10991APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
BUILDING PROJECT I DENTIFICATI ON
APPLICATION & PERMIT
— ELECTRICAL— PLUMBING — MECHANICAL
UILDING
PERMIT NUMBER
10991
BUILDING
ADDRESS Z39S A
OWNER'Sq
4q& NAME
-S'SO'9
'; a
OTV. ELECTRIC PERMIT FEE
PLAN CHECK VALIDATION
�
,Ax AK
L Z—A AK -- PHONE
C*ons
NAME -
NAME
UTLETS- SWITCHES -RECEP 10.00/1.00
LIGHTING FIXTURES 10.00/1.00
LIC. NO.
CONTRACTOR' s
ADDRESS
PPLIANCES- RESIDENTIAL 4.00
PANELS 10,00
PHONE
DATE OF APPLICATION
ARCHITECT
O
OR
ENGINEEn �'
LIC. NO
PANELS(OVER 200 AMP) 20,00
PLAN CHECK FEE P.C. NO.
,
SIGNS TRANS. 3.00
ARCH. OR ENG,
SS
SPECIALCIRCUIT 5,00
PERMIT VALIDATION
TEMP. METER OR POLE INS. 20.00
ZIP
APPLICANT'S
ADDRESS
MOTORS SEE FEE SCH.
SERVICE CHANGE 20.00
LICENSED CONTRACTORS DECLARATION
1 hereby affirm that I am licensed under provisions of Chapter 9
(commencing with Section 7000) Of Division 3 Of the Business and
Professions Code, end any license is in full force and effect.
License Class Lic. Number
ISSUANCE DATE
BLDG. ELECT.
❑ ❑
PLG. MECH.
❑
Uate Contractor
BUILDING PERMIT
INFORMATION
OWNER -BUILDER D17CLARATION
I hereby collo that I am exempt from the Contractor's License
Law for the followingntywreason. (Sac.uireta,Busit 10 CodProfessions
Code: Any city or county which requires a permit to construct, alter,
MISC. — REFER TO ORD
PERMIT ISSUANCE 10.00
VALUATION
$/FT.
ELEG CONTR. LIQ NO. EIEC.
TOTAL
OT - PLUMBING PERMIT FEE
improve, demolish, or repair any structure, prim to its issuance, also
requires the applicant for such permit to filen 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
PERMIT TO
STORIES
TYPE CONSTR.
the basis for the alleged exemption. Any violation of Section 7031.5
1
by any applicant for a perinusubjects the applicant ma civil penalty
of not more than five Imndred 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 Bol
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 Contractor's License Law does not apply to an owner of
FIXTURES - PER TRAP 5.00
SO. FT. FLOOR AREA
TOTAL ACREAGE
property who builds or improves thereon, and who does such work
himself or through his own employees, provided that such improve-
mentsurenotintended or offered for sale. ll, however, the building
GAS - EA. SYSTEM -1INC. 40 6.00
ur 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 ofsale.).
❑ 1, as owner of the property, an, exclusively contracting with
GAS - EA. SYSTEM -OVER 4 IEA.) 2 OQ
BUILDING USE
RES IND CON PB Omer
❑ ❑ ❑ ❑ ❑
INDUSTRIAL WASTE IN "3,
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 WEIVV.8. 6.0
LAWN SPRINKLERS- OVE I%
ASSESSORS PARCEL NO.
,
contracts for such projects with a contractorfs) licensed pursuant to
the Contractor's License Law.
SEWER-SANITARYV-STORM A. 200ft/10.00
TRACT NO.
PARCEL NO.
❑ I am exempt under Sec.., fl.&P.C. for this
reason
WATER HEATER W/VENT 6.00
Owner
WATER SYSTEM — 5.00
ACC. DATE
ACG FILE NO.
WATER TREATING EQUIP. 5.00
WORK I'-RS'COMPIiNSATION DECLARATION
1 hereby uNlrm that I have a certificate OI consent t0 SCINnsure,
or a certificate of Workers' Compensation Insurance, or n certified
rr 1 1 �/. _ —�
h WWLUL
ZONING
ENG. SITE NO.
copy lhereof(Sce. 3800, Lab.C.L
.-
Policy No. Company
FIRE SPRINK
y ❑ ry❑
ENERGY T-24
y ❑ ry❑
❑ Certified copy is hereby furnished.
❑ Certified copy is 'Bled with the city inspection division.MISC.-
Applicant
REFER TO ORD.
CERTIFICATE OF EXEMPTION I°ROM WORKERS'
PERMITASSUANCE 10.00 0 W
FLOOD ZONE
A.I.U.C.
COMPENSATION INSURANCE
(This section need not be completed if the permit is for one
PLG. CONTR. LIC. NO.
PLG.
TOTAL S ~ ,
Y ❑ N ❑
Y ❑ N ❑
hundred dollars ($ 100) or less.)
-
1certify that in the performance Of the work for which this ver-
mit is issued, I shall not employ any person in any manner so as to
QTY. MECHANICALz.PERMIT FEE
FEE SUMMARY
BUILDING
become subject to the Workers' Compensation Laws of California.°
Date Applicant
ALTER OR ADD TO MECH. 5.00
NOTICE TO APPLICANT: If, after making this Certificate of Ex-
APPLIANCE 5.00
PLAN CHECK
FEE
emption, you should become subject in the Workers' Compensation
provisions of the Labor Code, you most forthwith comply with
such provisions or this permit shall be deemed revoked.
AIR HANDLING UNIT (TO 10MC.F.M.) 4.00
AIR HANDLING UNIT (OVER IQOOOC.EM.) 6.00
SEISMIC FEE
CONSTRUCTION LENDING AGENCY
I hereby affirm that (hem is a construction lending agency for
EXHAUST HOOD (WITH DUCT) 5.00
the performance of the work tar which this permit is issued (Sec.
3097, Civ.CJ.
MICROFILM
HEATING UNIT (TO 100,000 B.T.U.) 8.00
Lender's (dame
Lender's AddressELECTRIC
HEATING UNIT (OVER 100,000 B.T.U.)9.50
VENTILATION' FAN (SINGLE) 4,00
I certify that 1 have read this application and state that the above
nfonnatwo is correct. 1 agree to comply with all city and county
ordinances and state laws relating to building construction, and
PLUMBING
BOILER- OOMP(3 H.P. or 100,000 B.T.U.) 6.00
BOILER -COMP (Over 100,000 BTU) SEE FEESCH.
MECHANICAL
hereby authorize representatives of this city to enter upon the
above-mentioned property for inspection purposes.
(We) agree to save, indemnify and keep harm less the City of
MISC. - REFER TO ORD.
Cupertino against liabilities, judgments, costs and expenses which'
may in a )/way accrue, against said Cit n consequence of the
CONST. TAX
PERMIT ISSUANCE 10.00
granting this Peron' /y��tp 1-7
CH. CONT. LIC. NO. MECH.
/{
TOTAL
TOTAL
Signal c pylic of/C tractor '/Tl/tel^Da`tc
UFFICE COPY