9149APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
BUILDING PROJECT IDENTIFICATION
APPLICATION & PERMIT
PERMIT NUMBER
BUILDING
PDDRE55
BUILDING -ELECTRICAL- PLUMBING -MECHANICAL
9149
OWNER'S
N°"'E /
e' L PHONE
QTY. ELECTRIC PERMIT FEE
PLAN CHECK VALIDATION
rvrRncroR's
NAME
OUTLETS-SWITCHES-RECEP 10.00/1.00
LIGHTING FIXTURES 10.00/1.00
LIC. No.
CONTRACTORS
ADDRESS
ADDRESS
APPLIANCES- RESIDENTIAL 4.00
PANELS 10.00
PHONE
DATE OF APPLICATION
ARCHITECT -
OR
ENGINEER
LIC
PANELS (OVER 200 AMP) 20.00
PLAN CHECK FEE P.C. NO.
SIGNS TRANS.3.00
-.NO.
ARCH, OR END.
SPECIAL CIRCUIT fi.00 -
PERMIT VALIDATIONADDRE
I
EMP. METER OR POLE INS. 20.00
ZIP
APPLICANT S
ADUR
IzAell U) DRESS
MOTORS,1 , SEE FEE SCH.
SERVICECHANGE 20.00
LICENSED CON'FRACfORS DECLARA'f1oN
TEMP. POLE 30.00
-
1 hereby affirm that I an, licensed under provisions of Chapter 9
(commutcing with Section 7000) of Division 3 of the Pusines4nnd
Professions Code, unit my license is in full for a�'r%g'yI�f�If�/et�y/E /b
License Cla,;; l 4/ Lic. Nnlllher / /"' / ✓'
ISSUANCE DATE
'•
BLOQ
❑
ELECT.
❑
PLG. MCH.
❑
/
DntvI;__y �J-.�-Contractor
�� W 1•%
OWNIi K-BUILDIiR DECLA Rn TION
1 hereby affirm that I um exempt from the Contractors License
Law lortlm lDllowing remOli:(Scc. 7031.5. liusincssand Professions
Code: Any city or county which requires a permit to con.front, alter,
BUILDING PERMIT
INFORMATION
MISC. - REFER TO ORD
VALUATION
5/FT-
PERMIT ISSUANCE 10.00
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 signal slaternent that
In, is licensed pursuant In the provisions of the Contractor's License
Law (Chapte(commencing with Section 7000)of Division 3 of IIIc
Raciness and Professions Code) or tlmt Be is Crtempt therefrom and
'
PERMIT TO
OA fii
QTY. PLUMBING PERMIT FEE
the basis for the alleged exemption. Any violation of Section 7031.5
STORIES
CONSTR.
by any applicant for a permit subjeclsthe applicant too civil penalty
of not more than five hundred dollars (5500).):
ALTER -DRAIN -WATER (EA.) 5.00
❑ I, as owner of the property, or my employeeswith wages as
their sole compensation, will do tie work, and the stnsture is not
BACK FLOW PROTECT. DEVICE 4.00
OCC. GROUP
RES. UNITS
DRAINS -FLOOR, ROOF, AR EA,COND. 5.00
intended or offered for sale (Sec. 7044, Business and Professions
Code: 'Che Contractor's Licence Law does not apply to art owner of
FIXTURES -PER TRAP 5.00
SD. FT. FLOOR AREA
TOTAL ACREAGE
property who builds or improves thereon, and who docs such work
himself or through hie over employees, provided that such improve-
Rents are not intended or offered for sale. If, however, the building
GAS-EA.SVSTEM-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 Or ire-
prove for purpose Of sale.).
❑ I, as owner of the property, am exclusively contracting with
GAS - EA. SYSTEM - OVER 4 (EA.) 2.00
BUILDING USE
RES IND CON PB Orae,
❑ ❑ ❑ ❑ ❑
INDUSTRIAL WASTE INTER. 30.00
licensed contractors to construct the project (Sec. 7044, Business
and Professions Code: The Contractors License Law does nut apply
to an owner of property who builds or improves thereon. and who
LAWN SPRINKLERS- 1 INC 5 V.B. 6.00
ASSESSORS PARCEL NO.
'
LAWN SPRINKLERS - OVER 5 (EA.) 1.00
contracts for such projects with a conlractorlsl licensed pursuant to
the Contractors License Law.
SEWER -SAN V -STORM EA. 200ft/10.00
TRACT NO.
PARCEL NO.
❑ [am exempt under Sec.-, 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
WORKERS'COMPENSATION DECLARATION
I hereby affirm that I have a certificate of consent to self -insure,
or certificate of Workers' Compensation Insurance, or a certified
♦
ZONING
ENG. SITE NO.
copy thereof(Sec.3800, Lab C.)
��'�-�,
Policy No. Company_}_/-q-/•�'%+
FIRESPRINK
Y❑ N❑
ENERGY T-24
Y❑ N❑
C CertifiedcopyiSheRbyfu nos ed.
❑ Certified copy is filed with the city inspection division.
Applicant
1 11 Y •
CERTIICAT.OP I KlihlPl'ION I'ROh1 WORKERS'FLOOD
MISC.- REFER TO ORD.
PERMIT ISSUANCE 10.00
ZONE
A.L. U.C.
PLG. CONTR. LIC. NO.
PLG.
TOTAL
COMYENSA'IAON INSURANCE
(This section need ran be compleled if the permit is for one
Y ❑ N ❑
'
Y ❑ N❑
.�
QTY. ei MECHANICAL PERMIT FEE
r(
FEE SUMMARY
hundred dollars IS 100) or less.)
I vilify that in tine pert ofmwlce Of the work for which this per
mit is issued, 1 shall not enmloy any person in any manner so us to
bCCDllle subjeel to the Workers' Compensation Laws of California.
Date Applicam
BUILDING
ALTER OR ADD TO MECH:, 5.00
SUE In: 'f0 APPLICANI It, al'ler making this Certificate of Ex-
APPLIANCE 5.00
PLAN CHECK
emption, you should become subject to the Workers'COmpcnsation
provisions of the Labor Code, you nuns) tbrlhwith comply with
such grovisiore or this permit shall he deemed revokeA.
FEE
AIR HANDLING UNIT (TO 10)000C.F.M.) 4.00 U
HANDLING UNIT 10000M.) 6.00
- AIR HANDLGE
SEISMIC FEE
CONSTRUCT ION 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.L
MICROFILM
,Z HEATINGUN IT (TO 100,000 B.T.U.) 8.00 th
HEATING UNIT (OVER 100,000 B.T.U.)9.50
ELECTRIC
Lender's Name
Lender's Address
I certify that I have read this application and "Vel
tate that the above
VENTILATION FAN (SINGLE) 4.00
information is correct. I agree to comply with .II city and county
ordinances and state laws relating to building construction. and
PLUMBING
BOILER -COMP (3 H.P. or 100,000 B.T.U.) 6.00
gOILER-COMP Over 10G000BTUISEE FEESCH.
MECHANICAL
hereby authariee representatives of this city to anter upon the
above mentioned property for inspection purpous.
MISC. - REFER TO ORD.
(We) agree to save, indemnify and keep hornless the City of
Cupertino against liabilities, judgments, costs Wd expenses whichCONST.
may in any way acme against said City i consequence of the
TAX
PERMIT ISSUANCE 10.00 red
granting of th ermiL
MECH. CONT. LIC. NO.
MECH.
TOTAL
n
TOTAL
S' oat of n n r ate
v I INSPECTOR COPY