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APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
BU LDI NG PROJECT 1 DENTI FICATI ON
APPLICATION & PERMIT
sPSjILDING— ELECTRICAL— PLUMBING — MECHANICAL
PERMIT NUMBER
6797
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CITY@LEL�TRIr"C4P-ERMITI L' $
PLAN CHECK VALIDATION
DATE OF APPLICATION
CONTRACTOR'S
QIFLS 4
OUTLETS - SWITCHES - RECEP 5.00/1.00
LIGHTING FIXTURES 5.00/1.00
ADDRESS tugs 1rseC?#WAa %% 44
CONTRA �F
94s39 FNONE�j/�%//
PPLIANCES- RESIDENTIAL 4.00
PANELS 5.00
ARCHITECT
on
ENGINEER
uc. NO.
SIGNS 6.00
PLAN CHECK r7 P.C. NO.
SIGNS TRANS. 3.00
ADDRESS E"G'
SPECIAL CIRCUIT 5.00
PERMIT VALIDATION
rrEMP. METER OR POLE INS. 15.00
ZIP
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..APPLICANTS
ADDRESS
MOTORS SEE FEE SCH,
SERVICE CHANGE 10.00
LIC[NSLD CONI' RACTORS DECLARATION
1 hereby allirm that I ran licensed under provisions Of Chapter 9
(mmmcncing with Section 7000) of Division 3 of the Business and
Professions Code, and my license Is m 1'u If orce agd ffe,ct. ,�
License Class—G. Lie. Nun r -'
ISSUANCE DATE
BLDG. ELECT, PLG. MECH.
❑ ❑ ❑ ❑
it
Dmc_ Cnn a
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OWNER -BUIL UIi ECLA RATI M
I hereby infirm that I am exempt from the Contractor's License
Law for the following reason. (Sec. 7031.5, Businessand Professions
Code'. Any city ar county which requiresa permit toconsinact.alter,
improve, demolish, or repair any structure, prior to its issuance, also
requires the applicant fur such permit to file a signed statement that
he is licensed pursuant Io the provisions of the Contractor's License
Law (Chapter 9(commencing with Section 70001 of Division 3 ofthe
Business and Professions Code) or that he is exempt therefrom and
the basis for the alleged exemption. Any violation ofSection 70315
_..CrY
MISC.— REFER TO OR
PERMIT ISSUANCE
VALUATION
f/FT.
ELEC. CONTE. L IC. NO.
ELEC. .
TOTAL; 1
M
PERM TO
M /
_
GTI/: ;�4�^PlUM81NQP6RMLT l"rJ �M'�'9s•
4.R4'--..I-i':4'. ?t± re:. •a ?"``^V
,..5 RIES
TYPE CONSTR.
by any applicant fora permit subjects the applicant to a civil penally
of not more than five hundred dollars (S500)):
ALTER -DRAIN &VENT -WATER (EA .)4.00
C L as owner of the property, or my employees with wagesas
the it 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 (See. 7044, Business and Professions
Code: 'Tlm Contractor's License Law does not apply to an owner of
FIXTURES - PER TRAP 4.00
SO. FT. FLOOR AREA
TOTAL ACREAGE
properly who builds or improves thereon, and who does such work
himself or through his awn employees, provided that such improve-
ments are not intended oroffered for Sale. IL however, the building
GAS - EA. SYSTEM -1INC. 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 int -
prove fors owner of sale.). (tiep
O I, as owner of the properly, am exclusively contracting with
. ..
GAS - EASYSTEM -OVER 4 IEA) 100
BUILDING USE
RES IND CON PB Omer
Cl EI 0 ❑ ❑
INDUSTRIAL WASTE INTER. 20.00
l iecnsed contractors to construct the project (Sec. 7044, Business
and Professions Cnde: '1'be Contractor's License Law does not apply
to an owner ul' property who builds or improves thereon, and who
LAWN SPRINKLERS - 1 INC 5 V.B. 5.00
LAWN SPRINKLERS - OVER 5 (EA.) 1.00
ASSESSORS PARCEL NO.
contracts or .such projums with u conlractohs) licensed pursuant to
the Contractor's License Law.
SEWER -SANITARY -STORM EA. 200ft/8.00
TRACT NO.
PARCEL NO.
0 Iwo exempt under See. ,B.&PC. for this
,ca,.n
WATER HEATER W/VENT 4.00
Owner Date
WATER SYSTEM 4.00
ACC. DATE
ACC. FILE NO,
WATER TREATING EQUIP. 4.00
WORKERS'COMPENSATION DECLARATION
I hereby allirm that I have a certificate of consent to self -insure'
or a certificate of Workers' Compensation Insurim ora rtified
copy thenol 1 `c. 3AOQ, j.,rh
Policy ,No. 1 i}Ih(bjy{i
ZONING
ENG. SITE NO.
❑ Certille y u here u rasher
N[j Certif y is f toil th cit inspection division.
plu:am
FIRE SPRINK
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ENERGY T-24
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MISC.- REFER TO ORD.
CIi TIRICATE OP EXEMPTION FROM WORKERS'
C14TI
PERMIT ISSUANCE 6.00
FLOOD ZONE
A.L.U.C.
PLG. CONTE. UC. NO.
PLG.
TOTAL
COMPENSATION INSURANCE
(This section need not be completed if the permit is for one
Y❑ NE]
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CiY , MECHANICAL PERMIT 'k„r'' j&) :FEV
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7.'L,;r; :F�ESUMMAR
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hundred dollars(SIDD) or less.l-
1 certify that in the performance of the work for which this Per
mit Is issued. I shall not employ any person in any mannersoasto
become subject to the Workers' Compensation Laws of California.
Date Applicant
BUILDING
�s� Q
gk^?�
CIL.)
ALTER OR•ADD TO MECH 400
NOTICE TO APPLICANT: If, after making this Certificate of Ex-
emmum, you should become subject to the Workeri Compensation
proviomm of the Labor Code, you must forthwith comply with
such provisions or this permit shall be deemed revoked.
APPLIANCE 4.00
PLAN CHECK
FEE
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7j
AIR HANDLING UNIT (TO 109MC.F.NL) 3.00
AIR HANDLING UNIT (OVER 10=CF.M.) 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 perlormance of the work for which this permit is issued (Sec.
3097. ('is C.).
MICROFILM
HEATING UNIT (TO 100,000 B.T.U.) 4.00
HEATING UNIT (OVER 100,000 B.T.U.)7.50
ELECTRIC
LenderName
Lender's Address
I certify that I have read this application and state that the above
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. ODMP(3 H.P. or 100,000 B.T.U.) 4.00
BOILER -COMP 10", 11X1,000 BTUI SEE FEE SCH.
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 age 'st liabilities, judgments, costs and expenses which
may In any y accrue a ainn id City in consequence of the
PERMIT ISSUANCE 3.00
gmntin /nJ permit
l
MECH. CONT. LIC. NO. MECH.
TOTAL
: •-'— -..
TOTrAL;
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Signature of Applicant Contrac or Date
OFFICE COPY