9481APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
BUILDING IDENTIFICATION
APPLICATION & PERMIT
UILDING - ELECTRICAL- PLUMBING -MECHANICAL
PERMIT NUMBER
p ��
4
(PROJECT
BUILDINGO `' S `G.VQII J cy R
ADDRESS n.
OWNER'$ t
PLAN CHECK VALIDATION
N E
I rv1-- N A (" a r PHONE20074 4
QTY. ELECTRIC PERMIT FEE
-
CONTRACTORS
NAME
NAME
UTLETS- SWITCHES -RECEP 10.00/1.00
LIGHTING FIXTURES 10.00/1.00
LIC. NO.
CONTRACTORS
A'
ADDRESSDRESS.
PPLIANCES- RESIDENTIAL 4.00
PANELS 10.00
PHONE
DATE OF APPLICATION
ARCHITECT
OR
PANELS (OVER 200 AMP) 20,00
PLAN CHECK FEE P.C. NO.
ENGINEER
LIC. No,
SIGNS TRANS. 3.00
ADDRESS ENG.
5.00
PERMIT
PERMIT VALIDATION
EMP. METER OR POLE INS. 20.00
' ZIP
Ars
ADDRESS
oREss
MOTORS SEE FEE SCH.
SERVICE CHANGE 20.00 O-
l.0
(f�/�� f/
LICENSEDCONI'RACPORSDECLARATION
TEMP. POLE 30.00
I hereby affirm that I am licensed under provisions of Chapter 9
(commencing with Section 7000) of Division 3 Of the Business and
Professions Code, and Illy Ilce... e Is in full bure and effect.
Class Lic. Number
ISSUANCE DATE
BLDG.
❑
ELECT.
PLG. MECH.
❑ El
Date Contractor
BUILDING PERMIT
INFORMATION
OWNER -BUILDER DECLARATION
I hereby attire that I am exempt from the Contractor's License
Code:Law Any city countywhng icheeuires S,Bosin essand Professions
Code:e,deiol Or county structurepermit0 sISSome, also
improve,demolish,of repair anystructure,torliPrior to its atement also
requires the applicant for such permit to file a signed statement that
hl'i1Accostedpursuant
en ting with provisions of lhl'Contractor's)ofDivis3oftlSC
ofDivision t hent 3 of the
Law (Chapter 9 (commencing with Section is exempt
Business and professions Code) or that he i5 exempt therefrom and
MISC. - REFER TOIORD
PERMIT ISSUANCE 40.00 !/�
VALUATION
.. SIFT.
ELEC.CONTR. LIC. NO.
ELEC.
TOTAL Q
PERMIT TO
/ /r
GL.G G
QTY. PLUMBING PERMIT FEE
STORIES
TYPE CONSTR.
the basis for the alleged exemption. Any violation Of Section 7031,5
malty
by any applicant fora oruteddojectstheapjdicunttouaivil penalty
of not more than five hundred dollars (85001.)
ALTER-DRAIN-WATER(EA.)5.00
❑ L 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
himself or through his own employees, provided that such improve-
mentsare not intended oroffered for safe. It. however. the building
FIXTURES - PER TRAP 5.00
SO, FT. FLOOR AREA
TOTAL ACREAGE
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-
prove for purpose of sale.).
❑ I, as owner of the property, am exclusively contracting with
- . -..
GAS EASYSTEM OVER 4 IEA) 200
BUILDING USE
RES IND CON PB Other
❑ ❑ ❑ ❑ ❑
INDUSTRIAL WASTE INTER. 30.00
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
LAWN SPRINKLERS- 1 INC 5 V.B. 6.00
LAWN SPRINKLERS - OVER 5 IEA.) 1.00
ASSESSORS PARCEL NO.
contracts tins' Projects With ucomrucnsns)limnsed pursumv to
License L
the Contractors License Law,
SEWER -SANITARY -STORM EA. 200ft/10.00
TRACT NO.
PARCEL NO.
❑ I an, exempt under Sec. , BAP.C. for this
reason
WATER HEATER W/VENT 6.00
Owner. Date ff1kfl3J
WATER SYSTEM 5.00
ACC. DATE
ACC. FILE NO,
WATER TREATING EQUIP. 5.00
W' M'ENSATION DECLARATION
I hereby affirm that I have a certificate of consent to sell:insure,
or a certificate of Workers' Compensation Insurance, or a certified'
y
ZONING
ENG. SITE NO.
copy thereof (Sec. 3800, Lab.C.L
Policy No. Company
FIRE SPRINK
Y ❑ N ❑
ENERGY T-24
Y ❑ No
❑ Certified copy is hereby famished.
O Certified copy is filed with the city inspection division.
Applicant
MISC. - REFER TO ORD.
CER'I'I FICATE 01' EXEM PTION I' ROM WORKERS
PERMIT ISSUANCE 10.00 -
FLOOD ZONE:
L. u.C.
PLG.CONTR. LIC. NO.
PLG.
TOTAL
COMPENSATION
• COMPENSATION INSURANCE
('this section need not be completed if the permit is for one
Y ❑ N❑
Y ❑ N❑
hundred dollars (S 100) or less.)
I certify that in the performance of the work for which this per-
mit ix issued, 1 shall not employ any person in any manner so as to
QTY. MECHANICAL PERMIT FEE
FEE SUMMARY
BUILDING
becmne subject to the Workers' Competsation Laws of Celil'nmiu.
Date ApplicantALTER
'1'0
OR ADD TO MECH. 5.00
NOTICE APPLICANT: If, after making this Certificate of Ex-
emption, you should become subject to the Workers' Compensation
APPLIANCE 5.00
PLAN CHECK
provisions of the Labor Code, you must forthwith comply with
such provisions or this permit shall be deemed revoked.
FEE
AIR HANDLING UNIT (TO IOMCF.M,) 4.00
AIR HANDLING UNIT (OVER 10MC.EM.) 6.00
SEISMIC FEE
. CONSTRuc'fION LENDING AGENCY
I hereby affirm that there is a construction lending agency for
EXHAUST HOOD (WITH DUCT) 5.00
tire performance of the work for which this permit is issued (Sec.
3097Civ.C.k
MICROFILM
HEATING UNIT (TO 100,000 B.T.U.) 8.00
Lender's Name
Lendm's Address
HEATING UNIT IO VER 100,000 B.T.U.)9.50
ELECTRICO�
I certify that I have read this up,licution and state that the above
VENTILATION FAN (SINGLE) 4.00
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.) 6.00
BOILER -COMP (Over 100,000 BTU)SEE FEE SCH.
MECHANICAL
hereby authorize representatives of this city to enter up
above-mentioned property for inspection purposes4 on the
,
(We) agree to save, indemnify and keep harmless (lit City of
MISC. - REFER TO ORD.
Cupertino against liabilities, judgments, costs and expenses which
ray in any way accrue against said City in consequence of the
CONST. TAX
PERMIT ISSUANCE 10.00
I nting of this perm t.
I F
J
MECH. CONT, LIC. NO.
MECH.
TOTAL
TOTAL
Signature p ca ritr z Dat
INSPECTOR COPY