9170APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY y6�9
BU LDI NG PROJECT 1 DENTI FICATI ON
APPLICATION & PERMIT
BUILDING-ELECTRICAL-PLUMBING-MECHANICAL3
PERMIT NUMBER
9170
BUILDING
ADDRESS
OWNER'5
NAME
QTY. ELECTRIC PERMIT FEE
PLAN CHECK VALIDATION
sX a PHONE
DATE OF APPLICATION
CONTRACTOR
NAME
e ,,-/, t7 SGr✓ CG LIC NO, 171"
OUTLETS -SWITCHES-RECEP 10.00/1.00
LIGHTING FIXTURES 10.00/1.00
CONTRACTOR'S
ADDRESS O ,y
a C �. `� PIT 0NI _V
APPLIANCES -RESIDENTIAL 4.00
PANELS 10.00
ARCHITECTPANELS
OR
(OVER 200 AMPI 20.00
PLAN CHECK FEE P.C. NO.
ENGINEER
LIC. NO,
SIGNS TRANS. 3.00
ADDRESS E"G'
ZIP
SPECIAL CIRCUIT �!a 5.00
P VALIDATION
8 t
U \ U�
EMP. METER OR POLE INS. 20.00
ADD ESSTS
MOTORS SEE FEE SCH.
s Sf
SERVICE CHANGE 20.00
pUG Lp e�60
�xII Q` CoQ
C1}}ISSOANCE DATE
LICENSED CONTRACTORS DIiCLARA'fION
1 hereby affirm that I am licensed under provisions of Chapter 9
TEMP. POLE 30.00
(commencing with Section 7000) of Division 3 of the Business and
Professions Code,'td JJfccense is in full force nI eifectp
Classy_ Lic. Number'j�,S,,,x-z-_
BLDG_
❑
ELECT.
❑ LL
PLG. MECH.
❑ 1:1License
Data -I?- , Contructor(y,q._�._�E/'yyE
.
BUILDING PERMIT
OWNER -BUILDER DECLARATION
1 hereby afloor that I anmpt from the Contractor's License
d cxe
Law ar the following reason, 7031.5, Businessand Professions
Code: ny city or county which requiresa permit to construct. alter,
improv demolish, or repair any structure, prior to its issuance, also
}equires t c applicant for such permit to file a signed statement that
he is.licens pursuant to the provisions of Ore Contractor's License
Law (Chaptc 9(commeneing with Section 7000)of Uivision3 of the
Business and fessions Cole) or that he is cxempt therefrom anti
INFORMATION ;
MISC. REFER TO ORD •
.
VALUAfO77
$/FT.
PERMIT ISSUANCE 10A0
ELEC. CONTR. LIC. NO,
ELEC.
TOTAL
PERMIT TO
�I
QTV. PLUMBING PERMIT FEE
STORIES
-TYPE ONSTR.
Ilse basis for the leged exemption. Any viol,tmn o(Seclion 7031.5.
by any applicant a permit subjects the applicant to a civil penalty
aC not more than fiv unJrcd dollars (SSOOIJ:
ALTER -DRAIN & VENT -WATER (EA.) 5.00
O I, as owner of t • property, Or try employees with wages as
their sole compensation, 'ill do the work, and the structure is not
BACK FLOW PROTECT. DEVICE 4.00
OCC. GROUP
RES. UNITS
DRAINS -FLOOR, ROOF, AREA, COND. 5.00
intended or offered for s . (Sec. 7044, Business and Professions
Code:,The Contractor's Lic a Low does not apply to an owner of
F IXTUR ES - PER TRAP 5.00
50. FT FLOOR AREA
TOTAL ACREAGE
property who builds or impro s thereon, and who does such work
himself or through his own emp ces, provided that such improve
ments are not intended or offered I, sale. If, however, the building
GAS - EA. SYSTEM-11NC.40UTLETS 6.00
or impmvenm, ix sold within one •Br of completion, the owner-
builder will have the burden o(provi that he did not buil) or it,,-
prove for purpose ofsale.).
❑ I, as owner of the property, am a usively contracting with
GAS - EA. SYSTEM -OVER 4 (EA.) 2.00
BUILDING USE
RES IND CON PO Omer
❑ ❑ ❑ ❑ ❑
INDUSTRIAL WASTE INTER. 30.00
liccnscd contractors to cmHURct the prat -I ($cc. 7044, 11miness
and Professions Cole: The Comractoh Liee Law does not apply
to an owner of property who builds or impro thereon, and who
LAWN SPRINKLERS - 1 INC 5 V,B. 6.00
LAWN SPRINKLERS - OVER 5 (EA-) 1.00
ASSESSORS PARCEL NO.
cmdmds for 5och projects with a nmtrumnrl s) II •nsed pursuant in
the Contractor's License Law.
SEWER -SANITARY -STORM EA. 200ft/10.00
TRACT NO.
PARCEL NO.
❑ I am exempt under Site .B.&P.C. for this
reason
WATER HEATER W/VENT 6.00
Owner Date
WATER SYSTEM 5.00
ACC. DATE
ACC. FILE NO.
WATER TREATING EQUIP. 5.00
WORKERSCOMPENSATION DECLARATION
1 hereby alfirm that I have a certificate of consent to sell' -insure'
or a certificate of Workers' Compensation Insurance, or a certified
ZONING
ENG. SITE NO.
copy thereoffSec. 3800, Lab .C.).
PMicywy {'ynlpanY ��l1 ria
❑ Cc lle coy h ere by' fitrushed
, crtified 'upy is filed s ith tl city inspec -on Division.
p m.uv
FIRE SPRINK
Y❑ N❑
ENERGY T-24
Y❑ N❑
MISC.- REFER TO ORD.
CERTIFICATE OF EXEMPTION FROM \ ORKERS•
PERMIT ISSUANCE 10.00A2 92a
FLOOD ZONE
AL.0 c.
PL . CONTR. LIC. N0.
PLG.
TOTAL
COMPENSATION INSURANCE
1'1'llis section need not be completed If the permit is for o,
hundr Rollers fS 1001 orless'
v E] _ N ❑
Y E] N ❑
I cert ' that in the performance of the work for which this per-
mit is issue I shall not enmloy any person in any manna so IN to
CITY MECHANICAL PERMIT FEE
FEE SUMMARY
BUILDING
become subjec the Workers' Compensation Laws of Ca liforn ia.
Date licant
'NOTICE TO APPIIQ L after making this Certificate of Ex-
ALTER OR ADD TO MECH. 5.00
APPLIANCE 5.00
PLAN CHECK
emption, you should become s t to the Workers' Compcm.tlon
provisions of the Labor Code, yo st forthwith comply with
such provisions or this permit shall be dee -d revoked.
FEE
AIR HANDLING UNIT (TO 1Op00C.F.M.) 4.00
AIR HANDLING UNIT(OVER 10=C.6M.) 6.00
SEISMIC FEE
CONSTRUC'T'ION LENDING AGENCY
I hereby affirm that there is a construction lending agency for
EXHAUST HOOD (WITH DUCT) 5.00
the Pc mance at the work for which this permit is issued (Scc.
3097, Co..,.
MICROFILM
HEATING UNIT (TO 100,000 61T.U.) 8.00
Lenders w m
HEATING UNIT OVER 100,000 B.T.U.0.50
ELECTRIC
Lender's Address
I certify that l have read this application and State that the above
VENTILATION FAN (SINGLE) 4.00
information is correct. I agree to comply with all city and county
ordinances and stale laws relating to building constclioo, and
ru
PLUMBING
BOILER-COMP13 H. P. or 100,0008.T.U.) 6.00
BOILER -COMP (Over 100,000 BTU) SEE FEE SCH.
MECHANICAL
hercby mdhorme representatives ol'this city to enter upon Ole
above-mentioned property for inspection purposes. '
MISC. - REFER TO ORD.
(We) agree to save, indemnify and keep harmless the City of
Cupertino against liabilities, judgments, costs and expenses which
may in any way accrue against Said City in consequence of the
CONST. TAX
PERMIT ISSUANCE 10.00
granting of this permit
MECH. CONT. LIC.ND.
MECH.
'
TOTAL
TOTAL
Signature o Applicant Contractor le
INSPECTOR COPY