09929APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
BUILDING PROJECT I DENTIFICATI ON
APPLICATION & PERMIT
BUILDING - ELECTRICAL- PLUMBING - MECHANICAL
, PERMITNUMBER
09929
BUILDING
ADDRESS
/06/ ! lhiO
C
OWNER'S
PLAN CHECK VALIDATION
NAME
6 vlsoNE �,� <(� ' )?
QTY. ELECTRIC PERMIT FEE .
,
NAMERAcrofls
OUTLETS - SWITCHES -RECEP 10.00/1.00
LIGHTING FIXTURES 10.00/1.00
UC. NO,
CONTAcrofls
ADDRESS
APPLIANCES -RESIDENTIAL 4.00
PANELS 10.00
PHONE
DATE OF APPLICATION
ARCHITECT -
OR
ENGINEER
LIC. No.
PANELS (OVER 200 AMP) 20.00
PLAN CHECK FEE P.C. NO.
SIGNS TRANS. 3.00
ARC ENG.
SPECIAL CIRCUIT 5.00
PER MIT VALIDATION
frEMP. METER OR POLE INS. 20.00
ZIP
n
J
ADRES-
ADDRESS
' MOTORS SEE FEE SCH.
SERVICE CHANGE PAID 20.00 Ad
Q � y -
LICENSED CONTRACTORS DECLARATION
TEMP. POLE 30.00
1, �e..
I hereby affirm that I am licensed under provisions of Chapter 9
(commencing with Section 7000) Of Division 3 of the Business and
Pro fessums Colne, and my license Is In fit]] force and effect.
License Class Lic. Number
Dale Contractor
ISS ANCE DATE
BLDG.
El
ELECT.
El
PLG. MECH.
El [:J
Cityot Cupertino
BUILDING PERMIT
.OWNER -BUILDER DECLARATION
1 hereby affirm that I am exempt front the Contractor's License
Law for the following reason. (Sec. 7031.5, Business and Professions
Code: Any city or county which requires a permit 1a construct, alter,
improve, demolish, or repair any structure, prior to its issuance, also
INFORMATION
MISC. - REFER TO ORD
VALUATION
$/FT.
PERMIT ISSUANCE 10.00 C/
ELEC. CONTR. LIC. NO.
'LEC. O.4
requires the applicant for such permit to file a signed sLdement that
he is licensed pursuant to the provisions or the Contractor's License
Law (Chapter 9(commencing with Section 7000)of Division 3 ofbe
Business and Professions Code) or that he is exempt therefrom and
TOTAL
PERMIT TO
VF2✓t •�
QTY. PLUMBING PERMIT FEE
STORIES
TYPE CONSTR.
the basis for the alleged exemption. Any violation of Section 7031.5
by any applicant for a peruhit subjects the applicant to a civil penalty
of not more than five hundred dollars (8500).):
ALTER -DRAIN -WATER (EA.). 5.00
❑ 1, as owner of the property, or my employees with wages as
their sole 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
F IXTUR ES - PER TRAP 5.00
So. FT FLOOR AREA
TOTAL ACREAGE
himself or through his own employees, provided that such improve-
mentsarenotinlendedoroffered for sale If, however, the building
GAS - EA. SYSTEM -1 INC.4 OUTLETS 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 im-
o e for purpose ofmle.).
I, as owner of the property, am exclusively contracting with
. . .
GAS - EASYSTEM -OVER 4 IEA) 200
BUILDING USE
RES IND CON PB Omer,
❑ ❑ ❑ ❑ ❑
INDUSTRIAL WASTE INTER. 30.00
LAWN SPRINKLERS - 1 INC 5 V.B. 6.00
LAWN SPRINKLERS - OVER 5 (EA.) 1.00
ASSESSORS PARCEL No.
'
tic ed contractors to construct the project (See. 7044, Business
and Professions Code:'fhe Contractor's License Law does not apply
to an owner of property who builds or improves thereon. and who
contacts fofsu projects pursuant to
the Contractor's for such
License Law. -
SEWER -SANITARY -STORM EA. 200ft/10.00
TRACT NO.
PARCEL NO.
❑ l am exempt It S,B.&P.C. fm this
WATER HEATER W/VENT 6.00
caner Date
WATER SYSTEM 5.00
ACC. DATE
ACG FILE N0.
WORKERS'COMPF-NSATION DECLARATION
WATER TREATING EQUIP. 5.00
1 hereby affirm that I have a certilicate of consem to self -insure.
or a certificate of Workers' Compensation Insurance, or a certified
-
ZONING
ENG. SITE NQ
copy lhercof(Sec. 3800, Lab.C.).
Policy No. Company
❑ Certified copy is hereby furnished.
❑ Certified copy is filed with the city inspection division.
Applicant
FIRE SPRINK
Y ❑ N ❑
ENERGY T 24
Y ❑ N❑
MISC.- REFER TO ORD.
CIIRTIFICATE OF EXEMPTION FROM WORKERS'
PERMIT ISSUANCE 10.00
FLOOD ZONE
A.L.U.C.
PLG. CONTE. LIC. NO.
PLG.
TOTAL -
COMPENSATION INSURANCE
(This section need not be completed if the permit is for one
Y ❑ N ❑
Y ❑ N ❑
u
CITY. MECHANICAL PERMIT FEE
FEE SUMMARY
hundred dollars(S100)orless .)
I certily that In the performance of tire work for which this per-
nit is issued. I shall not employ any person in any manner so as to
BUILDING
become subject to the Workers' Compensation Laws of California.
Date 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 most forthwith comply with
such provisions or this permit shall be deemed revoked.
FEE
M
AIR HANDLING UNIT (TO JOOWCF.-) 4.00
AIR HANDLING UNIT(OVER 10=C.EM.) 6.00
SEISMIC FEE
CONSTRUCTION LENDING AGENCY
EXHAUST HOOD (WITH DUCT) 5.00
MICROFILM
I hereby. affirm that there is a construction lending agency for
The rformance of the work for which this permit is issued (Sec.
HEATING UNIT (TO 100,000 B.T.U.) B.00
HEATING UN IT (OVER 100,000 B.T.U.19.50
ELECTRIC
��j
Lender's Name
Lender's Address
VENTILATION FAN (SINGLE) 4.00
PLUMBING
I certify that I have read this application and state that the above
information is correct. I agree to comply with all city and county
ordinances and slate laws relating to building construction, and
BOILER -COMP 13 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 enter upon the
above-nhentioned property for inspection purposes.
MISC. - REFER TO ORD.
CONST. TAX
-
(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 mid City in consequence of the
gtanting of [his pen
1O � /p
PERMIT ISSUANCE 10.00
MECN. CONT. LIC. NO. MECH.
TOTAL
TOTAL
ngnature of mann/Con ractor Pate
OFFICE COPY