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APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
BUILDING PROJECT IDENTIFICATION
APPLICATION &PERMIT
ILDING - ELECTRICAL- PLUMBING - MECHANICAL
PERMIT NUMBER
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BUILOING � 1T.E ItOy
4DDREss
CJ ' > C.P�C L
OwrvER'S
PHONE
n. A, ".-+ '�, -• K. b
'ELECTRIC PERMIT''? p'°' .? 4 FEH.a
PLAN CHECK VALIDATION
CONTRACTORS P/-.; ^..,, ••II
NAME1• `ASN
Mt►J kL-S uc.N
UTLETS-SWITCHES-RECEP 5.00/1.00
LIGHTING FIXTURES 5.00/1.00
CONTRACTOR'S
ADORE ylrj�
APPLIANCES -RESIDENTIAL 4.00
//
Af�,pMe 'PHONE
DATE OF APPLICATION
PANELS 5.00
OR
ENGINEER
uc, No.
SIGNS 6.00
PLAN CHECK FEE
P.C. NO.
SIGNS TRANS. 3.00
ADDRESS ENG"
SPECIAL CIRCUIT 5.0Q
PERMIT VALIDATION
TEMP. METER OR POLE INS. 15.00
ZIP
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APPUC
ADDRESS SS ����
MOTORS SEE FEE SCH.
SERVICE CHANGE 10.00
'
J%
LICENSED CONTRACTORS DECLARATION
1 Ilerehy affirm dial I am licensed Under provisions of Chapter 9
(commencing with Section 7000) of Division 3 of the Busincss and
1'rolessions Co a� y 'cense is in full fore�as4j'tY,
Liole,io lags_ Lie Number T /
Date AM-, /j /FYI Qmvacmr M'LC�--k .L
owrUSR-eulu)ISR urcLA Ar oN �%
I hereby affirm that I am exempt train the Contractor's License
Law for the following mason. (See. 7031.5, Businessand Professions
Cade: Any city or county which requiresa permit Loconstruct, alter,
ISSUANCE DATE
BLDG. ELECT.
E:] ❑
PLG. MECH.
® ❑
BUILDING PERMIT
" INFORMATION:--'-" "
fMISC. - REFER TO ORD
PERMIT ISSUANCEVALUATION
6.00
S/FT.
ELEC. CONTR. LIG NO. ELEC.
TOTAL
- - "'
QTY.':' PLUMBING PERMIT, -"'FEE'.',
improes, demolish, or repair any structure, prior n its issuance, also
frit titch permit ns file a (Cont statement i ilia[
he is licensed a(co [o the provisions of the Contractor's License
lie isles IIIedp pursuant
w(Chand Plco,kon,Codeng with Section is 00) exemftthelefamn the
Business
Business and Professions that he is exempt therefrom and
PERMIT TO
/�
PLUN.e/N f.Y
the emptor
the allegedexemption.Any of
STORIES
TYPE CONSTR.
nya(of
by 01 more that lore permit xjoIIats the ,(S5OI plimnunacivil penally
applicant o a cion malt$
pl' nal nmrc than five hundred dollars 155001.):
ALTER -DRAIN & VENT -WATER IEA.) 4.00
❑ 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 F LOW PROTECT. DEV ICE 2.00
OCC. GROUP
RES. UNITS
DRAINS -FLOOR, ROOF, AREA,COND. 4.00
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 4.00
properly who builds or improves thereon, and who dot's such work
himself or through his own employees. provided that such improve-
ments are not intended or offered far sale. If, however, the building
SO. FT. FLOOR AREA
TOTAL ACREAGE
GAS-EA.SYSTEM-11NC.40UTLETS 4.00
or improscment is sold within one year of completion. the owner-
builder will have the burden of proving that he did not build or am-
move far purpose ol'sale.l.RES
❑ I, as owner of the property, am exclusively contracting with
GAS - EA. SYSTEM -OVER 4 IEA.) 1.00
BUILDING USE
IND CON Pe Other
❑ ❑ ❑ ❑ ❑
INDUSTRIAL WASTE INTER. 20.00
IicenseJ contractors In 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 INC 5 V.B. 5.00
LAWN SPRINKLERS - OVER 5 IEA.I 1.00
ASSESSORS PARCEL NO.
contracts far such projects with a contractor(s) licensed pursuant to
the Conlractnr'a License Lew.
SEWER -SANITARY -STORM EA. 200ft/8.00
TRACT NO.
PARCEL NO.
❑ I ant exempt under Sec.-, B &P.C. for this
reason
WATER HEATER W/VENT q,p0
Owner Date
WATER SYSTEM 4.00
ACG OATE
ACC. FILE N0,
WATER TREATING EQUIP. 4.00
WORKERS'COMPENSATION DECLARATION
I hereby affirm [hat I has, a Certificate of consent to self -insure.
or a certificate of Workers' Compensation Insurance, or a certified
ZONING
ENG. SITE NO.
copy thereof (Sec. 3800. Lab.C).
Policy No. Company
❑ Certified copy is hereby furnished.
❑ certified copy is Tiled with the city inspection division.
Applicant
FIRE SPRINK
Y ❑ N ❑
ENERGY RN
Y ❑ N�
MISC. - REFER TO ORD. lv
CIi RT'IFICA"TE OF' EXEMPTION FROM WORKERS'
PERMIT ISSUANCE 6.00 `�
FLOOD ZONE
A.L.U.C.
COMPENSATION INSURANCE
I"this action need not be completed if the permit is for one
Y ❑ N ❑
Y ❑ N❑
PLG. CONTR, LIC. NO.
PLG. '7`�
TOTAL
hundred dollars at in the pe orm
I certify that in the performance of the work for which this per
N� b,C l H4 t M� F"IEE�'{
'y �j i �� y"- a "' ,�aNN,1���1/tp��
QTY'. t' MECHANICAL PERMIT
a
< FEE y
1 "L -a_
_
nit is issued I shall not employ any person in any manner so as [o
be,olp1j��suhle 11pp�t1IeWarkers'C pensatlf/I laws of lifomta.
DatnfM _P& flAppli!anl %�
NOTICE 'TO APPLICANT: W. after kmg llf erlificate of Ex-
- P meT1"*y .ti, .
T
"
BUILDING
ALTER OR ADD TO MECH. 4.00
APPLIANCE 4.00
PLAN CHECK
emption. you should become subject m the W�kers' Compensation
provisions of the Labor Code, you must forthwith comply with
such provisions or this permit shall be deemed revoked.
AIR HANDLING UNIT (TO 10,0MCF.M.) 3.00
FEE
AIR HANDLING UNIT (OVER 10,000CEM.)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 performance of the work for which this permit is issued (Sec.
3097, Civ C.).
MICROFILM
HEATING UNIT (TO 100,000 B.T.U.) 4.00
Lender's Name
Lender's Address
HEATING UNIT (OVER 100,000 B.T.U.)7.50
ELECTRIC
I certify that I have read this application and state that the aboveVENTILATION
information is correct I agree to comply with all city and county
ordinances and slate laws relating to building construction, and
FAN (SINGLE) 3.00
PLUMBING
BOILER-CONP I3 H. P. Or 100,000 B.T.U.) 4.00
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.
IWeI agree to save. indemnify and keep harmless the City of
Cupertino against liabilities, judgments costs and expenses which
may in any way accme against said City in consequence of the
MISC. - REFER TO ORD.
CONST. TAX
PERMIT ISSUANCE 3.00
granting of this permit.
MECH. CONT. LIC. NO. MECH.
- -
TOTAL
;y TOTAL"; ..
-
Signature of Applicant/Contractor Dale
OFFICE COPY