11924 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN GNLY
BUILDING PROJECT 1 OENTI FICATI ON PERMIT NUMBER
SRI BUILDING
APPLICATION & PERMIT
a..R 7s� �� /, , 11924
n ( BUILDING— ELECTRICAL—PLUMBING—MECHANICAL
NWNR'L
AEPLAN CHECK VALIDATION
3 / OTY. ELECTRIC PERMIT FEE
/ ( \ PHONE
oNTRACTOR's OUTLETS-SWITCHES-RECEP 10.00/1.00
NAM
- LIGHTING FIXTURES 10.00/1.00
LIC.NO.
/ CaO0N0TRREA55CTOAPPLIANCES-RESIDENTIAL 4.00
N /(yPHONE
PANELS 10.00 DATE OF APPLICATION
RcufTscT PANELS (OVER 200 AMP) 20.00 PLAN CHECK FEE P.0.NO.
O
OR
ENGINEER
uc.No. SIGNS TRANS. 3.00
ARCH.OR ENG. SPECIAL CIRCUIT SOO PERMIT VALIDATION
ADDRESS .
ZIP rrEMP. METER OR POLE INS. 20.00 q
ao a ANTS MOTORS SEE FEE SCH.
SERVICECHANGE ��'. 20.00
w o a_ LICENSED CONTRACTORS DECLARATION
a v I hereby affirm that I um licensed ,.dor provisions of Chapter 9 w ❑ ISSUANCE DATE
H 4 w (commencing with Section ]000)of Division 3 of the Business and ( BLDG. ELECT. PLG. MECH.
H o z rofessiGas Code, d my license is in full fo ce J e e ❑ 1 ❑ ❑
a, O 1/', - icensc Cl Lic.Numbe c
O z F O Date�Contractoi �^ �
¢ Y BUILDING PERMIT
¢ ¢ w¢ OWNER-BUILDER DECLARATION INFORMATION
ioa " MISC.— REFER TO ORD
s ;u y 1 hereby affirm that 1 am exempt from the Contractor's License
w LLo ¢ Law for the following reason. 7031.5,Businessand Professions PERMIT ISSUANCE 10.00 VALUATION 5/FT.
Code:Any city or county which requires a permit to construct,alter,
O
¢ ¢ 2 improve,demolish,or repair any structure,prior to its issuance,also ELEC.CONTR. LIC.NO. ELEC. 2,(
DLL requires the applicant for such permit to file a signed statement thatCa
TOTAL 3 V ` PERMIT TO
w he is licensed pursuant to the provisions of the Contractor's License `G7
H z a Law(Chapter 9(commencing with Section 7000)of0ivision 3 o fthe CLG
Nie
Business and Professions Code)or that he is exempt therefrom and DTV. PLUMBING PERMIT FEE
¢ H $ by any
a for the alleged exemption.Any violation of Section malty STORIES TYPE CONSTR,
by any applicant fore permit subjects S500d.licunttoacivil penalty ALTER-DRAIN -WATER (EA.) 5.00
of not more than flue hundred dollars(my em:
❑ 1,as owner at the property,or my employees with wages as BACK FLOW PROTECT. DEVICE 4.00 OCC.GROUP RES.UNITS
their sole compensation,will(S the work,and the and
Prof is not
Code:The
offered for Luce(Sec. 7044, Business and Processions DRAINS-FLOOR,ROOF,AREA,CON D. 5.00
Code: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 so.PT FLOOR AREA TOTAL ACREAGE
himself re through his own employees,provided that such intprove-
or improvemenotnt is sold w thinoffered
onefor
year
lt',however,thelookingowner. GAS-EA.SYSTEM-1 INC.4OUTLETS 6.00
or improvement is sob within one year of he didlio t the owner- GAS-EA.SYSTEM-OVER 4(EA.) 2.00
builder will have the burden of proving that he did not build or in BUILDING USE
prove for purpose of sale.). INDUSTRIAL WASTE INTER. 30.00 RES IND CON Pa olner
❑ 1,as owner of the property,am exclusively contracting with ❑ ❑ ❑ ❑ ❑
licensed contractors to construct the project(Sec.7044,Business LAWN SPRINKLERS-1 INC 5 V.8. 6.00 ASSESSORS PARCEL NO.
and Professions Code:The Contractor's License Lew does not apply
10 au owner of property who builds or improves thereon.and who LAWN SPRINKLERS-OVER 5(EA.) 1,00
contracts for such projectawithacontractorls)licenced pursuant to
the Contractor's License Lew. SEWER-SANITARY-STORM EA.200ft/10.00 TRACT NO, PARCEL NO.
❑ I am exempt under Sec..,B.&P.C.for this WATER HEATER W/VENT 6.00
reason
Owner Date WATER SYSTEM 5.00
ACC.DATE ACC.FILE NO.
WORK ERS'COMPENSATION DECLARATION WATER TREATING EQUIP. 5.00
I hereby affirm that l have a certificateofconsent tosell'-insure, - ZONING ENG.SITE NO.
or a certificate of Workers'Compensation Insurance,or a certified
copy thereof(Sec 3800,Lab.C.).
Policy No. Company /'I-
O ❑ Certified copy is hereby furnisll FIRE SPRINK ENERGY T24
Z Z ❑ Certific4 cary is flEit with the city ins ctwn division. MISC.- REFER TO ORD.
P: O' Applicant - V❑ N❑ V ❑ N❑
rn PERMIT ISSUANCE 10.00
LU CERTII'ICCOMPE M1 INSU OMWOR iR5' FLOOD ZOrvE A.LU.L.
W � COMPENSATION INSURANCE PLG.CONTE. LIC.NO. PLG.
CL Z 1 'I'his section need not be completed If the permit Is for one TOTAL Y❑ N❑ V ❑ N❑
hundred dollars IS]00)or less.)
U O 1 certify that in the performance of the work for which this per- QTY. MECHANICAL PERMIT FEE FEE SUMMARY
LL I- mit is issued,1 shall not employ any person in any mannerso as to
O L)ELI become subject to the Worker Compensation laws of California. BUILDING
a Date Applicant ALTER OR ADD TO MECH. 5.00
} to NOTICE TO APPLICANT: If,after making this Certificate of Ex
F Z emption,you should become subject to the Workers'Compensation APPLIANCE 5.00 PLAN CHECK
provisions of the Labor Code, you must forthwith comply with FEE
U such provisions or this permit shall be deemed revoked. AIR HANDLING UNIT(TO 10MC.F.M.) 4.00
CONSTRUCTION LENDING AGENCY AIR HANDLING UNIT(OVER 10MC.F.M.) 6.00 SEISMIC FEE
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. MICROFILM
3097,G'v.C.). - - 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 I C30 [1T�
I certify that I have reed Otis application and state that the above VENTILATION FAN (SINGLE) 4,00
i nformalion is correct. I agree to comply with all city and county PLUMBING
BOILER H.P.Of 100,000 B.T.U.) 6.00
ordinances and state laws relating to building construction, and
hereby authorize representatives of this city to enter upon the
above-mentioned property for inspection purposes. BOILER-COMP (Over 100,000 BTU)SEE FEE SCH. MECHANICAL
(We) agree to save,-indemnify and keep harmless the City of MISC.- REFER TO ORD.
Cupertino against liabilities,judgments, costs and expenses which PERMIT ISSUANCE 10.00 CONST.TAX
may in any way accrue Sail'nst said City in consequencP.of the
In'
g of.K16 permi I O ''Z,S// MECH.CONT. LIC.NO. MECH.
/I/ J fl, - 'f ^ to GGOJJ f( TOTAL TOTAL
Signature of Applicant/ ontracto Dale -
OFFICE COPY