09648APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
BUILDING PROJECT IDENTIFICATION
-
) APPLICATION & PERMIT
BUILDING - ELECTRICAL- PLUMBING - MECHANICAL
PERMIT NUMBER
09 48
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rt_nUY QI Q'' J"`Qr"� CQ
OWNER'S
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25S OjOO
""ME M,
To M �c15 �rPHDNE
QTY. ELECTRIC PERMIT FEE
PLAN CHECK VALIDATION
NAMEngcrORs',
M10 V Ak ^��r rl sec,(t
OUTLETS-SWITCHES-RECEP 10.00/1.00
LIGHTING FIXTURES 10.00/1.00
coNTRAcroR's
AOOREES �1
APPLIANCES- RESIDENTIAL 4.00
(•L J ` LP, 93AM
DATE OF APPLICATION
PANELS r 10.06
ARCHITECT
OR
ENGINEER
LIC. NO.
p
PANELS (OVER 200 AMP) 20.00
PLAN CHECK FEE P.C. NO.
SIGNS TRANS. 3.00
ARCH,OR ENG.
ADDRESS
SPECIAL CIRCUIT 5,00
PERMIT VALIDATION
EMP. METER OR POLE INS. 20.00
ZIP
p
'
ASS
Ess
ADDRESS
MOTORS SEE FEE SCH.
SERVICE CHANGE 20.00
`
LICENSED CONT'RACT'ORS DECLARATION
TEMP. POLE 30:00
-
s+^'
I hereby affirm that I am licensed under provisions of Chapter o
(commencing with Section 70001 of Division 3 of the Business andBLDG.
Professions Code, and my' license is in full force and effect.
Class Lic. Numbe
ISSUANCE DATE
v
ELECT.
❑
PLG. MECH.
❑ 1:1License
Date Contractor
BUILDING PERMIT
INFORMATION
OWNER -B i.. .R DECLARATION
I hereby affirm that I am exempt from Dm Contractor's License
Law for the following reason.(Sec. 7031.5, Business and Professions
Code. Any city or county which requiresa permit to construct, alter,
improve, demolish, or repair any structure, prior to its issuance, also
it to e a signed statement that
requires the applicant for such permth
he is licensed pursuant to the provisions of me Contractors License
M ISC.'- REFER TO ORD '
1
PERMIT ISSUANCE - 10.00
VALUATION
/) �OC
e,J p0
$/FT.
/
/
ELEC. DONTB. LIC. NO,
EL..J EC. j
TOTAL 1
PERMIT TO
QTY. PLUMBING PERMIT FEE
Law (Chapter 9 (commencing with Section 7000)of Division 3 of the
Business and Professions Code) or that he is exempt therefrom and
STORIES
TYPE CONSTR.
the basis for the alleged exemption Any violation of Section 7031.5
by any applicant for a permit subjects the applicant to a civil penalty
of not more than five hundred dollars (5500).):
ALTER -DRAIN -WATER (EA.) 5.00
❑ I, 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
REB. UNITS
DRAINS -FLOOR, ROOF, AREA, GOND. 5.00
intended or offered for sale ISce. 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 enrploycaS, provided that such improve-
nmmsarenotintendedorofferedforsale. If, however. the building
FIXTUR ES - 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 Ilial he did not build or iia-
prove for purpose ofsale.).
1. as owner of the property', am exclusively contracting with
GAS- EA. SYSTEM - OVER 4 IEA.) 2.00
BUILDING USE
RES Irvo CDN PB Omit,
❑
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 in owner of property who builds or improves thereon. and who
LAWN SPRINKLERS - 1 INC 5 V.B.' 6.00
LAWN SPRINKLERS - OV ER 5 (EA.) 1.00
ASSESSORS PARCEL NO.
contracts for such projects with a conlmt4orts) licensed pursuant to
the Contractors License Law.
gEWER-SANITAR V -STORM EA. 200ft/10.00
TRACT NO,
PARCEL NO.
❑ lam exempt under Sec.-, BAP.C. for this
reason
WATER HEATER W/VENT 6.00
Owner Dale
WATER SYSTEM 5.00
ACC. DATE
ACC FILE NO.
WORK ERS'COMPENSATION DECLARATION
WATER TREATING EQUIP. 5.00
I hereby affirm that I have a certificate of consent to self -insure.
m a certificate of Workers' Compensation Insurance, or a certified
ZONING
ENG. SITE NO.
copy thereof (Sec. 3800, Lab.C.l.
A__
Policy No. Company s unci Pvl rte. .
FIRE SPRINK
Y ❑ N�
ENERGY T-24
Y ❑ NE]
❑ Certified copy is hereby to n¢ ie
❑ Certifiedc y is fled with the city inspection division.
'Applicant
MISC.- REFER TO ORD.
CERTIFICA ' O ° "oMPI'ION FROM WORKERS'
PERMIT ISSUANCE 10.00
FLOOOZONE
A.L.U.C.
COMPENSATION INSURANCE,
(This section need not he completed if the permit is for One
PLG. CONTE. LIC. NO.
PLG.
TOTAL
Y ❑ N ❑
Y E) NE]
hundred dollars IS 100) or less.)
I certify that in the Performance of do work for which this per-
mit is issued, 1 shall not employ any person in any manner.so as to
QTY MECHANICAL PERMIT FEE
FEE SUMMARY
BUILDING
become subject to the Workers' Compensation Laws of Calionnia.
Daw Applicant
NOTICE TO APPLICANT: If, alter making this Certificate of fix-
'
ALTER OR ADD TO MECH. 5.00
APPLIANCE 5.00
PLAN CHECK
FEE
O Z
eruption, you should become subject to the Workers' Compensation
provisions of. the Labor Code, you must forthwith comply with
such provisions or this permit shall be deemed revoked.
AIR HANDLING UNIT (TO 10=C.F.M.) 4.00
AIR HANDLING UNIT (OVER 10=C.F.M.) 6.00
SEISMIC FEE
50
CONSTRUCTION LENDING AGENCY
I hereby affirm that there is a construction lending agency for
EXHAUST HOOD (WITH DUCT) 5.00
the performance of the work for which this permit is issued (Sec.
3097, Civ.CL
MICROFILM
HEATING UNIT (TO 100,000 B.T.U.) 8.00
Lender's Name
Lender's Address
HEATING UNIT ER 100,000 B.T.U.)9.50
r��y
ELECTRIC
/� (%T/
I certify that I have read this application Ind state that the above
VENTILATION FAN (SINGLE) 4.00
n ornlation is correct. I agree to comply with all city and County
ordinances and stele I'ws relating t building construction, and
PLUMBING
BOILER-COMP13 H.P. or 100,000 B.T.U.) 6.00
BOILER -COMP IDVC! 100,0008TU1 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 the City of
Cupertino against liabilities, judgments, costs and expenses which
may in any way accrue against said City in consequence of the
MISC. - REFER TO ORD.
CONST. TAX
PERMIT ISSUANCE 10.00
grant ingo permit.
MECH. CONT. LIC. NO.
MECH.
TOTAL
TOTAL
7 7 0 2
�i
I at He Atipicant n Ifclor Date
INSPECTOR COPY