6361APPLICANT TO FILL IN INFORMATION WITHIN RED LINES -USE BALL POINT PEN ONLY
BUILDING PROJECT IDENTIFICATION-
& PERMIT
BUILDING - ELECTRICAL- PLUMBING - MECHANICAL
PERMITNUMBER
6361
.UIHPIADDREss r -APPLICATION
OWNEH'a-
NAME r
•^
QTY: - -^ ELECTRIC PERMIT
PLAN CHECK VALIDATION
CONTRACTORS
NAME I
OUTLETS - SWITCHES -RECEP 5.00/1.00'
L I LIC. No %
„
LIGHTING FIXTURES 5.0011.00
ADD ESS TO s
[itliPPOANCES-FIESIDENTIAL 4.00
PHON
PANELS 5.00
DATE OF APPLICATION
NARRCHITEC
ENGINEER
' LIC. No,
SIGNS 6.00
PLAN CHECK FEE P.C. NO.
SIGNS TRANS. 3.00
FooR'EssENG' •
SPECIAL CIRCUIT '5.00
PERMIT VALIDATION
ZIP
TEMP. METER OR POLE INS., 15.00
-
9�41-jl
APPLICANT'S
AooHEss
MOTORS SEE FEE SCR.
•'
SERVICE CHANGE '• :10.00
9/e5z�
LICENSED CONTRACTORS DECLARATION
0 'T2e4D D -F
I hereby affirm that I am licensed under provisions of Chapter 9
(commend., with Section 7000) of Division 3 of the Business and
PfOfCS610n9 Code -d ICC. Li 161. od fOf'
License C a - Lic. Number
-
ISSUANCE DATE
,LUG. ELECT- PLG. MECH.
❑ -❑ ❑
FI/14 L 2 C n O e F. Jt r rs f
-
Date '- Contractor Flo
- .OWNER -BUILDER UECLARAT'
I hereby affirm that l am exempt from the Contractor's License
Law for the following mason. (Sec. 7031.5, Business and Professions
Code: Any city or counly which requires 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 or the Contractor's License
BUILDING PERMIT',r ay"'
- 'INFORMATION"'
MISC. - REFER TO ORD
PERMIT ISSUANCE 6.00
S/FT.
_
J
E
ELEC. CONTR. - LIC. NO.
ELEC.
TOTAL
Law (Chapter 9 (commencing with Section 7000) of Division 3 ofthe
Business and Professions Code) or that he is exempt therefrom and
the basis for the alleged exemption, Any violation of Section 7031.5
by any applicant fora permit subjects the applicant to a civil Penalty
of not more than five hundred dollars (S500)J:
QTY. PLUMBING PERMIT F.EE''
QYPE CONSTR.
- ALTER -DRAIN -WATER (EA.) 4.00
❑ L as owner of the property, or my employees with wages i s
their sole compensation, will'do the work, and the struclure.is not
intended or offered for sale (Sec. -7044, Business and Professionso!-zf
Code: The Contractor's License Law does not apply to an owner of
BACK FLOW PROTECT. DEVICE 200
.
G
OCC. aOUP
�1 GAN
RES. UNITS
DRAINS -FLOOR, ROOF, AREA,COND. 4.00
FIXTURES - PER TRAP4.00
GAS-EA.SYSTEM-11NC.40UTLETS 4-00
-
Property who builds or improves thereon, and who does such work
himself or through his own employees, provided that such improve-
memsare not intended oroffered for Sale. If, however, the building
Sa FT. FLOOR AREA
TOTAL ACREAGE
or improvement is sold within one year of completion,' the owner-
builder wet have the burden of proving [hat he did not build or im.
prove for purpose ofseleJ. -
❑ 1, as owner of the property, am exclusively contacting with
GAS - EA. SYSTEM - OVER 4 (EA.) 1,00
BUILDING USE
RES IND CON PB Other
- El.
INDUSTRIAL WASTE INTER. 20.00
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 [hereon, and who
contracts for such projects with a commelor(s) licensed pursuant to
the Contractor's License Law. ,
.❑ I am exempt under Sec. ,B.dP.C. for this
Mason
LAWN SPRINKLERS - 1 INC5 V.B. 5.00
-
LAWN SPRINKLERS - OVER 5 (EA.) 1.00
ASSESSORS PARCEL NO.
SEWER -SANITARY -STORM EA. 200f(/8.00
TRACT NO.
PARCEL NO.
WATER HEATER W/VENT 4.00 -
Owner Date
WATER SYSTEM 4.00
ACC. GATE
ACC. FILE NO.
WORKERS'COMPENSATION DECLARATION
WATER TREATING EQUIP. 4.00
I hereby affirm that I have a certificate of consent to self -insure.
ZONING
ENG. SITE NO.
m a certificate en Workers' Comp f a certified
copy thereof (Sec. 3800; Lah.C.l. 0 7
Policy No. Company
MISC. - REFER TO ORD..
Certified copy is hereby faint
,VoQ Cerlifie opy is filed It t city inspection division.
Applicant
FIRE SPRINK
Y C] N ❑
ENERGY T-21
v❑ NQ
PERMIT ISSUANCE 6.00
CERTIFICATE OF EXEMPTION FR M WORKERS'
COMPENSATION INSURANCE
(This section need not be completed if the permit is for one
FLooD ZONE
•Y,❑ NC]
A.L.u.C.
Y 'N�
PLG. CONTR. LIC. NO.
PLG. -
TOTALv 1
hundred doll... IS 100) or less.) "'
1 certify that in the performance of the work far which this per.
mit is issued, I shall not employ any person in any manner so as to
QTY. MECHANICAL PERMIT FEE
'�.,_
'`FEE SUMMAWY '-
become subject 10 the Workers' Compensation Laws of California.
Date Applicant
NOTICE TO APPLICANT: If, after making [his Certificate of Ex-
BUILDING
SZ
ALTER OR ADD TO MECH. '4.00
APPLIANCE 4.00
AIR HANDLING UNIT (TO 10p00GF.M.) 3.00
'PLAN CHECK
FEE
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.
CONSTRUCTION LENDING AGENCY
AIR HANDLING UNIT (OVER 10)[1000EM.15.00 `'
SEISMIC FEE
d -O
1 hereby affirm that there is a construction lending agency for
the performance of the work for which this permit is issued (Sec.
3097, Civ.CJ. ,
EXHAUST HOOD (WITH DUCT) 2.00
MICROFILM'
HEATING UNIT ITO 100,000 B.T.U.) 4.00
Lender's Name
Lender's Address
H EATI N G UNIT (OV ER 100,000 B.T.U'.)7.50''
ELECTRIC
VENTILATION FAN (SINGLE) 3.00
I certify that I have read this application and state that the above
information is correct. I agree to comply with all city and county-
ordinances and state laws relating to building construction, and
hereby authorize representatives of this city to enter upon the
above-mentioned properly for inspection purposes.
PLUMBING
I
BOILER- COMP (3 H.P. or 100,000 B.T.U.) 4.00
B OILER -COMP (Over 100,000 BTU) SEE FEE SCR.
MECHANICAL
' (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
gran g, this erm' .
I, s _
ignature of plica. contra ate
MISC. - REFER TO ORD.
PERMIT ISSUANCE 3.00
CONST. TAX
-
MECH. CONT. LIC. NO.
-
MECH.
TOTAL.
TOTAL,
t W
/
OFFICE COPY