09548APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
' BUILDING PROJECT IDENTIFICATION
APPLICATION &PERMIT
BUILDING - ELECTRICAL- PLUMBING - MECHANICAL
PERMIT NUMBER
09548
BUILDING
ADDRESS
!
He12, 44
O R'S -
NAME r.,L/�`�
PHONECu
OTY. ELECTRIC PERMIT FEE
PLAN CHECK VALIDATION
NAME AU I oRs
OUTLETS-SWITCHES-RECEP 10.00/1.00
LIGHTING FIXTURES 10.00/1.00
q ylc. No.
R'croRs
ADDRESS
APPLIANCES -RESIDENTIAL 4.00
PANELS 10.08
PHONE
DATE OF APPLICATION
OgcHITECT
ENGINEER EN
LPC. No.
PANELS(OVER 200 AMP) 20.00
- PLAN CHECK FEE P.C. NO.
SIGNS TRANS. 3.00
ARC Ess ENG.
SPECIAL CIRCUIT S.QQ
PERMIT VALIDATION
PAID
TEMP. METER OR POLE INS. 20.00
ZIP
G
APPLICANTS
ADDRESS
MOTORS SEE FEE SCH.
SERVICE CHANGE 20.00
23 i9R5
ity
C1y.qm
LICENSED CONTRACTORS DECLARATION
TEMP. POLE 30.00
1 hereby u1Onn that I am licensed under provisions of Chapter 9
6
4W
(cmmnendng will, Section 7000) of Division 3 of the Business and
Professions Code, and my license is in full force and effect.
License Class Lic. Number_
BLDG. ELECT. P G. MECH.
E El
Uale�.L� Contractor
BUILDING PERMIT
INFORMATION
OWNER -BUILDER DECLARATION
1 hereby affirm that I am exempt from the Contractor's License
Law for the following reason. (Sec. 7031.5, Businessand Professions
Code Any city or county which mquiresa permit to construct, alter,
MISC.- REFER TO ORD
PERMIT ISSUANCE10.00
VALUATION
S/FT.
ELEC. CONTR. LIC. N0.
ELEC.
TOTAL
improve, demolish, or repair any structure, prior to its issuance, also
requires the applicant for such permit to file a signed statement ODA
he is licensed pursuant to the provisions of the Contractors License
PER T TO
QTY. PLUMBING PERMIT FEE
Low (Chapter 9 (commencing with Section 7000) of Division 3 of the
Business and Professions Code) or that he is exempt therefrom and
•
the basis for the alleged exemption. Any violation of Section 7031.5
TYPE ONSTR.
hyanyapplicant for a permit subjects the applicant to a civil penalty
of not more than five hundred Jolla.. (S500)J:
ALTER -DRAIN -WATER (EA.) 5.00
O 1, as owner of the properly, or my employees with wages as
their sole compensation, will do the work, and the structure is not
BACK F LOW PROTECT. DEV ICE 4.00
OCC. GROUP
RES. UNITS
ROOF, AREA,COND. 5.00
intended or offered for sate (Sec. 7044. Business and ProfessionsDRAINS-FLOOR,
Code: The Contractor's License Law does not apply to an owner of
FIXTURES - PER TRAP 5.00I-r-rc52
GAS - EA. SYSTEM -1 INC. 40UTLETI 6.00 p
properly who builds or Improves thereon, and who does shell work
himself or through his own employees, provided that such improve-
mentsarenotintendedorofferedforsale. If, however. the building
FT. FLOOR AREA
TOTAL ACREAGE
or improvement is sold within one year of completion, the owner-
builder will have lire burden of proving that lie ,lid not huild or hit --BUILDING
prove for purpose ofaile.).00
❑ I, as owner of the property, ahs exclusively contracting with
GAS - EA. SYSTEM -OVER 4 (EA.) 2.00
USE
E IND CON PB Omer
) 0 0 0 0
INDUSTRIAL WASTE INTER. 30.
licensed contractors to construct the project (Sec. 7044, Business
and Professions Cade. The Contractor's License Law does not 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 contractor(s) licensed Fromm to
the Contractor's License Law.
SEWER -SANITARY -STORM EA. 200ft/10.00 'l
( UeJ
TRACT NO.
PARCEL NO.
❑ Inm exempt under Se<. ,B.&P�C. for this
son
WATER HEATER W/VENT 6.00 p()
Owner Date
WATER SYSTEM 5.00 OC/
ACC.DATE
ACC. FILE NO.
WATER TREATING EQUIP. 5.00
WORK 1: RS'COMPENSATION DECLARATION
I hereby affirm that I have a certificate of consent In SCIf-insm,
or a eertifica le of Workers' Compensation Insurance, or a certified
ZONING
ENG. SITE NO.
copy thereof (Sec. 3800, Lab.C.).
Policy No. Company
❑ Certified copy is hereby furnished.
ApWCert ificd pY is filed with the city inspection division.
antA riC /�i64ird
FIRE SPRINK
Y❑ M❑
ENERGY T 24
Y❑ NE]
MISC.- REFER TO ORD.
CFR1'IFICArt'. of EXEMPFION FROM WORKERS'
PERMIT ISSUANCE 10.00 CO
FLOOD ZONEA.L.U.C.
COMPENSATION INSURANCE
(This section need not he completed if the permit is for one
V N
Y N
PLG. CONTE. LIC. NO.
PLG. W
TOTAL
hundred dollars ($ 100) or less.)
I certify that in the performance of thnwork for which thisper!
mit is issued, 1 shall not employ any person in any manner so as to
become subject to the Workers' Compensation Laws ol'California.
Date Applicant
OTY. MECHANICAL PERMIT FEE
FEE SUMMARY.
BUILDING
ALTER OR ADD TO MECH. 5.00
NOTICE "10 AI'I'I,ICAN'I': If, after making this Certificate of 1: .s.
APPLIANCE 5.00
PLAN CHECK
FEE
you should become subject to the Workers' Compensation
provisions of the Labor Coda you must forthwith comply with
such provisions or this permit shall be deemed revoked
AIR HANDLING UNIT (TO 10MC.F.M.) 4.00
AIR HANDLING UNIT(OVER IODMC.EM.) 6.00
SEISMIC FEE
CONSTRUCT ION LENDING AGENCY
1 hereby affirm, that there is a construction lending agency for
the performance of the work for which this permit is issued (sec.
3097, Civ.C.).
EXHAUST HOOD (WITH DUCT) 5.00
MICROFILM
HEATING UNIT (TO 100,000 B.T.U.) 8.00
Lender's Name
Lender's Address
HEATI NG UN IT (OV ER 100,000 B.T.U.) 9.50
ELECTRIC
VENTILATION FAN (SINGLE) 4.00
I certify that l 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
ou
BOILER- COMP (3 H.P. or 100,000 B.T.U.) 6.00
hereby authorize representatives of this city to enter upon the
above-mentioned property for inspection purposes.
BOILER -COMP (Over 100,000BTU)SEE FEESCH.
MECHANICAL
(WC) agree to Save, indennify 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
granlipgy fit permit
MISC. - REFER TO ORD.
PERMIT ISSUANCE 10.00
CONST. TAX
H. CONT. LIC. NO.
MECH.
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9-�`
TOTAL
-TOTAL
,
00
slerta,mrco nNlcarTt/C$nl��T mal(
INSPECTOR COPY