILER -COMP Over 100,000 BTU) BEE FEE BCH.
MECHANICAL
hereby authorize representatives of this city to enter upon the
above-mentioned property for inspection purposes.
MISC. - REFER TO ORD.
CONST. TAX
(We) agree to save, indemnify and keep harmless the City of
Cupertino against liabilities, judgments, costs and expenses which
may in any way accrue, against said City in o osequencu of the
PERMIT ISSUANCE 10.00
granting of this permit.
MECH, CONT. LIC. NO. MECH.
TOTAL
TOTAL
�"
Signature of Applicant/Contractor Date
OFFICE COPY