9307APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
BU LDI NG PROJECT 1 DENTI FICATI ON
APPLICATION &PERMIT
BUILDING -ELECTRICAL- PLUMBING -MECHANICAL
PERMIT NUMBER
9307
BUILDING
ADDRESSYCi"lAY� a e SjeOQ"S crvLk
OWN
is s43-ZtiJ63
QTY. ELECTRIC PERMIT FEE
PLAN CHECK VALIDATION
PHONE
CONTERACTORS
NAMMID LI0. NO.
OUTLETS-SWITCHES-RECEP 10.00/1.00
LIGHTING FIXTURES 10.00/1.00
LGrvrRAcroRs
CONTRA
R
PPLIANCES- RESIDENTIAL 4-00
PANELS 10.00
p1C93
A PMOIJt 1
DATE OF APPLICATION
ARCHITECT
OR
O
ENGINEER
LIC. No.
PANELS (OVER 200 AMP) 20,00
PLAN CHECK FEE D.C. NO.
SIGNS TRANS. 3.00 U -c
ADDDRESS ENc.
SPECIAL CIRCUIT 5,00 '�
PERMIT VALIDATION
EMP. METER OR POLE INS. 20.00
ZIP
A
ADDDRESSDRESS
MOTORS SEE FEE SCH.
SERVICE CHANGE 20.00
{"•flG
LICENSED CONTRACTORS DECLARATION
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 Badness and
Professions Code, and my he,,,. if in full force and effect.
Liccnsc Class Lic,Numbcr
ISSUANCE DATE
BL G.
ELE T-
PLG. MECH.
Dutc Contractor
BUILDING PERMIT
INFORMATION
OWNER-BUILDI>R DECLARATION
1 hereby affirm that I am exempt from the Contractor's License
Law for the following reason. (Sec. 7031.5, Businessand ProfessionspERM1T
Code: Any city or county which requiresa permit to construct, alter,
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 to the provisions .1 the Contractors License
MISC. - REFER TO ORD
ISSUANCE 10.00 (%T/
VALUATION
700
$/FT.
ELEC.CONTR. LIC. NO.
ELEC.
TOTAL 0_*
PERMIT TO
CITY. PLUMBING PERMIT FEE
Law (Chapter 9 ( commencing with Section 7000) of Division 3 office
Business and Professions Code) or that he is exempt therchom and
STORIES
TYPE CONSTR.
the basis for Ilse alleged exempting Any violation ul Sed ion 7031.5
by any applicant for a permit subjects the applicant to a civil penalty
of not more than five hundred dollars ($5001.):
ALTER -DRAIN -WATER IEA.) 5.00
❑ 1, as owner of the property, or my employees with wages as
their sole compensation, will du the work, and the structure Is. not
BACK FLOW PROTECT. DEVICE 4.00
oca. CROUP
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 inmrove-
ments 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- 1 INC.4 OUTLETS 6.00
or improvement is sold within one year of completion, the owner-
h wilder will have the burden of proving that h e did not build or int-
Prove purposeoffile.).
❑ I; as ownernerol'thum nl
aso e Property, exclusively coructing wilt
. ..
GAS - EASYSTEM -OVER 4 (EA) 200
BUILDING USE
RES IND CON PB Glint,
0 ❑ ❑ 0
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 (EA.) 1.00
N ASSESSORS PARCEL No.
'
contracts for such projects with a contrxetods) licensed pursuant to
the Contractor's License Law.
❑ 1 am exempt under Sec.-, B.&P.C. for this
reason
SEWEfl'SANITAR V -STORM EA. 200it/10.00
TRACT NO.
-
PARCEL NO.
, '.l• •-
WATER HEATER W/VENT 6.00
Owner Date
WATER SYSTEM 5.00
ACC.OATE
ACCT FILEOZ}-
WATER TREATING EQUIP. 5.00
WORK ERS'COMPENSATION DECLARATION
1 hemby affirm that 1 hove a certificate of consent to felt-insum-
or a cercate of Workers' Compensation Insurance, or a certified
ZONING
ENG. SITE NO -
copy thereof(Sec. 3800, Lob.C.).
Policy No. Company
Gfied copy is hereby furnished.
❑ Cer ified copy is filed with the city inspection division.
Applic
FIRE SPRINK
v N0
ENERGY.L74
v ❑ NE]
MISC. - REFER TO ORD,
CERTIFICATE OF EXEMPTION FROM WORKERS'
PERMIT ISSUANCE 10.00
FLOOD ZONE
A.L.U.C.
PLG. CONTR. LIC. NO.
PLG.
TOTAL
COMPENSATION INSURANCE
I This section need not be completed if the pert.. it if for one
Y 0 NE]
Y ❑ IN
lumdred dollars 1$ 100) or IcsfJ
I certify that in the performance of the work for which this per-
Fit is issued. I shall not employ any person in any manner so as to
QTY. MECHANICAL PERMIT FEE
FEE SUMMARY
BUILDING
-�
become subject m the W rakers' Compensation Laws of Califontia.
Date - Applicant
. .
ALTER OR ADD TO MECH. 500
NOTICE TO APPLICANT': If, after making this Certificate of Gx-
emption, you should become subject to the W orkers'Compensation
provisions of the labor Code, you must forthwith comply with
such provisions or this permit shall be deemed revoked
APPLIANCE 5.00
PLAN CHECK
FEEV
rte'
D�
AIR HANDLING UNIT (TO 10=C.F.NL) 4.00
AIR HANDLING UNIT (OVER 10p00C.F.M.) 6.00
SEISMIC FEE
CONSTRUCT ION LENDING AGENCY
1 hereby affirm that there is a construction lending agency for
1110 3097 Performance Of ol'thc work for which this permit is issued (Sec.
EXHAUST HOOD (WITH DUCT) 5.00
MICROFILM
p
ti
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
I certify that I have read this application and state that the above
VENTILATION FAN (SINGLE) 4.00
information is correct. I agree to comply with alt city and county
ordinances and state laws relating to building construction, and
PLUMBING
BOILER-OOMP(3 H.P. or 100,000 B.T.U.) 6.00
BOILER -COMP IOver 100,000 BTU) SEE FEE SCH.
MECHANICAL
hereby authorize representatives of this city to enter upon the
above mentioned property for inspection purposes.
(We) agree to save, indemnify and keep harmless lire City of
Cupertino against liabilities, judgments, costs and expenses which,CONST.
..
may in any way acer c against said City in consequence ob'the
gr;murm d permit. ��
MISC. - REFER TO ORD,
TAX
h
'-PERMIT ISSUANCE 10.00
MECH.CONT. LIC. NO.
MECH.
TOTAL
TOTAL3
0
Igo o Ianl cel+ D to r
INSPECTOR COPY