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APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY / / 0
BUILDING PROJECT I DENTIFIC/ N
APPLICATION & PE. .IIT
BUILDING -ELECTRICAL -PLUMBING -MECHANICAL
PE MiT 9EB
1709
BUILDING c
ADD:SOCV .7
OwNEWa
" A
�YLde PRONE .J'IO
- - "A>i'�x 14. r.T.� {" ; -' St iti
TY."'I ,,'`ELECTRIC PERMIT + 1'�7 FEE,
�- �j• ✓ L.l".LK�N /� J:
PLAN CHECK VALIDATION
oNrFACTOR 's
NAM
UTLETS- SWITCHES -RECEP 5.00/1.00
LIGHTING FIXTURES 5.00/1.00
L.C. No,
CONTRA
CONTRACTORS
ADDRESS
PPLIANCES- RESIDENTIAL 4.00
PANELS 5.00
PHONE
DATE OF APPLICATION
AR
ARCHITECT
ENGINEER
uc. No.
SIGNS 6,DQ
PLAN CHECK FEEP.C. NO.
SIGNS TRANS. 3.00
ADDRESS E"D'
SPECIALCIRCUIT 5.00
PERMIT VALIDATION
TEMP. METER OR POLE INS. 15.00
ZIP
S�
APPuunrs
ADDRESS
MOTORS SEE FEE SCH.
SERVICE CHANGE 10.00
�
LICENSED CONTRACTORS DECLARATION
--{}�--{,
I hereby affirm that I am licensed under provisions of Chapter 9
ow e�
ISSUANCE DATE
(commencing with Section 7000) of Division 3 of the Businessand
Professions Code, and my license is in full force and effect.
License Class Lic. Number
BLDG.
ELECT.
[:]1-1
PLG. MECH.
❑
Dam Contractor
BUILDING' PERMIT'
OWNER -BUILDER DECLARATION
1 herebyaffirm that I am exempt from the Contractors License
P
c. 703 requires S. a permness itProfessions
ylor ing reason, I county which
Copt: Any cityor countyir any rcquircia permittOcoasuanc,also
Code: Any cityto construct.
improve, demolish, or repair any structure, prior n its issuance, also
requires the applicant for such permit ns File a signed statement that
he is licensed pursuant to the provisions of the Contractor's License
Law (Chapterand Professions Code) or Section is exempt theref o andthe
Business and Professions Cadet or that he is exempt therefrom and
the basis for the alleged exemption. Any violation of5ection7031.5
f::"_-:.:�I N FORMATION- .r''"I::P
'
MISC. - - .ER TO ORDLaw
VALUATION
SIFT.
PERMIT ISSUANCE 6.00
ELEC. CONTR. LIC. NO. ELEC.
TOTAL
PERMIT TO
.i/•
7 ` ;' i + 1' -f 'e yafglt
QTY.':., - PLUMBING PERMIT' F r, FEE
t:ie. ... + - rj'v..YI �; .%'
STORIES
TYPE CONSTR.
by any applicant for a permit subjects the applicant to a civil penalty
of not more than five hundred dollars (SS00).):
ALTER -DRAIN & VENT -WATER (EA.14.00
❑ I, as owner of the property, or my employees with wages as
their sole compensation, will do the work, and the structure is not
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 (hereon, and who does such work
himself or through his own employees, provided that such improve.
mems are not intended or offered for sale. If, however, the building
BACK FLOW PROTECT. DEVICE 2.00
CC, GROUP
��
RES. UNITS
DRAINS -FLOOR, ROOF, AREA,COND. 4.00
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 of proving that he did not build or im-
prove for purpose of sale.).
��p I as owner of the property, am exclusively contracting with
GAS - EA. SYSTEM - OVER 4 (EA.) 1.00
BUILDINGUSE
RES IND CO PB Other
❑ ❑ ❑ ❑
INDUSTRIAL WASTE INTER. 20.00
LAWN SPRINKLERS- 1 INC 5 V.B. 5.00
LAWN SPRINKLERS - OVER 5 (EA.) 1.00
ASSESSORS PARCEL NO.
n
i .�D
000Y
licer)Seit 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
contracts for such projects with a contractors) licensed pursuant to
the Contractor's License Law.
SEWER -SANITARY -STORM EA. 200ft/8.00
TRACT NO.
PARCEL NO.
❑ lam exempt under Sec.-. BAP.C. for this
reason
WATER HEATER W/VENT 4.00
at O ler
WATER SYSTEM 4.00
ACC. DATE
ACC. FILE NO.
WORBERS'COMB ' raFM•'
WATER TREATING EQUIP. 4.00
I hereby affirm that I have a certificate of consent to self -insure,
or a certificate of Workers Compensation Insurance. or a certified
copy thereof (Sec. 3800, Lab.C.).
ZONING
ENG. SITE N0.
Policy No. Company
❑ Certified Copy is hereby furnished.
❑ Canopied copy is filed with the city inspection division.
Applicant
FIRE SPRINK
e,..,,(
v`Y 1 N ❑
ENERGY T-24
Y)< N ❑
MISC.- REFER TO ORD.
CE RTI FICATE OF EXEMPTION FROM WORKERS'
PERMIT ISSUANCE 6.00
FLOOD ZONE
PLG. CONTR. LIC. NO.
PLG.
TOTAL
COMPENSATION INSURANCE
(This section need not be completed if the permit is for one
Y ❑�
-
OTY. MECHANICAL PERMIT FEE
,
-
- FEE SUMMARY
hundred dollars IS 100) or less.)
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
BUILDING
Io
become subject to the Workers' Compensation Laws of California.
Date Applicant
ALTER OR ADD TO MECH. 4.00
NOTICE TO APPLICANT: If. after making this Certificate of Ex-
emption, you should become subject to the Worker' Compensation
APPLIANCE 4.00
PLAN CHECK
provisions of the Labor Code, you must forthwith comply with
such provisions or this permit shall be deemed revoked.
FEE
AIR HANDLING UNIT ITO 10=C.F.M.) 3.00
AIR HANDLING UNIT IOVER 10=C.F.M.15.00
SEISMIC FEE
CONSTRUCTION LENDING AGENCY
I hereby affirm that there is a construction lending agency for
EXHAUST HOOD IW ITH DUCT) 2.00
the performance of the work for which this permit is issued ISec.
3097. Civ.C.).
MICROFILM
HEATING UNIT ITO 100,000 B.T.U.) 4.00
Lender's Name
HEATING UNIT (OV ER 100,000 B.T.U.17.50
ELECTRIC
Lender's Address
1 certify that I have read this application and state that the at
VENTILATION FAN (SINGLE) 3.00
information is correct. I agree to comply with all city and county'
ordinances and state laws relating to building construction, and
PLUMBING
BOILER-COMP(3H.P.or100,000B.T.U.) 4.00
IOver 100,000 BTU) SEE FEE BCH.
MECHANICAL
hereby authorize representatives of this city to enter upon theBOILER-COMP
above-mentioned property for inspection purposes.
MISC. - REFER TO ORD.
TAX
(We) agree to save, indemnify and keep harmless the City of
Cupertino against liabilities. judgments, costs anJ expenses whichCONST.
may in any way accrue gamst said City in consequence of the
I is of thi per f. /j
C��Ce s LLIA.",
Igs Ilurc Applicant/ omractor vjf'ee
PERMIT ISSUANCE 3.00
MECH. CONT. LIC. NO.
MECH.
TOTAL
'TOTAL '
ns
F
OFFICE COPY