09662APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
BU I LD ING PROJECT I DENTIFICATI ON
APPLICATION &PERMIT
BUILDING - ELECTRICAL- PLUMBING - MECHANICAL
PERMIT NUMBER
09662
BUILDING
ADDRESSDFESS
OWNER'S
NAME `
R" PHONE
DTV. ELECTRIC PERMIT FEE
PLAN CHECK VALIDATION
CONTRACTOR'S
G-( C>
UTLETS- SWITCHES -RECEP 10.00/1.00
ft
LIGHTINGFIXTURES 10.00/1.00
uc.No.
CONTRA
ADDRESS
APPLIANCES APPLIANCES- RESIDENTIAL 4.00
PANELS 10,00 '•�
PHONE 2
DATE OF APPLICATION
ORCITEC
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
EMP. METER OR POLE INS. 20.00
ZIP
APPLICANT
ADDRESS
ADDRESS
MOTORS SEE FEE SCH.
SERVICECHANGE 20.00
SEP 04198S
LICENSED CONTRACTORS DECLARATION
TEMP. POLE 30.00
hereby affirm that I am licensed under provisions of Chapter9
(commencing will, Suction 7000) of Division 3 of the Business and
1'rofessions Code n=my icense is in full force 1 eft c 4
Leena Class Lic. Nwnber
-
BLDG. MEDH.-
❑ ❑ ❑
Date C Contracmr_.d(/
BUILDING PERMIT
INFORMATION
OWNER -BUILDER DECLARATION
I hereby affirm that I am exempt frons the Contractor's License
Law forProfessions
nthe ycit llorcountreason, (h requires a permit to
Code: Any city or county which requirese permit to construct, alteq
MISC.- REFER TO ORD
PERMIT ISSUANCE 10.00
VALUATION
SIFT.
ELEC. CONTE. LIG NO.
ELEC.
TOTAL
improve, demolish, or repair any structure. prior to its issuance, also
t t tiro permit ns file ll signed t statement that
he is licensed pursuant en Oce provisions of the Contractor's 3 License
lie Ulric tire dp pursuant
of Division 3 of the
Law (Chapter 9 (commencing with Section is exempt
Business and Professions Code) or that he is exempt therefrom and
p M TO
DTV. PLUMBING PERMIT FEE
STORIES
TYPE CONSTR.
the (lases kir the alleged exemption. Any violation of Section 7031.5
by any applicant fora anile!dollar,$5subjects 000.licanttoacivil penalty
malty
of not more than five banded dollars f8500)J�.
ALTER -DRAIN -WATER (EA.) 5.00
❑ I, as owner of the properly, 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 uttered for sale (Sec. 7044, Business and Professions
Code: The Contractor's License Law docs 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.
mems are not intended or offered for sale. if, however, the building
FIXTURES - PER TRAP 5.00
SO, FT. FLOOR AREA
TOTAL ACREAGE
GAS-EA.SYSTEM-11NC.4OUTLETS 6.00
or improvement is sold within one year of completion, the owner-
-
builder will have the harden of proving that he did not build or III,--
prove lot purpose of sale.).
❑ 1, as owner of the property', am exclusively contracting with
. -
GAS EASYSTEM OVER 4 IEA.1 2.00
BUILDIN USE '
RES IND 0 PB Diner
❑ El ❑ 11licensed
INDUSTRIAL WASTE INTER. 30.00 -
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
LAWN SPRINKLERS - 1 INC 5 V.B. 6.00
LAWN SPRINKLERS - OVER 5 (EA.) 1.00
ASSESSOR s A CEL rv0.
contracts for such projects with a contractors) licensed pursuant to
the Contractor's License Law.
SEWER -SANITARY -STORM EA. 200ft/10.00
TRACT NO.
PARCEL NO.
0 lam exempt under Sec.-, BAP.C, for this
reason
WATER HEATER W/VENT 6.00
Owner Date
WATER SYSTEM 5.00
ACC. DATE
ACG FILE NO.
_ WATER TREATING EQUIP. 5.00
W0RKERS'COMPENSA7'ION DECLARATION
I hereby affirm that I have a certificate of consent to self -insure.
or a certificate of -workers' Compensation Insurance, r' cern ficJ
ZONING
ENG. SITE N0.
cup, thercaf (Sec. 3800, Lab.C.) 0
Policy No. Company
❑ C co ly i5 hereby furnished.
❑9T� rt fie Is filed Th the city inspection division.
:.n 1- j
FIRE SPRINK
y ❑ N ❑
ENERGY T-24
V ❑ N❑
MISC.- REFER TO ORD:
AGI! I., CA's 1: F LX CM ll N FROM WORKERS'
PERMIT ISSUANCE 10.00
FLOOD ZONE
A.L.U.C.
-"-' CONUTNSA'hON INSURANCE
111,11 Sectim, need not be completed if the permit is for one
PLG. CONTR. LIC. NO.
T 'LG
.AL
V ❑ NE]v
❑ N❑
hunitred dDllpn ($100) or less.)
I certify that in the performance of the work for which this per-
not is issued, 1 Jr.]]1not employ any person in any manner, so as to
OTV. MECHANICAL PERMIT FEE
FEE SUMMARY
BUILDING
become subject to the Workers' Compensation Laws of California.
Dal° Applicallt
'10
ALTER OR ADD TO MECH. 5.00
NOTICE APPLICANT': If, after making this Certificate of L'x-
emption, you should become subject to the Workers' Commensal ion
provisions of the Labor Code, you must forthwith comply with
such provisions or this permit shall be deemed revoked.
APPLIANCE 5.00
AIR HANDLING UNIT (TO 10900GF.M.) 4.00
PLAN CHECK
FEE
AIRHANDLING UNIT(OVER 10=C.F.M.) 6.00
SEISMIC FEE
. CONSTRUCTION LENDING AGENCY
I hereby affirm that there is a construction lending agency for
EXHAUST HOOD (WITH DUCT) 5.00
the performance at 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
Linder s 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
ordinances and state laws relating to building construction, and
PLUMBING
BOILER-COMP13 H. P. or 100,000 B.T.U.1 6.00
BOILER -COMP (Over 100,000 BTU) SEE FEE SCH.
MECHANICAL
hereby authorize representatives of this city to enter upon the
above-mentioned property for inspection purposes.
MISC. - REFER TO ORD.
CONST. TAX
(We) agree to save, indemnify Oil keep harmless the City of
Cupertino against liabilities, judgments, costs and expenses which
in 'ny wiry accrue against said City in consequence of the
PERMIT ISSUANCE 10.00
gra ingo lispennll.
`+. V �S
MECH. CONT. LIC. NO.
MECH.
TOTAL
TOTAL
Si f cant lop I'M., Date
INSPECTOR COPY