13175APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
BUILDING PROJECT I DENTIFI N
APPLICATION & P IT
BUILDING -ELECTRICAL -PLUMBING -MECHANICAL
PERMIT NUMBER
13175
BUILDING
�
!Y "sem ec.t
OWNER'S
NAME
LF PHONE
CITY. ELECTRIC PERMIT FEE
PLAN CHECK VALIDATION
DNTRAciDR
NAME
UTLETS-SWITCHES-RECEP 10.00/1.00
"e'r NO, Q ,
LIGHTING FIXTURES 10.00/1.00
DATE OF APPLICATION
CONTRACTOR s
ADDRESS CUA/'
JJL n
'cue iF /fJ� 191* PHONE /0111
PPLIANCES- RESIDENTIAL 4.00
PANELS 10.00
ARCHIi ECiPANELS
OR
ENGINEER
" No.
(OVER 200 AMP) 20.00
PLAN CHECK FEE P.C. NO.
ISIGNSTRANS. 3.00
_LIC.
ADDRESS ENL
SPECIALCIRCUIT 5.00
PERMIT VALIDATION
TEMP. METER OR POLE INS. 20.00
ZIP
`�
APPLICANTS
ADDRESS
MOTORS SEE FEE SCH.
SERVICE CHANGE 20.00
�`-
(//-7 e;7
LICENSED CONTRACTORS DECLARATION1p
I hereby affirm that I am licensed under provisions Of Chapter 9
(commencing with Section 7000) of Division 3 of the Business and
Professions Cod�nse is in full fore pf
License Cla Lie. Number 4
ISSUANCE DATE
BLOC. ELECT.
PLG. I MECH.
Date Contractor
BUILDINGORMAT MIT
INFORMATION
OWNER -BUILDER DECLARATION
I hereby affirm that I am exempt from the Contractor's License
Law for the following reason. (Sec. 7031.5, Buslnessand Professions
Code: Any city or county which requires a permit to construct, alter,
improve, demolish, or repair any structure, prior to its issuance, also
requires the applicant for such permit to file a signed statement that
he is licensed pursuant to the provisions of the Contractors License
Law (Chapter 9(commencingwith Section 7000) of Division 3 ofthe
Business and Professions Code) or that he is exempt therefrom and
MISC.- REFER TO ORD
PERMIT ISSUANCE - 10.00
VALUATION
$/FT.
SLED, CONTR. LIC. NO.
ELEC.
TOTAL
PERMIT TO
,a, p
/ 04 q�.
DTV. PLUMBING PERMIT FEE
STORIES
TYPE CONSTR.
the basis for the alleged exemption. Any violation of Section 7031.5
by any applicant for a permit subjects the applicant to a civil penalty
of not more than five hundred dollars (85000.):
ALTER-DRAIN&VENT-WATER (EA.) 5.00
❑ 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 4.00
OCC. GROUP
RES. UNITS
DRAINS -FLOOR, ROOF, AR EA, COND. 5.00
intended or offered for sale (Sea 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.
meats are not intended or offered for sale. If, however, Ore building
SO, FT. FLOOR AREA
TOTAL ACREAGE
/ FIXTURES - PER TRAP 5.00 Q
GAS - EA. SYSTEM - 1 I NC. 4 OUTLETS 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 ofsale.).
❑ I, as owner of the property, am exclusively contracting with
licensed contractors to construct the project (Sec. 7044, Business
and Processions Code: The Contractor's License Law does not apply
to an owner of property who builds or improves thereon, and who
. ..2.00
GAS - EASYSTEM -OVER 4 (EA) 200
BUILDING USE
IND CON PB Other
❑ ❑ ❑ ❑ ❑
INDUSTRIAL WASTE INTER. 30.00
LAWN SPRINKLERS -I INC 5 V.B. 6.00
LAWN SPRINKLERS - OVER 5 (EA.) 1.00
ASSESSORS PARCEL NO.
contracts for such projects with B contructons) licensed pursuant to
the Contractor's License Law.
TRACT NO. PARCEL NO.
SEWER-SANITARY-STORMEA. 200f1/10.00 O
❑ 1 am exempt under Sec. , B,&P.C. for this
WATER HEATER /VENT 6.00
reason
Owner Date
WATER SYSTEM�, ry 'jt',` f 5.00 rte'
ACC. DATE
ACC. FILE NO.
WATER TREAT.ING`EQUIP. 5.00
WORKERS'COMPENSA'I' ION DECLARATION
I hereby affirm that I have a cerfificate of consent to self-insure
or a certificate of Workers' Compensation InsnrBnOC, ar a curtificd,
r t)n0
ZONING
ENG. SITE NO.
copYhergol' �,8��7/)Ju`
PolicyNcc�t�frr// m a
c
❑ C title opy is hereby fun fished
❑ Certified a ����y`•le aly I spection division.
Applicant �1......F. %� /
MISC. - REFER TO ORD.
FIRESPRINK
Y ❑ N❑
ENERGY T-24
Y ❑ N❑
CER'11FICAII:01; EXEMPTION FROM WORKERS'
PERMIT ISSUANCE 10.00
FLOOD ZONE
A.LU.C.
COMPENSATION INSURANCE
(This section need not be completed if the permit is for one
PLG, CONTR, LIC. NO.
PLG.
TOTAL ` v 7
"
Y ❑ N❑
Y ❑ N❑
hundred dollars IS 100) or less.)
I certify that in the performance of the work for which this per.
alit is issued, I shall not employ any person in any meaner so as to
mea
CITY. MECHANICAL PERMIT FEE
FEE SUMMARY
BUILDING
become subject to the Workers' Compensation Laws of California.
Date Applicant
NOTICH 1'0 APPLICANT': If, otic, making this Certificate 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.
AIR HANDLING UNIT (TO 10=r-F.M.) 4.00
FEE
AIR HANDLING UNIT(OVER 10=1C.EM.) 6.00
SEISMIC FEE
CONSTRUCT ION LENDING AGENCY
I 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
Lender's Name
H EATING UNIT (OVER 100,000 B.T.U.)9.50
ELECTRIC
Lender's Address
I certify that I have read this application and state that the above
is Correct. 1 agree to comply with all city and county
ordinances and state laws relating to building construction, and
VENTILATION FAN (SINGLE) 4.00
PLUMBING
CA..?
l
BOILER- COMP (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.
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 consequence of the
PERMIT ISSUANCE 10.00
6 rantin of erml
MECH. CONT. LIC. NO. MECH.
TOTAL
TOTAL
Sigilartlae of Applicant/Contractor Date
OFFICE COPY