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APPLICANT TO FILL IN INFORMATION WITHIN RED LINES -USE BALL POINT PEN ONLY
BUI LDI NG PROJECT 1 DENTI FICA
APPLICATION & PEF•T
BUILDING - ELECTRICAL- PLUMBING - MECHANICAL
PERMIT NUMBER
gg53
;BDILDING -
HaJILDIN
^r
1
OWNER
NAME T
OTY. ELECTRIC PERMIT FEE
PLAN CHECK VALIDATION
l vNorvE
ON
DATE OF APPLICATION
CONTRACTORS
NAME
NAME
S 142J_uc.N-,
u
p JOUTLETS - SWITCHES -RECEP 10.00/1.00
LIGHTING FIXTURES 10.00/1.00 36
CONTRACTORS
O5 �J
FHONon (
APPLIANCES- RESIDENTIAL 4.00
PANELS tO.00
eHITEc
OR
ENGINEER
LIC. No.
PANELS (OVER 200 AMP) 20.QO Q
PLAN CHECK FEE P.C. NO.
SIGNS TRANS. 3.00
ADDRESS ENG
SPECIALCIRCUIT 5.00
PERMIT VALIDATION
EMP. METER OR POLE INS. 20.00
ZIP
•rp....�
ADDRESS rs
Aass
MOTORS SEE FEE SCH.
-- SERVICE CHANGE 20.00
lf^"'
LICENSED CONTRACTORS DECLARATION
TEMP. POLE ppon 30.00
Ct_,
a
I hereby affirm that I am licensed under provisions of Chapter 9
(commencing with Section 7000) of Division 3 of the Business and
1'romen.ns C - y license is in fullfol t
License la s Lic. Number
ISSUANCE DATE
BLDG. ELECT. PLG. MECH.
Date Con tmcto -
OWNER -BUILDER DECLARATION
I hereby affirm that I am exempt from the Contractor's License
Law for the following reason. (See, 7031.5, Business and ProfessionsVALUATION
Code: Any city or county whichmouiresa permit to construct, alter,
attire
BUILDING PERMIT
INFORMATION
MISC. - EFER TO ORD
PERMIT ISSUANCE 10.00
S/FT.
ELEC. CONTE. LIC. NO. ELEC.
TOTAL
OTY. PLUMBING PERMIT FEE
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 of the Contractor's License
Law (Chapter 9 (commencing with Section 7000) of Division 3 of the
Businessand Professions Code) or that he isexempt therefrom and
PERMITTO
STORIES
TYPE CONSTR.
the basis for the alleged exemption. Any violation of Section 7031.5
by any applicant for a permit Subjects the applicant Ica civil penalty
of not more than five hundred dollars ($500l):
ALTER -DRAIN -WATER IEA.) 5.00
❑ I, as owner of the property, or my employeeswith wages as
their sole compensation, will do the work, and the structure is not
BACK FLOW PROTECT. DEVICE 4.00
OCC. GROUP
RES. UNITS
DRAINS -FLOOR, ROOF, AREA, COND. 5.00
intended or offered for sale (Sce. 7044, Business and Professions
Code: The Contractor's License Law docs not apply to an owner of
FIXTURES - PER TRAP 5.00
GAS-EA.SYSTEM-11NC.40UTLETS 6.00
sO. FT. PLooR AREA
TOTALACREAGE
property who builds or improves thereon, and who does such work
himself or through his own employees, provided that such improve-
mentsarenot intended or offered for sale. If, however, the building
or improvement is sold within one year of completion, the owner-
builder will have the burden of proving that he did not build or im-
GA$ - EA. SYSTEM -OVER 4 (EA.) 2.00
BUILDING USE
prove for purpose of sale.).
❑ I, as owner of the property, am exclusively contracting with
RES IND CON PB Othar
❑ ❑ ❑ ❑ ❑
INDUSTRIAL WASTE INTER. 30.00
licensed contractors to construct the project (Sec. 7044, Business
and Professions Code: The Contractor's License Law does not apply
to an owner of properly who builds or improves thereon. and who
LAWN SPRINKLERS - 1 INC 5 V.B. 6.00
LAWN SPRINKLERS - OVER 5 (EA.) 1.00
ASSESSORS PARCEL NO.
contracts frrsuch projects with a contractor(s) licensed pursuant to
the Contractor's License Law.
SEWER -SAN ITAR V -STORM EA. 200ft/10.00
TRACT NO.
PARCEL NO.
reason ❑ I am exempt under Sec. ,B.&P.C. for this
WATER HEATER W/VENT 6.00
Owner Date
WATER SYSTEM 5.00
ACC. DATE
ACC FILE NO.
WATER TREATING EQUIP. 5.00
WORKERS'COMPENSATION DECLARATION
1 hereby affirm that 1 have a certificate of consent to self -insure,
or a CER fiQCC��L I� ff{W11orkers'C ompensation Insurance, or a certified
ZONING
ENG. SITE NO.
I'oleyhNoeU]rt °mpan.Y.)./' K�6w-A
❑ Certified copy ishereby furnished'
`Certified opy is filed it the City inspec on division.
Applican`,-%%
FIRE SPRINK
Y ❑ N ❑
ENERGY T$4
v ❑ N❑
MISC. - REFER TO ORD.
CERR-TIIFFI/CA�TE OMP EXXEEMPTION FROM WORKERS'
PERMIT ISSUANCE 10.00
FLOOD ZONE
A. L. U. C.
COMPENSATION INSURANCE
(This section need not be completed if the permil is for one
PLG. CONTR. LIC. No.
PLG.
TOTAL
Y ❑ IN
Y ❑ IN
hundred dollars /5100) or less.)
I certify Ihut 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
QTY. MECHANICAL PERMIT FEE
FEE SUMMARY
become subject to the Workers' Compensation Laws of California.
Date Applicant
BUILDING
ALTER OR ADD TO MECH. 5.00
NOTICE TO APPLICANT: If, after making this Certificate of Ex-
iti,
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.
LI ANCE 5.00
AIR HANDLING UNIT (TO 10=C.F.M.) 4.00
PLAN CHECK
FEE
AIR HANDLING UNIT (OVER I0MC.F.M.) 6.00
SEISMIC FEE
CONSTRUCTION LENDING AGENCY
I hereby affirm that there is a construction lending agency for
EXHAUST HOOD (WITH DUCT) 5.00
the performance of the work for which this permit is issued (Sec.
3097, Civ.C.).
MICROFILM
HEATING UNIT (TO 100,000 B.T.U.) 8.00
Lender's Name
Lender's Address -
HEATING UNIT 100,000 B.T.U.)9.50
ELECTRIC
VENTILATION FAN (SINGLE) 4.00
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
PLUMBING
BOILER- COMP (3 H.P. Or 100,000 B.T.U.1. 6.00
BOILER-COMP (Over 100,000 BTUI SEE FEE SCH.
MECHANICAL
hereby authorize representatives of this city to enter upon the
above-mentioned property for inspection purposes.
(We) agree to save, indemnify and keep harmless the City of
MISC. - REFER TO ORD.
Cupertino against liabilities, judgments, costs and expenses which
may in any way accrue against said City in consequence of the
mut ingof [hlspe'lo
J ;Lp-9L
PERMIT ISSUANCE 10 00
CONST. TAX
MECH.CONT.- LIC. NO. MECH.
TOTAL
TOTAL
Signature of Applicant/Contractor Date
OFFICE COPY