13399n_ APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
BUILDING PROJECT IDENTIFICATION
APPLICATION & PERMIT
BUILDING -ELECTRICAL -PLUMBING -MECHANICAL
PERMIT NUMBER
13399
BUILDING
ADDRESS
> 7
OWNER'S
OTY. ELECTRIC PERMIT FEE
PLAN CHECK VALIDATION
DATE OF APPLICATION
CONTRACTOR'S
SME 9r //fJ
S �(�7p.No./71.:,37
UTLETS-SWITCHES -RECEP 10.00/1.00
LIGHTING FIXTURES 10.00/1.00
CONTRACTOR'a
rDRREESS / J�am%JaQ
y96 �� PRDNE QC/t7
PPLIANCES- RESIDENTIAL 4.00
PANELS 10.00
ARCHITECT
OR
ENGINEER
LIc.NO,
PANELS (OVER 200 AMP) 20.00
PLAN CHECK FEE P.C. N0,
SIGNS TRANS. 3.00
ADDRESS tea
SPECIALCIRCUIT 5.00
PERMIT VALIDATION
EMP. METER OR POLE INS. 20.00
ZIP
(l,Iy z�TJ
-7 /
/ T oc,
APPLICANT'S _
qHESS
L"p
/f,CLE.b`.7% �✓
MOTORS SEE FEE SCH.
SERVICE CHANGE 20.00
LICENSED CONTRACTORS DECLARATION
1 hereby affirm that I am licensed under provisions of Chapter 9
(commencing with Section 7000) of Division 3 of the Business and
Professions Code, �d m 'cense ism full fur e
License ass Lic. Number
ISSUANCE DATE
BLDG. ELECT.
❑ ❑
PLG. MECH.
❑
Dete Contractor
BUILDING PERMIT
OWNER -BUILDER DECLARATION
I herebyaffirm that I am exempt from the Contractor's License
P
Professions
Law forthefollowing reason. (Sec.uires a, emit to
Code: Any city or county which structure permit to consuance, also
improve, demolish, or repair any structure, prior to its issuance, also
requires the applicant fur such permit to file a signed statement that
nee
he is licensed pursuant en the provisions of the Contractor's License
is7000) 3 of the
Business and Professions Code) or Ihat he is exempt therefrom and
Buss (Chapter 9 (Commencingwith that exempt
INFORMATION
MISC. - REFER TO ORD
VALUATION
$/FT.
PERMIT ISSUANCE 10.00
ELEC. CONTR. LIC. N0.
ELEC.
TOTAL
PERMIT TO
�C (�
QTY. PLUMBING PERMIT FEE
STORIES
TYPE CONSTR.
the basis for the alleged exemption. Any violation of Section 7031.5I
by any applicant for a permit subjects the applicant to a civil penalty
of not more than five hundred dollars (8500)::
ALTER-DRAIN&VENT-WATER(EA.) 5.00
❑ 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 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
Cade: The Contractor's License Law does not apply to an owner of
property who builds or improves thereon, and who does such work
FIXTURES - PER TRAP 5.00 Q,QQ
SQ FT. -FLOOR
TOTAL ACREAGE
himself or through his own employees, provided that such improve.
mems are not intended or offered for sale. If, however, the building
GAS- EA. SYSTEM- 1 INC.4 OUTLETS 6.00 . BL7
or improvement is sold within one year of completion, the owner-
builder will have the burden Of proving that he did not build or ire-
prove for purpose of sale.).
❑ I, as owner of the property, am exclusively contracting with
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
- GAS - EA. SYSTEM -OVER 4 (EA.) 2.QD
BUILDING USE
RES IND CON PB Omar
❑ ❑ ❑ ❑ ❑
INDUSTRIAL WASTE'I NTER. 30.00
LAWN SPR I N K LERS.,-17lINC 5 V.B. 6.00
'
LAWN SPRINKLER -OVER 5 (EA.) 1.00
ASSESSORS PARCEL NO.
contracts for such projects with a contractor(s) licensed pursuant to
the Contractor's License Law,
SEWER -SANITARY RM A. 200ft/10.00 -tW
TRACT NO.
PARCEL NO.
❑ I am exempt under Sec. ,B.&P.C. for this
reason
ACC, DATE
ACC. FILE N0,
WATER HEATER /VENT \ 6.00
\.• '��
Owner Date
WATER SYSTEM 5.00 �, P;V
WORK RS'COMPENSATION DECLARATION
WATER TREATIN(fE UIP. 5.00
1 hereby affirm that I have a Certificate of consent to self -insure,
or a certificate of Workers' Com pgmention Insurance, or a certified
ZONING
ENG. SITE NO.
copy (here f Sec. , La
Policy N Pd/,�C ErE'vF V
ompany
n
❑ Certified copy is hereby fu ishe.
}pJ"Certifi ro y is file I( t Cty in st f inion.
XPPlicant
FIRESPRINK
Y ❑ N❑
ENERGY T-24
Y ❑ N❑
MISC.- REFER TO OR D.
CERTIFICATE OF EXEMPTION FROM &KERS'
PERMIT ISSUANCE 10.00 �,QY/
FLOOD ZONE
A.L.U.C.
P . C TR. ,r/��p�,/ LIC. N0.../
A. L.K/el X61 /�
LG.
TOTq 7"
COMPENSATION INSURANCE
(This section need not be completed if the permit is for one
Y ❑ 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 this per-
mit is issued, I shall not employ any person in any manner so as to
BUILDING
become subject to the Workers' Compensalion Laws Of California.
Dote Applicant '
NOTICE FO APPLICANT. ll, after nloking Ibis Certificate of En
ALTER OR ADD TO MECH. 5.00
APPLIANCE 5.00
PLAN CHECK
emption, you should become subject to the Workers' Compensation
provisions of the Labor Code, you must I,orthwith comply with
such provisions or this permit shall be deemed revoked
FEE
AIR HANDLING UNIT (TO 10=11F.M.) 4.00
AIR HANDLING UNIT (OVER 10010C.FM.) 6.00
SEISMIC FEE
• CONSTRUCTION LENDING AGENCY
I 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) 5.00
MICROFILM
HEATING UNIT (TO 100,000 B.T.U.) 8.00
HEATING UN IT (OVER 100,000 B.T.U.) 9.50
ELECTRIC
Lender's Name
Lender's Address
I certify that I have read this application and stale 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 -COW (3 H.P. or 100,000 B.T.U.) 6.00
BOILER -COMP (Over 100,0008TUISEEFEESCH.
MECHANICAL
hereby authorize representatives of this city to enter upon the
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, crisis and expenses which
may in any way acct a against said City in consequence of the
gra goflhis'Pfr it ,
11 % %aIC
PERMIT ISSUANCE 10.00
MECH. CONT. LIC. NO, MECH.
TOTAL
fCONST.
OTAL
ignaturc of Applicant/Contractor Date
OFFICE COPY