09537APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
BU LDI NG PROJECT I DENTI FICATI ON
APPLICATION & PERMIT
BUILDING - ELECTRICAL -PLUMBING -MECHANICAL
PERMIT NUMBER
QQ537
aUILDING
ADDREss
OW RS
NAME L�,J�l,y
.� PHONES%''1/0
QTY. ELECTRIC PERMIT FEE
PLAN CHECK VALIDATION
NAME croR's
UTLETS-SWITCHES-RECEP 10.00/1.00
o A uC. No. - /
LIGHTING FIXTURES 10.00/1.00
.oNTRA s
ADDREss
PPLIANCES- RESIDENTIAL 4.00
PANELS 1()C0DATE
vHON 7
OF APPLICATION
oD RW
PANELS (OVER 200 AMP) 20.00
PLAN CHECK FEE P.C. NO.
ENGINEER
LIC. No.
SIGNS TRANS. 3.00
ADDREss ENG
SPECIAL CIRCUIT 5.00
PERMIT VALIDATION
'AID
TEMP. METER OR POLE INS. 20.00
ZIP
lVU
AS
MOTORS SEE FEE SCH.
SERVICE CHANGE 20.00'
31988ADDRESS
/
pH
Cl�10�r/Ip
LICENSIi1) CONI' RACTORS Df CLARATION
TEMP. POLE 30.00
hal
I hereby affirm ( I am licensed under provisions of Chapter 9
Iss rtrvue
(commencing will, Section 7000) of Division 3 of the Business and
Professions Code, :md my license is in full force and effecter
License Class Lic. Number 2S:Ghon
BLDG. ELECT. PLG. MECH-
❑ ❑ ❑
Uutc Contractor
BUILDING IT
INFOR AERM
TION
' OWNER -BUILDER DECLARATION
I hereby affirm that I am exempt from the Contractor's License
Law for the following reason.(Sec. 703 1.5, Business and ProfessionspERMIT
Code: Any city or county which requires permit to construct, alter,
'
MISC. - REFER TO ORD
ISSUANCE 10.00
VALUATION
5/FT.
ELEC. CONTE, LIC. NO,
ELEC.
TOTAL
Improve, demolish, Or repair any Structure, prior to its issuance. also
requires the applicant for such permit t0 file a signed Statement that
he is to tine provisions of the Contractor's License
P EMIT TO
QTY. PLUMBING PERMIT FEE
(Chapter 9 (comm
Law (Chapter 9 (commencing with Section of Division 3 of the
Business and Professions Code) or that his exempt is exempt therefrom and
the basis for the alleged exemption. Any violation of Section
T E CONSTR.
malty
subjects S500).licam loo civil penalty
by any applicant fora hundred
than
of not more Than five hundred dollars (5500). ):
ALTER -DRAIN VENT -WATER (EA.) 5.00
❑ I, as of the property, or my employees with wages as
their sale compensation, will 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 sale (Sec. 7044, Business and Professions
Code: The Contractor's 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,
g r YCes, sale, ever, ch improve -
merits
mans arc not inlenJed'or offered for sale lL however, the budding
building
FIXTURES - PER TRAP 5.00 C0
C
SD.FL FLOOR AREA
TOTAL ACREAGE
GA$-EA,SVSTEM-11NC.40UTLE TS 6.00 v(%
or improvement is sold within one year of completion, the owner-
builder will have the burden of proving that he did not build or im.
prove for purpose W sale.).INDUSTRIAL
131, as owner of tire m exclusively.
e properly, ucontracting with
GAS - EA. SYSTEM -OVER 4 (EA.) 2.00
BUILDING USE
R IND CON PB Omer
El ❑ ❑ El
WASTE INTER3000
.
LAWN SPRINKLERS- 1 INC 5 V.B. 6.00
licensed contractors to construct the project (See. 7044, Business
and Professions Code: The Contractor's License Law does not apply
air n owner ofproperty who builds or innproves thereon. and who
ASSESSORS PARCEL NO.
LAWN SPRINKLERS - OVER 5(EA.) 1.00 '
contracts lou such projects with it contractods) licensed pursuant to
(be Contractor's License Law.
SEWER -SANITARY -STORM EA. 200ft/10.00 1O0
TRACT NO.
PARCEL NO.
❑ Iwo exempt under Sri.-,B.&P.C. for ibis
on
WgTER HEATER W/VENT 6.00 'OQ
Owner Date
WATER SYSTEM 5.00 to
ACC.DATE
ACC. FILE NO.
WATER TREATING EQUIP. 5.00
WORK Ii RS'COMPE NSATION DECLARATION
I hereby affirm that I have a certificate of consent to self -insure,
or a certificate of Workers' Compensation Insurance, or a certified
ZONING
ENG. SITE NO.
copy drCmuf (Sce. 3800,. Lab.C.).
Policy No. Company
❑ Certified copy is hereby furnished.
qq(� Cetlified copy is filed with the city inspection division.
Alipficam {Gt ler�G ✓�-S
F IRE SPR INK
Y � N �
ENERGY T-24
Y � N�
MISC. - REFER TO ORD.
CERTIFICATii OF EXEMPT ION FROM WORKERS'
PERMIT ISSUANCE 10.00
FLOOD ZONE
A.L. U.C.
COMPIiNSATION' INSURANCE
(This seclidn need nor be completed it the permit is for one
PLG. CONTE. LIC. NO.
PLG.
TOTAL
Y ❑ N
YE] N
hundred dollars IS 100) or less,)
1 certify that in tire performance of Ore 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
become subject to the Workers' Compensation Laws of California.
Dale Applicam
ALTER OR ADD TO MECH. 5.00
NOTICE '1'O APPLICANT: If, after making this Certificate of Ex-
APPLIANCE 5.00
AIR HANDLING UNIT (TO 10=C.F.M.) 4.00
PLAN CHECK
FEE
emption, you should become subject to the Workers'Compensation
provisions of the Labor Code, you must forthwith comply with
such provisionsor this perinit shall be deemed revoked.
AIR HANDLING UNIT(OVER 10=C.F.M.) 6.00
SEISMIC FEE
CONSTRUCTION LENDING AGENCY
I hereby af'firm,that there is a construction lending agency for
EXHAUST HOOD (WITH DUCT) 5.00
the Perfanmance of (be work for which this permit is issued (Sec.
3097, Civ.C.).
MICROFILM
HEATING UNIT (TO 100,0008.T.U.) 8.00
Lender's Name
Lenders Address
HEATING UNIT (OVER 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
state ordinances and laws relating to building construction. and
PLUMBING
UU
BOILER-COMP(3 H.P. or 100,000 B.T.U.) 6.00
BOILER -COMP IOver 100,000 BTU) SEE FEE SCH.
MECHANICAL
hereby audmrize representatives of this City to enter upon tie
abuve-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.
PERMIT ISSUANCE 10.00
CONST. TAX
gramCngo hispennit.
MECH. CONT. LIG NO.
MECH.
^,1� �%� !
G
Lia A1IZ (,�((�
-
TOTAL
TOTAL
tlurn r of ate
�igrr5l�r�P scan r LJ�o}-d Date
INSPECTOR COPY