9133APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
BUILDING PROJECT IDENTIFICATION
APPLICATION & PERMIT
BUILDING -ELECTRICAL- PLUMBING -MECHANICAL
PERMIT NUMBER
9133
BUILDING
ADDRESS
111161�o E v
OWNER'5
NAME
S. PHONE
QTY. ELECTRIC PERMIT FTE
PLAN CHECK VALIDATION 4T
.PAID
JUN N q
CONTRACTORS
NAME
UTLETS -SWITCHES-RECEP 10.00/1.00
V t!.GGI uc. NO. S
LIGHTING FIXTURES 10.00/1.00',
{�
I�tl
,Defy of cpertino
DATE OF APPLICA ON
nooeess DR's ,e �„ %
- 'HONE i 5�926y
/ (bL/ T r rY
PPLIANCES-RESIDENTIAL 4.00
PANELS 10.00
ET
OR
PANELS (OVER 200 AMP) 20.00
PLAN CHECK FEE
P.C. NO.
ENGINEER
uc. No.
SIGNS TRANS. 3.00
ARCH. OR ENG.
ADDRESS
SPECIAL CIRCUIT 5.00
PERMIT VALIDATION
EMP. METER OR POLE INS. 20.00
' ZIP
/
I
ADDRESS
aooREss
MOTORS / 41 SEE FEE SCH.
SERVICE CHANGE 20.00
LICENSED CONTRACTORS DECLARATION
TEMP. POLE 30.00
1 hereby affirm that I am licensed under provisions of Chapter 9
(commencing with Section 7000) of Division 3 of the Business and e
Professions Code. and my license is in full _te!d eC1'1-
License Class c. NumberrYY
-p
ISSUANCE DATE
BLDG.
O
ELEC
PLG. MECH.
❑ ❑
r
Date &i Contractor 664 -'r
e
OWNER -BUILDER DECLARATION
I hereby affirm that I am exempt from the Contractor's License
Law for A thenycityfolor countyng whiSec.uiresa.Businessanaltos
Code: Any city or county which requirese peonit Loconstruct, , also
or for repair any structure, tofi prior to its issuance, also
Im hires ire applicant
ns dp ursuat ti,r such permit to file a signed statement that
requires licensed
he is J pursuant to the provisions of the Contractor's License
BUILDING PERMIT
IA ORMATION
MISC. - REFER TO ORD
PERMIT ISSUANCE 10.00
VALUATION
5/FT.
ELEC. CONTR. LIC. NO,
ELEA
TOTAL S (�
EMIT T
PLUMBING PERMIT FEE
Low (Chapter') (commencing with Section 7000) oC Division 3 of the
(Chapter
Business and Professions Code) or that he is exempt therefrom andQTY.
ST ES
PE CONSTR.
Bre basis for file alleged exemption. Any violin inn oC Section 7031.$
by any applicant for a permit subjects the applicant to a civil penalty
of not more tltan five hundred dollars (S500).):
ALTER -DRAIN &VENT-WATER(EA.) 5.00
❑ 1, as owner of the property, or my employees with wages as
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,CONO. 5.00
intended nr offered for sale (Sec 7044, Business and Professions
Code: The Contractors License Law does not apply to an owner of
property' who builds or improves thereon. and who docs such work
himself or through his own employees, provided that such improve-
mUrrts are n of intended or offered for sale. It, however, the building
FIXTURES - PER TRAP 5.00
SO. FT. FLOOR AREA
TOTAL ACREAGE
GAS - EA. SYSTEM-11NC.40UTLETS 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 ofsale.).
tr
0 1, as owner of the property, an exclusively contracting jib
GAS - EA. SYSTEM -OVER 4 (EA.) 2.00
BUIL ING SE
RES IND 0 PB Omer
❑ ❑ ❑ ❑
INDUSTRIAL WASTE INTER. 30.00
licensed contractors to construct the pryjeci (Sec. 7044, Business
and Professions Code:' I' he Contractor's License Law docs not apply
to un owner of properly who builds or improves thereon. and who
LAWN SPRINKLERS - 1 INC 5 V.B. 6.00
ASSESSOR PA EL NO.
LAWN SPRINKLERS - OVER 5 (EA.) 1.00
contracts for such projects with a contractur(s) licensed pursuant to
the Contractor's License Law,
SEWER -SANITARY -STORM EA. 200ft/10.00.
TRACT NO,
PARCEL NO.
❑ Inco cxampt colder Sec. ,13.&I'.C. for this
reason
WATER HEATER W/VENT 6.00
Owner Date
WATER SYSTEM 5.00
ACC.DATE
ACG FILE NO.
WORK ERS'COMPENSATION DECLARATION
WATER TREATING EQUIP.``, 5.00
1 hcmhy affirm that I have a certificate o fconsent to shlf-insure,
ur a certificate of Workers' Compensation Insurance, or a certified
ZONING
ENG. SITE N0,
/
copy thereof(Sec. 3800. Lab.C.L
Policy No. Company
G Certified copy is hereby furnished.
�f1-64rllfie py is file with he city inspection division.
Apphcan
-
FIRE SPRINK
Y ❑ N ❑
ENERGY T"24
Y ❑ N❑
MISC.- I REFER TO ORD.
CIiRTIFICATE 01' EXEMI'1'107 FROM WORKERS'
PERMIT ISSUANCE ' 10.00
FLOODZONE
A.LU.C.
PLG. CONTE. LIC. NO.
-
PLG.)
TOTAL
COMPENSATION INSURANCE
I Ihis section need not be completed if file permit is for one
Y ❑ N❑
Y ❑ N❑
- -'
hundred dollars (S 100) or less.)
1 certify that in the performance of the work for which this per-
mit is issued, I shall not employ any person in any manner so as to
OTY. MECHANICAL PERMIT FEE
FEE SUMMARY
BUILDING
become object to the N'orkc,S CnmPcnsat inn Laws of California.
Date Applicant
NOTICE; TO APPLICAN"I': 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 must forthwith comply with
such provisions or this permit shall be deemed revoked.
FEE
AIR HANDLING UNIT (TO IOPMC.F.M.) 4.00
AIR HANDLING UNIT(OVER 10)DOOC.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 of the work for which this permit is issued (Sec
3097, Civ.C.).
MICROFILM
H EATING UN IT (TO 100,000 B.T.U.) 8.00
Lender's Name
Lender's Adders
HEATI NG UN IT (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 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 upon the
above-mentioned property for inspection purposes.
(We) agree to save• indemnify and kceP harmless the City of
MISC. - REFER TO ORD.
Cupertino against liabilities, judgments, costs and expenses which
may in any way accrue a in said City in consequence of the
CONST. TAX
PERMIT ISSUANCE 10.00
granting of Ih" eror
MECH. CONT. LIC. NO.
MECH.
TOTAL
TOTAL
nn re of� pplicanl/Contractor Date
INSPECTOR COPY