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APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
BUILDING PROJECT IDENTIFICATION
-
APPLICATION & PERMIT
4LDING- ELECTRICAL- PLUMBING -MECHANICAL
PERMIT NUMBER
6980
BUILDING
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NAMERS A 1//(� L6AGuG
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PHONE
OTV. ELECTRIC PERMIT FEE
PLAN CHECK VALIDATION
CONTRACTORS
NAME
UTLETS- SWITCHES -RECEP 5.00/1.00
LIGHTING FIXTURES 5.00/1.00
LIG. No.
'
CONTRACTORS
ADDRESS
PPLIANCES- RESIDENTIAL 4.00
PANELS, 5.00
PHONE
DATE OF APPLICATION -
ARCHITECT -
on
ENGINEER
LIC. No.
SIGNS 6.00
PLAN CHECK FEE P.C. NO.
'
-
SIGNS TRANS. 3.00
ADD ESS ENG -
SPECIALCIRCUIT 5.00
PERMIT VALIDATION
EMP. METER OR POLE INS. 15.00 -
ZIP
AADDRESS
ORE55 ,
MOTORS PSffFEE SCH.
SERVICE CHANGE 10A0
LICENSED CONTRACTORS DF;CLARATION � �
1
Utl, n 10sin
I hereby affirm that I 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 forceand effect
License Class - Lie. Number
ISSUANCE DA E
City of ClIppirtinrl
BLDG.
❑
ELECT.
❑
PLG. MECH.
❑ ❑
Uate Contractor -
BUILDINGPERMIT
INFORRMM ATION
OWNI:R-B(JILDI:R.DIiCLARA'r10N
I hereby affirm that I am exempt from'the Contractor's License
Law futile following mason. (See. 7031.5, Business and Professions
Code: Any city or county which requirespermit to construct, alter,
improve, demolish, or repair any structure, prior ,o its issuance, also
requires the applicant for such permit to file a signed statement that
he is licensed pursuant to (he provisions of the Contractor'slicense
Law (Chapter9(cammeaciny with Section 70001of Division 3ofthe
Business and Professions Code) or that he isexcmpt therefrom and
MISC. - REFER TO ORD
PERMIT ISSUANCE 6.0.�._
0
VALUATION
S/FT.
ELEC. CONTR. LIC. NO.
,.
ELEC.
TOTAL
PERMITTO
PO LU;3R.
QTY. PLUMBING PERMIT FEE
1
STORIES
TYPE CONSTR.
the basis for the alleged exemption, Any violation of Section 7031.5
by any applicant for a permit subjects the applicant toucivil penalty
of not more than five hundred dollars (SSOOM:
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
BACK FLOW PROTECT. DEVICE 2.00
-
OCC. GROUP
- RES. UNITS
DRAINS -FLOOR, ROOF, AREA, COND. 4.00
intended or offered for sale (Sec. 7044, Business and Professions
Code: Pile 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 impro
mvC-
ents are not intended or offered for sale. If, however, the budding
FIXTURES - PER TRAP 4.00
SO. FT, FLOOR AREA
TOTAL ACREAGE
GAS - EA. SYSTEM - 1 INC.4 OUTLETS 4.00
or improvement is sold within one year of completion, the owner.
builder will have the burden ofpmving that he did not build or im-
prove for purpose ofSale.).INDUSTRIAL
U I, as owner of the property, em exclusively contracting with
GAS - EA. SYSTEM -OVER 4 (EA.) 1.00
-
eutL01NG USE
RES IND CON PB Omar
❑ ❑ ❑ ❑ ❑
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 ptoperty who builds or improves thereon, and who
LAWN SPRINKLERS- 1 INC 5 V.B. 5.00
LAWN SPRINKLERS -OVER 5 IEA.) 1.00
ASSESSORS PARCEL NO.
contracts for such projects with a contraetoMs) licensed pursuant to
the Contractor's License L.ov.
SEWER -SANITARY -ST CAM EA. 200ft/8.00
TRACT NO.
PARCEL NO.
❑ l am uxempt under Sec. . B.&P.C. for this
mason
.WATER HEATER W/VENT 4.00
Owoer/- 6 Dare
WATER SYSTEM 4.00
ACC, GATE -
ACC. FILE NO.
WATER TREATING EQUIP. 4.00
WORKERS'COMPENSA'rION DLCLAkA(ag,� T10N
1 hereby affirm that I have a certificate of consent to sell' -insure,
or a certificate of Workers' Compensation Insurance, or a certified
ZONING
ENG. SITE NO.
copy thereof (See, 3800, LdNCJ.
'Policy No. Company
❑ Certified copy is hereby furnished.
❑ Certified copy is filed with the city inspection division.
Applicant - '
FIRE SPRINK
Y ❑ N ❑
ENERGY T-24
Y ❑ IN
MISC. - REFER TO ORD.
r
CERTIFICATE OF EXEMPTION FROM WORKERS'
- PERMIT ISSUANCE 6.00
FLOOD ZONE
A.L.U.C.
PLG.CONTR. LIC. NO.
PLG.
TOTAL
COMIIENSATION INSURANCI'
(This section need not be completed if the permit is for one
Y ❑ N❑
Y ❑ N❑
TY. MECHANICAL PERMIT FEE
FEE SUMMARY
himdred dollars ($100) of less.),
I ceHify, 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
become subject to toe Workeri Compensation Laws of California.
Date Applicant
BUILDING
ALTER OR ADD TO MECH. 4.00
NOTICE 1'0 APPLICANT: If, after making this Certificate of fix-
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,
APPLIANCE 4.00
PLAN CHECK
FEE
AIR HANDLING UNIT (TO 10MC.F.M.) 3.00
AIR HANDLING UNIT(OVER109MC.EM.)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 (Sec.
3097, 0,C.).
MICROFILM
HEATING UNIT (TO 100,000 B.T.U.) 4.00
HEATING UNIT (OVER 100,000 B.T.U.)7.50
ELECTRIC
a
Lender's Name
Lender's Address
I certify that I have read this application and state tile, the above
information is correct. Degree to comply with all City andCOUnt;
ordinances and stale laws relating to building construction, end
VENTILATION FAN (SINGLE) 3.00
PLUMBING
BOILER-COMPI3H.P.or100,000B.T.U.I 4.00
BOILER -COMP (Over 100,000 BTU) SEE FEE SCH.
MECHANICAL
hereby authorim representatives of this city Io enter upon the
above-tnenlinned properly 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 ex pensee which
may in any way accrue against said City in con seyRenee of the
PERMIT ISSUANCE 3.00
grant' gof thi permit.
G O
MECH,CONT. LIC. NO. MECH.
TOTAL
TOTAL
ignutme of Applcint/Con,rmfor Dat
OFFICE COPY