9131APPLICANT TO FILL IN INFOFWATION WITHIN RED LINES - USE BALL POINT PEN ONLY
BU I LDING PROJECT I DENTIFIC NI
APPLICATION &.P IT
BUILDING - ELECTRICAL- PLUMBING - MECHANICAL
. PERMITNUMBER
9131
BUILDING
ao
Je DREss
0
N,aMERS ��,..'y�C �/1
vnorvE
4 N L P T ce 39a s
QTY. ELECTRIC PERMIT FEE
PLAN CHECK VALIDATION
DATE OF APPLICATION.
CONTRACTOR'S
N
�%� �RQ /'' LIc. No�3 gg
OUTLETS-SWITCHES-RECEP 10.00/1.00
LIGHTING FIXTURES 10.00/1.00
CONTRACTORS
POOR E55
p[ HONE '3y7
PPLIANCES-RESIDENTIAL 4.00
PANELS 10.00
ARCHITECT
OR
ENGINEER
uc. NO.
PANELS (OVER 200 AMP) 20,00
PLAN CHECK FEE P.C. NO.
SIGNS TRANS. 3.00
AARCH. OR DDRESS ENG.
ZIP
SPECIAL CIRCUIT 5.00
PERMIT VALIDATION _
TEMP. METER OR POLE INS. 20.00
APPLICANTS
ADOREss
MOTORS SEE FEE SCH.
aTi/ e
SERVICEOK
CHANGE 20.00
LICENSED CONTRACTORS DECLARATION
ITEMP. POLE 30.00
I hereby affirm that I am licensed under provisions of Chapter 9UANCE
(commencing with Section 7000) of Division 3 of the Business and
Professions Code god y icense is in full for' d f L
License I� Number �y )T/
DATE
k�PIR PLG. MECH.
❑ ❑
C '
on
Dale Contractor
OWNER -BUILDER DECLARATION
I hereby affirm Thalt I am exempt from the Contractor's License
Law for the following mason. (Sec, 7031.5, Businessand Professions
Code: Any city oremorty which requires a permit loconstnmC alter,
improve, demolish, or repair any structure, prior to its issuance, also
requires the applicant for such permit to file a signed statement tial
he is licensed pursuant to the provisions of the Contractor's License
-BUILDING PERMIT
INF TION
I $/FT.
/ 0-50
•?
MISC. - REFER TO ORD
PERMIT ISSUANCE 10.00
ELEC. CONTR. LIC. NO.
ELEC.
TOTAL
MIT TO
o >
OTY. PLUMBING PERMIT FEE
Law (Chapter 9 (commencing with Section 7000) of Division 3 of the
Business and Professions Code) or that he is exempt therefrom and
* i�
STORIES
TYPE CONSTR.
the basis fur the alleged exemption. Any violation of Seclion7031.5
by any applicant for a permit subjects the applicant to a civil penalty
of not more than five hundred dollars ($500).):
ALTER -DRAIN -WATER (EA.) 5.00
C 1, as Owner of the properly, [Ir my employees with wages as
their sole compensation, will do dm work, and the structure is nm
BACK FLOW PROTECT. DEVICE 4,00
OCC. GROUP
RES. UNITS
DRAINS -FLOOR, ROOF, AREA,COND. 5.00
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 thereon, and who does such work
himself or through his own employees, provided that Such improve'
ments are not intended or offered for sale. If, however, the building
-
F IXTUR ES - PER TRAP 5.00
So. FT. FLOOR AREA
TOTAL ACREAGE
GAS-EA.SYSTEM-11NC.40UTLETS 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 m-('7
Prove for purpose ofsale.).
C1' 1, as owner of the properly, am exclusively contracting with
GAS - EA. SYSTEM - OVER 4 (EA.) 2.00
BUILDING USE
RES IND CON PB CO.,
❑ ❑ ❑ ❑ ❑
. .
INDUSTRIAL WASTE INTER3000
LAWN SPRINKLERS- 1 INC 5 V.B. 6.00
LAWN SPRINKLERS - OVER 5 (EA.) 1.00
ASSESSORS PARCEL NO.
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 thereon, and who
contracts for such projects with a contractors) licensed pursuant to
the Contractors License Law.
EA. 200ft 10.00
SEWER -SANITARY -STORM/
TRACT NO.
PARCEL NO.
❑ lam exempt under See. ,B.&P.C. for this
reason
WATER HEATER W/VENT 6.00
Owner Date
-
WATER SYSTEM 5.00
ACC. DATE
ACO. FILE NO.
WATER TREATING EQUIP. 5.00
WORK ERS'COMPENSATION DECLARATION
1 hereby affirm that I have a certificate of Consent to self -insure,
or a certificate of Workers' Compensation Insurance- It a enitictl
copy thereof (See. 800, /� ,,O16 C
ZONING
ENG. SITE NO.
Comp nyC'e.,
Policy No. Company !shed. LQ//// /�
❑ Certified copy is hereby nished.
FIRE SPRINK
ENERGY T-24
`5L Certi^ copyp's l w usy`nspection division.
pant G:
Y N
❑ ❑
V N
❑ ❑
MISC.- REFER TO ORD.
r�
CERTIFICATE OF EXEMPTION FROM WORKERS'
PERMIT ISSUANCE 10.00
FLOOD ZONE
A.L.U.C.
PLG. CONTE. LIC. NO.
PLG.
TOTAL
COMPFNSATION INSURANCE
(This section need not be completed if the permit is for one
V [:] N❑
V ❑ N❑
OTY. MECHANICAL PERMIT FEE
FEE SUMMARY
hundred dollars (S 100) or less.)
I certify that in the performance of the work for which (his per.
mil is issued, I shall not employ any person in any manner so as to
BUILDING
fL�
` L /
become subject to the Workers' Compensation Laws of California.
Date Applicant
ALTER OR ADD TO MECH. 5.00
NOTICE TO APPLICANT: IL after making [his Certificate of Ex-
emption, you should become subject to the Workers' Compensation
APPLIANCE 5.00
PLAN CHECK
provisions of the Labor Cade, you must forthwith comply with
such provisions or this permit shall he deemed revoked.
FEE
AIR HANDLING UNIT (TO 10=11F.M.) 4.00
AIR HANDLING UNIT (OVER 10,000C.FM.)6.00
SEISMIC FEE
CONSTRUCTION LENDING AGENCY
1 herehy affirm that there is a Construction ]ending agency for
the performance of the work for which this permit is issued (Sce.
3097, Civ.C.). �.D hp
Lender's Name
Lender's Address
EXHAUST HOOD (WITH DUCT) 5.00
MICROFILM
HEATING UNIT (TO 100,000 B.T.U.) 8.00
HEATING UNIT IOVER 100,000 13.T.U.)9.50
ELECTRIC
I certify that 1 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
VENTILATION FAN (SINGLE) 4.00
PLUMBING
BOILER -COMP (3 H.P. or 100,000 B.T.U.) 6.00
BOI LER-COMP (Over IGG,000 BTU) 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 against liabilities, . it mens, costs and expenses which
may in y way accrue ai said City i, cons quenc of the
PERMIT ISSUANCE 10.00
MECH.CONT. LIC. NO. MECH.
TOTAL
TOTAL
31
Q
U
grantin this permit
�� S�
nature of pplicanl/Contractor Da
'OFFICE COPY