18067 (2)APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
BUILDING PROJECT I DENTI FICATI ON
APPLICATION & PERMIT
BUILDING -ELECTRICAL -PLUMBING -MECHANICAL
PERMIT NUMBER
1 p O L+�j
jl' I 0 �J I
BUILDING n
ADDREss /7 Al4/J Q� %r/Qii
V 7 / / l..
NANER'S
"AME
fid %�S n�y,�,7;%'
']
CITY. ELECTRIC PERMIT FEE
P CHECK VALIDATION
,j vNONE r(00
,q7r
r�
DATE OF APPLICATION
CONTRACTOR'S
RNp E 2
r -r 0ORTCQ OKI Lie No. 73
OUTLETS-SWITCHES-RECEP 10.00/1.00
LIGHTING FIXTURES 10.00/1.00
CONTRACTORS �r
'5ADDAEEss(j �f �r/y�(, �1j
a)AIR,OL.'�a &V.),.ONE J%O
PPCIANCES- RESIDENTIAL 4.00
PANELS 10.00
ARCHITECT
OR
ENGINEER
LOC. No.
PANELS (OVER 200 AMP) 20.00
PLAN CH EE eC. NO.
ISIGNS TRANS. 3.00
ARCH. OR END
ADDREss
ISPECIALCIRCUIT 5.00
PERV 'IDATI
TEMP. METER OR POLE INS. 20.00
ZIP
M J96
APPLICANT'S
ADDRESS PPLICA
MOTORS SEE FEE SCH.
SERVICE CHANGE 20.00
'
LICENSED CONTRACTORS DECLARATION
In' Or Wptm.-
thereby affirm that I am licensed under provisions of Chapter 9
ISSUANCE DATE
(commencing with Suction 7000) of Division 3 of the Business and
ProfCSSlDIIs Cod,, anti Ln IICCn Sit Is ul toll lure- and 'f -_S tr��
License Class C^31 Con Number
Datc�lo'/V-Conlrador
BLDG. ELECT- I
❑ ❑
PLG. MECH.
❑
BUILDING PERMIT
/
OWNER-OUILUIiR DECLARATION
1 hereby affirm that I am exempt from the Com,arwr's License
Law forthe following reason. (Sec. 7031.5. Business and Professions
INFORMATION
MISC. - REFER TO ORD
VALUATION
$/FT.
PERMIT ISSUANCE 10.00
Code: Any city or county which requires a permit to construct. alter,
improve, demolish, or repair any structure, prior to its issuance, also
requires the applicant lir such permit to file u signed statement that
he is licensed pursuant to the provisions of the Contractor's License
ELEC. CONTR. LIC. NO.
ELEC.
TOTAL
PERMIT TO
DTV. PLUMBING PERMIT FEE
Law (Chapter 9 (commencing with Section 7000) of Division 3 of tie
and Professions Code) or that he isexempt therefrom and
the basis for the alleged exemption. Any violation of Section 7031.5
!he
'
STORIES
TYPE CONSTR.
ALTER -DRAIN & VENT -WATER (EA.) 5.00
by any applicant for a permit subjects the applicant to a civil penally
of not more than five hundred dollars (8500).):
❑ 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 sal, (Sec. 7044, Business and Professions
BACK FLOW PROTECT. DEVICE 4.00
OCC. GROUP
RES. UNITS
DRAINS -FLOOR, ROOF, AREA, COND. 5.00
Code The Contractors License Law does not apply to in owner of
Property Who builds or improves themon, and who does such work
FIXTURES - PER TRAP 5.00
50, FT. FLOOR AREA
TOTALACREAGE
himself or through his own employees. provided that such improve -I
mems are not intended or offered for sale. If, however, the building
GAS - EA. SYSTEM -1INC. 4 OUTLETS 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-
pfuve for par,,.,,o 'wlu.l.
❑ I, as owner of the property, am exclusively contracting with
licensed contractors to construct the project (Sec. 7044, Business
and Professions Code: 'I'he Contractor's License Law does not apply
to as owns, of property who huilds or improves thereon, and who
GAS - EA. SYSTEM -OVER 4 (EA.) 2.00
BUILDING USE
RES IND CON PB oma,
❑ ❑ ❑ ❑ ❑
INDUSTRIAL WASTE INTER. 30.00
LAWN SPRINKLERS- 1 INC 5 V.B. 6.00
LAWN SPRINKLERS - OVER 5 IEA.) 1.00
ASSESSORS PARCEL NO.
contracts for such projects stub a conlractorts) licensed pursumv to
the Contractor's License Law.
SEWER -SAN ITAR VSTORM EA. 200ft/10.00
TRACT NO.
PARCEL NO.
WATER HEATERW/VENT 10.1`"e
❑ 1ant exempt under Sec. ,B.&P.C.for this
reason
Owner Date
WATER SYSTEM 5.00
ACC. DATE
ACC. FILE NO.
WORK ERS'CONIPEN'SA'I' ION DECLARATION
WATER TREATING EQUIP. 5.00
1 hereby affirm that I have a certificate of consent to self -insure.
or a cenifi.n, of Workers' Compensation Insurance, air n certified
ZONING
ENG. SITE N0.
copy thcrc f(S.'.3S 0 LppCI). ,y�
Iblicy No. tl.11ll_Lg6L1ilI�I1QQ1 T MAW
-
FIRE SPRINK
Y ❑ N❑
ENERGY T 24
V ❑ IN
❑ Certified copy is lmmby furnished.
❑ Certified ep� Iyyfled�vifh the city inspection division.
Applicant_o/v-�xOS�_-_�
MISC. - REFER TO ORD.
PERMIT ISSUANCE 10.00
FLOOD ZONE
A.L.U.C.
CE RI' I FI CA' TE OP EXI'M PITON FROM WORKERS'
PLG. CONTE, LIC. NO.
PLG. /❑
TOTAL` �}a
COMPENSATION INSURANCE
1'rhis section need not be completed if the permit is for one
Y ❑ N
V N
❑ ❑
QTY. MECHANICAL PERMIT FEE
FEE SUMMARY
hundred dollars IS 100) or Icss.l
1 certify that in me Performance of the work lir which this per-
mit is issued, 1 shall not mnploy any person in any manner so as to
BUILDING
become subject to the Workers' CGmpeeSallDn Laws of California.
Dare Applicant
ALTER OR ADD TO MECH. 5.00
NOTICE "I'O APPLICANT: If, after making this CeHificate of Ex-
emption, you should become subject to the Worksrs'Con+pensution
APPLIANCE , 5-00
PLAN CHECK
provisions of the Labor Code, you most Rrthwilb comply with
such provisions or this permit shall be deemed revoked.
FEE
AIR HANDLING UNIT (TO 10=C.F.M.) 4.00
AIR HANDLING UNIT (OVER 10MC.F.M.) 6.00
SEISMIC FEE
CONSTRUCTION LENDING AGENCY
EXHAUST HOOD (WITH DUCT) 5.00
HEATING UNIT (TO 100,000 B.T.U.) 8.00
MICROFILM
I hereby affirm that there is a construction lending agency far
the performance of the work rim which this permit is issued (Sec.'
3097. Civ.C.).
H EATING UNIT (OV ER 100,000 B.T.U.)9.50
ELECTRIC
Lender's Name
Lender's Address
VENTILATION FAN (SINGLE) 4.00
PLUMBING
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 stale laws relating to building construction, and
BOILER-COMPI3 H. P. or 100,000 B.T.U.1 6.00
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.
MISC. - REFER TO ORD.
CONST. TAX
(we) agree to save, indemnify and keep harmless the City of
Cupertino against liabilities, judgments, costs and expenses which
ay in any way accrue against said City in consequence of the
PERMIT ISSUANCE 10.00
MECH. CONT. LIC. NO.
MECH.
TOTAL
TOTAL
ranting of this permit.
Signature of Applicant/Contractor Date
OFFICE COPY