139351
APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
�- BUILDING40140JECT IDENTIFICATION
APPLICATION & PERMIT
BUILDING - ELECTRICAL- PLUMBING - MECHANICAL
PERMIT NUMBER
13935
RUILOING,,
°°°REae f� \�
l�
OWNER'S
NAME �J , 1) 1 ' _10
Vl dHONE
CITY. ELECTRIC PERMIT FEE
PLAN CHECK VALIDATION
CONTI-�
croR's
NAME
IsAsE
OUTLETS -SWITCHES-RECEP 10.00/1.00
LIGHTING FIXTURES 10,00/1.00
LIC. No,
NTRA
ADREScroR's
CO
D
APPLIANCES - RESIDENTIAL '4.00
PANELS 10.00
PHONE
DATE OF APPLICATION
ARCHITECT
on
ENGINEEfl'
Llc. NO.
PANELS (OVER 200 AMP) 20.00
PLAN CHECK FEE
ISIGNS TRANS. 3.00
ARCH. OR ENG.
ADDRESS
SPECIAL CIRCUIT 5.00
PERMIT VALIDATION
-
TEMP. METER OR POLE INS. 20.00
- ZIP
_
fr
- n�
y�J t'( f til •.
APPLICANTDDREssMOTORS
Z` ®q/� 1 V �gIVY�v.I C- `
SEE FEE SCH.
SERVICE CHANGE 20.00
LICENSED CONTRACTORS DECLARATION
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 fm11 force and effect.
License Class Lia Number
UA oATE f..
BLDG.
ELECT.
PLG MECH.
❑
Date Contractor
OWNER -BUILDER DECLARATION
1 hereby ul'firm that I am exempt from Him
m Contractor's License
Law for the following reason. (Sec. 7031.5, Businessand Professions
Code Any city or county which requires a permit to construct, alley,
improve, demolish, or repair any structure, prior t0 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
REFER TO ORD
PERMIT ISSUANCE 10.00
VALVA ON
U^' -4.d
$/FT.
CLEC. CONTR. LIC. NO. ELEC.
TOTAL
OTY. PLUMBING PERMIT FEE
EBMIT TO�
I
the basis for the alleged exemption. Any violation of Section 7031.5
STORIES
TYPE CO STR.
by any applicant for a permit subjects the applicant tun civil penalty
of not more Ion five hundred dollars ($500).)-
ALTER-DRAIN&VENT-WATER (EA.) 5.00
❑ I, 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 4.00
OCC. GROUP
RES. UNITS
DRAINS -FLOOR, ROOF, AREA, COND. 5.00 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
himself or through his own employees, provided that such improve-
mentsamno( intended or cloned For 5111C. 11, however, the building
FIXTURES - PER TRAP 5.00 �iU
SG, FT. FLOOR AREA
TOTAL ACREAGE
GAS-EA.SYSTEM-11NC.4OUTLETS ,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 ofsaleJ.NSTRIA
❑ I, as owner of the property, on exclusively coming with
rud
GAS - EA. SYSTEM - OVER 4 (EA.) 2.00 Q
BUILDING USE
RES IND CON pe Omer
❑ ❑ ❑ ❑ ❑
WASTE INTER
INDUSTRIAL . 30.00
liconsed contractors to construct the project (Sce. 7044, Business
and Professions Code: The Contractor's License Law dues not apply
m as owner of property who builds or improves thereon, 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 contractoNs) licensed pursuant to
the Contractors License Law.
SEWER -SANITARY -STORM EA. 200ft/10.00
TRACT NO.
PARCEL NO.
❑ I am exempt under Sec. ,B.&P.C. for this
reason
WATER HEATER W/VENT 6.00
Owner Darn
WATER SYSTEM 5.00 -'
ACC.DATE
ACC, FILE NO.
WORKERS'COMPENSATION DECLARATION
WATER TREATING EQUIP. 5.00 tWP"
I hereby affirm that I have a certificate of consent to self -insure,
or a certificate of Workers' Compensation In science, or u certified
Alam D
ZONING
ENG. SITE NO.
copy Ihereol'(Sec. 3800, Lab.C.).
Policy No. Company
-
FIRE SPRINK
Y ❑ - N
ENERGY T-24
V ❑ NC]
❑ Certified copy is hereby furnished.
❑ Certified copy is Filed with the city inspection division.
Applicant
MISC.- REFER TO ORD.
CERTIFICATE OIr EXEMPTION 17ROM WORKERS'
PERMIT ISSUANCE - 10.00 ,
FLOOD ZONE
A.L.U.C.
COMPENSATION INSURANCE
(This section need not be completed if the permit is for one
Y ❑ N
Y ❑ N[]
PLG. CONTR. LIC. NO.
-
PLG,
TOTAL
hundred dollars ($100) or less.)
I certify that in the performance of the work for which this per-
sell is issued, I shall not employ any person in any nmnner so as to
CITY. MECHANICAL PERMIT FEE
FEE SUMMARY
BUILDING
become subject to the Workers' Compensat inn Laws of California.
WIP Applunut
NOTICE TO AI'1'LICANT: If, after making this Certificate of Lis
-
ALTER OR ADD TO MECH. 5.00
APPLIANCE 5.00
AIR HANDLING UNIT (TO 10=C.F.M.) 4.00
PLAN CHECK
FEE
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
AIR HANDLING UNIT (OVER 10MC.EM.) 6.00
SEISMIC FEE
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, Cie.C.).
MICROFILM
HEATING UNIT (TO 100,000 B.T.U.) 8.00
Lender's Name el,
Lender's Addie«
HEATING UNIT (OVER 100,000 B.T.U.)
ELECTRIC
I certify that I have read on apphNa ion and state Thal the above
information is correct. I agree to comply with all city end county
ordinances and state laws relating to building construction, and
VENTILATION FAN (SINGLE) 4.00
PLUMBING
v
BOILER- CONP(3 H.P. or 100,000 B.T.U.) 6.0017
BOILER -COMP (Over 100,000 BTU) SEE FEE SCH.
MECHANICAL
hereby authorize representatives of this city to enter upon the
above-mentioned property for inspection purposes.
(We) agree to save, indemnify and keep harmless the City of
Cupertino against liabilities, judgments, costs and expenses which
may in any way accrue again t said City in conset once of the
grunting of 0's pe »it.
Z8187
MISC. - REFER TO ORD.
PERMIT ISSUANCE 10.00
CONST. TAX
MECH. CONT. LIC. NO. MECH.
TOTAL
TOTAL
ev
Signamr lice / for a c
�'-"
OFFICE COPY