9211APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
BU LD1 NG PROJECT IDENTIFICATION
-
APPLICATION & PERMIT
PERMIT NUMBER
BUILDING
ADDRESS
BUILDING - ELECTRICAL- PLUMBING - MECHANICAL
9211
OWNER'S
NAME (!d
I � PHONE ? V
-
OTY- ELECTRIC PERMIT FEE
PLAN CHECKVALIDATION
CONTRA R'S
NAME iUskG L,'hK�
UTLETS-SWITCHES -RECEP 10.00/1.00
LIGHTING FIXTURES 10.00/1.00
WWuc.NU.
N RAcroR's
ADDRESS
APPLIANCES -RESIDENTIAL 4.00
PANELS 10.00
,a PHONE C(c( -
GATE OF APPLICATION
AFcmrrcr
OR
ENGINEER
LIC. No.
PANELS (OVER 200 AMP) 20.00
PLAN CHECK EEE P.C. No.
SIGNS TRANS. 3.00
AARCH OR
DDRESS ENG.
SPECIALCIRCUIT 5.00
PERMIT VALIDATION
EMP. METER OR POLE INS. 20.00
' ZIP
J
DRESS E55
ADDRESS A
MOTORS SEE FEE SCH.
SERVICE CHANGE 20,0
LICENSED CONT'RACT'ORS DECLARATION
TEMP. POLE 30.0
I hereby affirm that I am licensed under provisions of Chapter 9
(commencing with Section 7000) of Division 3 of the Business and
Professions Code, and my license is in full force and effect
License Class 1- Lic. Number
ISSUANCE DATE
BLDG.
❑
ELECT.
❑
PLG. MECH.
❑ ❑
Date_ L�.q Contractor ��
BUILDING PERMIT
INFORMATION
,/OWNER-BUILDF-R DIiCLARATION
I hereby uIfiRN that I ant exempt front the Contractor's License
Law for the following reason. (Sec. 7031.5, Businessand Professions
Code: Any city or county which requires a permit to construct, alter,
MISC.- REFER TO ORD
PERMIT ISSUANCE 10.00
VALUATION
$/FT.
ELEC. CONTR, LIC, NO.
ELEC.
TOTAL
improve, demolish, or repair any structure, prior to its issuance, also
requires the applicant for such permit to file a signed slalenicnl'Ihal
he is licensed pursuant to the provisions of the Contractor's License
Law (Chapter 9 (commencing with Section 7000) of Division 3 of the
Business and Professions Code) or Uml he is exempt Ihereflvnl unit
_
r PERMITTO
L
b" U{
QTY. PLUMBING PERMIT FEE
STORIES
TYPE CONSTR.
the basis for the alleged exemption. Any violation of Section 7031.5
by any applicant for a pemtit subjects the applicant loacivil penalty
of not more than five hundred dollars (S500).):
ALTER -DRAIN -WATER IEA.) 5.00
❑ 1, as owner of lire properly. or my employees with wages as
ol
their se compensation, will do the work, and the structure is not
BACK FLOW PROTECT. DEVICE 4.00
oce, caouP
RES. UNITS
DRAINS -FLOOR, ROOF, AREA, COND. 5.00
intended or offered for sale (Sec 7044, Business and Professions
Code: "fire Contractors License Law does not apply to an owner of
property who builds or improves thereon, and who does such. work
himself or through his own employees, provided that such imPnsve-
ments are not intended or offered for sale. If, however, the building
FIXTURES - PER TRAP 5.00
SO. FT. FLOOR AREA
TOTAL ACREAGE
GAS-EA.SYSTEM-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 far-
r int-
prove for purpose of sale.).
❑ I, as owner of the properly, am exclusively contracting with
. -..
GAS EASYSTEM OVER 4 (EA) 200
BUILDING USE
RES IND CON PB Oar
m❑ ❑ ❑ ❑ ❑
INDUSTRIAL WASTE INTER. 30.00
LAWN SPRINKLERS - 1 INC 5 V.8. 6.00
LAWN SPRINKLERS - OVER 5 (EA.) 1.00
ASSESSORS PARCEL NO.
licensed contractors to construct the project (Sec. 7044, Business
and Professions Code: The Contractor's License Law dues not apply
to an owner of property who builds or improves thereon, and who
contracts for such projects with a contractor(s) licensed pursuant to
the Contractors License Law.
SEWER -SAN EA. 2001t/ 10.00
TRACT NO,
PARCEL NO.
❑ l um exempt under Sec.-, IT&P.C. I'.. this
reason
WATER HEATER W/VENT 6.00
Owner Dale
WATER SYSTEM 5.00
ACC. GATE
ACC. FILE NO.
WATER TREATING EQUIP. 5.00
WORK I! RS'COMPENSATION DECLARATION
I hereby affirm that I have a certificate ofconsent to sel Ginsure,
or a certificate of Workers' Compensation Insurance, or a certified
ZONING
ENG. SITE NO.
copy thereof (Sec.3800, Lab.C.).
Policy NIti i er, y i+i�(p
❑ Cern" CopyI "In furnisls' tid. I
O Certified `opy is filed with the city inspection ision.
Appliearf w�•,jy, 'l a:. div�L
FIRE SPRINK
Y❑ N❑
ENERGY T-24
V❑ No
MISC.- REFER TO ORD.
CERTIFICAIF OF EXEMPTION FIOM WORKERS'
PERMIT ISSUANCE 10.00
PLOOOZONE
A.L.uc.
COPIER. LIC. NO.
PLG.
TOTAL
COMPENSATION INSURANCEPLG.
section need not be completed if the permit is for one
Y❑ NE]
V❑ NE]('This
hundred dollars IS 100) or Tess.)
I certify that in the performance of the work for which this per-
mit is issued, 1 shall not employ any person in any manner so as to
QTY. MECHANICAL PERMIT FEE
FEE SUMMARY
BUILDING
s
70 -O
become subject to the Workers'Cnmpensition Laws of California-
Dale Applicant
NOTICE TO APPLICANT: If, after making this Certificate of Ex-
ALTER OR ADD TO MECH. 5.00
APPLIANCE 5.00
PLAN CHECK
emption, you should become subject to the Workers' Compensation
provisions of the labor Code, you must forthwith comply with
such jlrovisions cur this permit shall be accrued revoked.
FEE
AIR HANDLING UNIT (TO 10=C.F.M.) 4.00
AIR HANDLING UNIT(OVER 10=C.F.M.) 6.00
SEISMIC FEE
f
CONSTRUCTION LENDING AGENCY
I hereby affirm that there is a construction lending agency for
EXHAUST HOOD (WITH DUCT) 5.00
the 3097 performance of the work for which this permit is issued (Sec.
MICROFILM
HEATING UNIT (TO 100,000 B.T.U.) 8.00
Lender's Name
Lender's Name
HEATING UNIT (OVER 100,000 B.T.U.)
ELECTRIC
I certify that I leave 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 state laws reading to building construction, and
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 cnler umal the
above mentioned property for inspection purposes.
(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
MISC. -, REFER TO ORD.
CONST. TAX
PERMIT ISSUANCE 10.00
granting of this permit.
G
MECH. CONT. LIC. NO.
MECH.
TOTAL
TOTAL
Bigna[ure of oplicant Contractor 'te
INSPECTOR COPY