13601APPLICANT TO FILL IN INFO 4TIO N WITHIN RED LINES- USE Bilk- POINT PEN ONLY
BU I LDING PROJECT I DENTI FICA
APPLICATION & PERW
BUILDING - ELECTRICAL- PLUMBING - MECHANICAL
PERMIT NUMBER _---
13601
BDILUtNc
ADORES r)
E^/J
OWNERS
pKI" Me
TV, ELECTRIC PERMIT FEE
PLAN CHECK VALIDATION
R CTORS 424O
A
OUTLETS - SWITCHES -RECEP 10.00/1.00
LIGHTING FIXTURES 10.00/1.0
Dco
iKn 1F o
DATE OF APPLICATION
CONTRACTOR
ngOREss _
'JJ PHONE
APPLIANCES - RESIDENTIAL 4.00
PANELS 10,00 30,0
ARCHITECT
OR u
ENGINEER --
LIC. NO.
PANELS (OVER 200 AMP) 20.00
PLAN CHECK FEE P.C. NO.
SIGNS TRANS. 3.00
ARCH. OR ENG.5.00
ADDRESS
ZIP
SPECIALCIRCUIT _
PERMIT VALIDATION
kr�/�
TEMP. METER OR POLE INS. 20.00
APPLICANTS
ADDRc55 + c��
a�_GJ IL\J
MOTORSI ) a SEE FEE SCH.
SERVICE CHANGE 20.00 - -
LICENSED CONTRACTORS DECLARATION
I hereby affirm that I am licensed under provisions of Chapter 9
ISSUANCE DATE
(commencing with Section 7000) of Division 3 of the Business and
Professions Coda -d ray license is in full ',g Zo_dffftylrj 7
Licenses lass /d}•f�� Li c. Numberr'-A'.599-1 J_
Date-3Ld.6- Conlmctor /_ 1 �i-��yy-
EON LI
OWNIi R -BUILDER DECLARATIONINFORMATION
I hereby affirm that 1 am exempt from the Contractor's License
Law for tire ityfollowing Professions
county requires 5. a permit to
Code: Any city or county which requirespermit to construct, alter,
improve, demolish, Or any structure,itti pit Orn Its issuance, alsothat
" vi
BLDG.
❑
ELECT.
PLG. MECH.
❑ ❑
)
QC ( BUILD NG PERMIT
MISC.- REFER TO CA"
VALUATION /
$/FT.
PERMIT ISSUANCE '10.00 Q O=
ELEC. CONTE. - LIC. NO.
ELEC.
requires les the applicant for such permit to file a signed statement
for such
he is licensed pursuant the provisions of the Contractor's License
TOTA x�
PERMIT TO
ELc�%
cing with Section of Division 3 of the
Law (Chapter 9 (commencing
exempt therefrom and
Business and Professions Code) or that ivi is is exempt
the basis for the alleged exemption. Any violation of Section 7031.5
by any applicant for a pemtit subjects the applicant to a civil penally
of not more than five hundred dollars (S5000.):
QTY. PLUMBING PERMIT FEE
STORIES
TYPE CONSTR.
ALTER -DRAIN & VENT -WATER (EA.) 5.00
IBACK FLOW PROTECT. DEVICE 4.00
DEC. GROUP
RES. UNITS
0 I, as owner of the property, or my employees with wages as
their sole compensation, will do the work, and the structure is not
intended or offered for sale (Sec. 7044, Business and Professions
DRAINS -FLOOR, ROOF, AREA, COND. 5.00
Code: The Contractor's License Law does not apply to an owner of
property who builds or improves thereon, and who docs such work
himself or through his own employees, provided that Such improve-
meats are not intended or offered for sale 11, however, the building
FIXTURES - PER TRAP 5.00
SO. FT. FLOOR AREA
TOTAL ACREAGE
GAS-EA.SVSTEM-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 im-
prove for purpose of sale.).
❑ 1, as owner .1 tire properly, inI exclusively contracting with
licensed contractors to constant the project (Sec. 7044, Business
GAS - EA. SYSTEM - OVER 4 (EA.) 2.00
BUILDING USE
RES IND CON PB Other
❑ ❑ ❑ ❑ ❑
INDUSTRIAL WASTE INTER. 30.00
LAWN SPRINKLERS- 1 INC 5 V.B. 6.00
ASSESSORS PARCEL NO.
and Professions Code: The Contractor's License Law does not apply
to as owner, of properly who builds or improves (herein. and who
LAWN SPRINKLERS - OVER 5 (EA.) 1.00
contracts for such projects with a contnctorl S) licensed pursuant to
the Contractor's License Law.
gEWEfl-SANITARY-STORM EA. 200ft/10.00
TRACT NO.
PARCEL N0.
WATER HEATER W/VENT 6.00
❑ l am exempt ltiMer-S:w:.��, B.&PC. Io,this
reason
Owner Date
WATER SYSTEM 5.00
ACC.OATE
ACC. FILE NO.
WORK ERS'COMPENSATION DECLARATION
WATER TREATING EQUIP. 5.00
1 hereby affirm that I have a certificate ofenaleat to self -insure.
or a certificate of Workers Compensation Insurance, ser a ,rtil'icd
ZONING
ENG. SITE NO.
Copy the. tl (Sec. 3800, Loh -C.)'
il
FIRE SPRINK
y ❑ N ❑
ENERGY T-24
y ❑ N❑
Policy NoContpuny�l/C}' .?
❑ Certified copy is hereby furnished.
Lnil'I• Ipy i lite stir t e cis i s ens n divis n.
pPlicant_V 1 91 _ _ les-��e- _ _
MISC. - REFER TO ORD.
PERMIT ISSUANCE 10.00
FLOOD ZONE
A.L.0 C.
CE R I F ICAT Ii 01' I;X 17 PTION PROM WO R K Ii RS'
PLO, CONTE. LIC. NO.
PLGTOTAL .
COMPENSWION INSURANCE
(This section need not be completed if the permit is for one
Y E)N ❑
Y ❑ N ❑
OTV. MECHANICAL PERMIT FEE
FEE SUMMARY
hundred dollars IS 100) or less.)
I certify that in the perform:mce of the work for which this per.
nut is issued, I shall not employ any person in any manner so as to
become subject to the Workers'Compensation Laws of California.
Dale ApplicantALTER
NOTICE TO APPLICANT: If, after making this Certificate of Ex-
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.
BUILDING
OR ADD TO MECH. 5.00
APPLIANCE 5.00
PLAN CHECK
FEE
AIR HANDLING UNIT (TO 1-O=C.F.M.) 4.00
AIR HANDLING UNIT (OVER 10DWC.F.M.) 6.00
SEISMIC FEE
CONSTRUCTION LENDING AGENCY
EXHAUST HOOD (WITH DUCT) 5.00
MICROFILM
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.C.).
Lender's Name •2 a,�
HEATING UNIT (TO 100,000 B.T.U.) 8.00
HEATING UNIT (OVER 100,000 B.T.U.)8.50
ELECTRIC
p� Q�
Lender's AddleIs
I certify that I have read th s 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
BOILER -COMP (Over 100,000 BTU) SEE FEE SCH.
MECHANICAL
hereby authorize representatives of this city to enter upon lire
above-mentioned properly for inspection purposes.
(We) agree to save, indemnify and keep hurmless the City of
Cupertino against liabilities, judgments, costs and expenses which
may in any way accrue, against mid City in consequence o1' the
MISC. - REFER TO ORD.
CONST. TAX
PERMIT ISSUANCE 10.00
MECH. CONT. UC. NO. MECH.
TOTAL
TOTAL
granting of this PC.'not. C-.. �T
.SOY'%
5 nature of App Icanl/C tractor DTIII•
OFFICE COPY