09538APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
BUILDING PROJECT IDENTIFICATION
APPLICATION &PERMIT
BUILDING - ELECTRICAL -PLUMBING -MECHANICAL
PERMIT NUMBER
09538
BUILDING
ADDRESS
A
ER'S
NAME 6d 011 P..NEv� -/Yb1
OTV. ELECTRIC PERMIT FEE
PLAN CHECK VALIDATION
NAAME Toms
OUTLETS-SWITCHES-RECEP 10.00/1.00
�IC.N
LIGHTING FIXTURES 10.00/1.00
1
ADDRESS D 7 's
A
APPLIANCES - RESIDENTIAL 4.00
PANELS 10.00
PHONE
DATE OF APPLICATION
onG
PANELS(OVER 200 AMP) 20,00
PLAN CHECK FEE PC NO.
ENGINEER
LIC. No.
RAI
SIGNS TRANS. 3.00
ADDRESS ENG. r
SPECIAL CIRCUIT 5.00
PERM/.IT A ION
ZIP
L.
AUG 23 1900,
JO
EMP. METER OR POLE INS. 20.00
ADDRESS
ADDRESS
MOTORS SEE FEE SCH.
City Of Cupertino
SERVICE CHANGE 20.00
LICENSIiD CONTRACTORS DECLARATION
TEMP. POLE 30.00
1 here by affirm that 1 at,, licensed under provisions of Chapter 9
(commencing with Section 7000) of Division 3 of (lie Business and
Professions C. anJ m license is in full force and c f-et�f'
License Cl s 7 Li, Number �]-/0
ISSUANCE DATE
BLDG.
ELECT.
PLG
MECH.
�-
Dmc Contractor
PERMIT
INFORMATION
OWNER -BUILDER DECLARATIONBUILDING
I hereby affirm that I am exempt from the Contractor's License
Professions
Law for the following reason. (Sec.uires a,emit to
Code: Any city or county which requirese permit to construct, alter,
MISC.- REFER TO ORD
PERMIT ISSUANCE 10.00
VALUATION
$/FT.
ELEC. GONTR, 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 statement that
he is licensed pursuant the provisions of the Contractor's License
PERMIT TO
en Division3of the
Law (Chapter9(commencingwith Section
,
is7000)
Business and Professions Code) or that he is exempt therefrom and
exempt
QTY. PLUMBING PERMIT FEE
the basis for the alleged examption. Any violation of Section 7031.5
by any applicant fora permit subjects the applicant to a civil penalty
u1' not than five hundred dollars ($500t):
):
STO
TYP CONSTR.
>
-
ALTER -DRAIN (EA.) 5.00
Inore
13, as owner of the property, or my employees with wages as
their sole compensation, will do the work, and the structure rs not
BACK F LOW PROTECT. DEV ICE 4.00
OCC. GROUP
RES. UNITS
DRAINS -FLOOR, ROOF, AR EA, COND. 5.00
intended or offered for sale (Sc, 7044, Business and Profession,
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, provided that such improve-
mentsarenotintendedorofferedfor sale- IC however. the building
FIXTURES - PER TRAP 5.00 GO
GAS - EA.SYSTEM - I INC.4OUTLETS 6.00 00
SD. FT. FLOOR AREA
TOTALACREAGE
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 ofsale.).
❑ I, as owner of the property, am exclusively contracting with
GAS - EA. SYSTEM -OVER 4 (EA.) 2.00
BUILDING USE
E . IND CON PB Other
❑ ❑ ❑ ❑
INDUSTRIAL WASTE INTER. 30.00
LAWN SPRINKLERS- 1 INC 5 V.B. 6.00
LAWN SPRINKLERS - OVER 5 (EA.) 1.00
licensed contractors to construct the project (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
ASSESSORS PARCEL NO.
contracts for such projects with a coutr:mtor(s) licensed pursuant to
the Contractors License Law.
SEWER -SAN ITARY-STORM EA. 200ft/10.00 G(7
TRACT NO.
PARCEL NO.
❑ I;un exempt under Sec. ,e.&P.C. for this
R'JYpll
WATER HEATER W/VENT 6.00 Off%
Owner Date
WATER SYSTEM 5.00 OV
ACC. DATE
ACC. FILE NO.
WORK ERS'COMPENSATION D1iCLARA'rION
WATER TREATING EQUIP. 5.00
1 hereby affirm that 1 have a certificate of consent to self -insure.
or a certificate of Workers' Compensation Insurance, or a certified
ZONING
ENG. SITE NO.
copy thereof (Sec. 3800, Lab C. ).
Policy No. Company
❑ Ce lified Copy is hereby furnished.
Certified copy is filed with the city inspection division,
scant K, 1PE.9, 4f1 `3
FIRE gPRINK
Y ❑ N❑
ENERGY L]4
Y ❑ IN E]
I MISC. - REFER TO ORD.
CERTIFIC'ATEOF EXEMPTION FROM WORKERS'
PERMIT ISSUANCE 10.00 w
FLOOD ZONE
A.L.II.C.
COMPENSATION INSURANCE
(Phis section need -not be conuplmcd if the permit is lin o,
Y [:]N❑
Y [:]N❑
PLG. CONTR. LIC. NO.
PLG, �,rl
TOTAL W
bonded dollars 1$ 1001 or less.]
I certify that in the performance of the work I'or which this per-
not is issued, I Shall not employ any person in any manner so as to
QTY. MECHANICAL PERMIT FEE
FEE SUMMARY
BUILDING
become subject to the Workers' Compenum ion Laws of California.
Date Applicant
ALTER OR ADD TO MECH. 5.00
NO'rl CE TO APPLICANT: If, after making this Certificate of Ex-
APPLIANCE 5.00
AIR HANDLING UNIT (TO 10=11F.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 provisions or this pemnit staff be deemed revoked.
AIR HANDLING UNIT (OVER 10=C.EM.) 6.00
SEISMIC FEE
CONSTRUCTION LENDING AGENCY
I hereby affirm that there is a construction lending agencv for
EXHAUST HOOD (WITH DUCT) 5.00
the pertitnnence of the work for which this permit is issued (Sec.
3097, Civ.C.).
MICROFILM
HEATING UNIT (TO 100,000 B.T.U.) 8.00
Lender's Name
Lender's Address
HEATING UNIT (OVER 100,000 B.T.U.)9.50
ELECTRIC
VENTILATION FAN (SINGLE) 4.00
I certify that l hale read this application ;uul state that the above
Incarnation is correct. I agree to comply with all city and county
ordinances and state laws relating to building construction, and
PLUMBING
�% G
gO1LER-COMP(3 H.P. or 100,000 B.T.U.) 6.00
hereby authorize representatives of this city to en tcr'upon the
above-mentioned property for inspection purposes.
BOILER -COMP (Over 100,000 BTU) SEE FEE SCH.
MECHANICAL
(We) agree to save, indemnify and keep harmless the City of
Cupertiagainst liabilities, judgments, costs and expenses which
in any way accrue against said City in consequence of the
misc.- REFER TO ORD.
pERMIT ISSUANCE 10.00CONST.
TAX
gra of is perm,.
MECH. CONT. LIC. N(T
MECH.
Inlay
�o f
�l�t _
TOTAL /
TOTAL
Applma- of/C'Mrai!t r
INSPECTOR COPY