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APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
BUILDING PROJECT IDENTIFICATION.
APPLICATION &PERMIT
BUILDING - ELECTRICAL -PLUMBING - MECHANICAL
PERMIT NUMBER
10151So7ADDRESS /
D dree-1'/'17 ,D2.
OWNERS
111-1r,
PLAN
NAM'/ %'
7/ Q . PHON
QTY. ELECTRIC PERMIT FEE
CHECK VALIDATION.
DATE OF APPLICATION
CONTRACTOR'S
NAME
j
iJ UC. No. ,213
16 OUTLETS - SWITCHES - RECEP 10,0011.00
LIGHTING FIXTURES 10,00/1.00 d
CONTRACTOR'S c Q e.
ADDRESS
jj{p
Q /- PHONE 'J(J
3 PPLIANCES-RESIDENTIAL 4.00 oC
PANELS 10.00 Q
ARcrItTECTPANEOR
ENGINEER
LIC. NO.
LS (OVER 200 AMP) 20.00
ALAN CHECK FEE
ISIGNS TRANS, 3.00
ARCH. OR ENG.
ZIP
SPECIAL CIRCUIT 5.00 PERMIT VALIDATION
f,Q
n
ISSUANCE DATE
EMP. METER OR POLE INS, 20.00
APPLICANT'S
ADDRESS
MOTORS' QC SEE FEE SCH. oo
SERVICE CHANGE 20.00
LICENSED CONTRACTO S DECLARA ION'
1 hereby affirm that I am licensed under provisions of Chapter 9
commencing with Section 7000) of Division 3 of the'Business and
Professions Code, d t y 'cense is in full force CerJQLicenseClassiLic. Number !
Contractor
OWNER -BUILDER DECLARATION
I hereby affirm that I am exempt from the Contractor's License
Law for the following reason. (Sec. 7031.5, Business and Professions
Code: Any city or county which requires a 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 of the Contractor's License
Law (Chapter 9 (commencing with Section 7000) ofDivision 3 of the
Business and Professions Code) or that he is exempt therefrom and
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 ($500).):
1, as owner of the property, or my employees with wages as
their sole compensation, will do'the work, and the structure'is not
intended or offered for,sale (Sec. 7044, Business and Professions
Code: The Contractors License Law does not apply to an owner of
property who buildsorimproves thereon, and who does such work
himself or through his own employees, provided that such improve-
mmes are not intended or offered for sale. If, however, the building'
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 purposa,ofsale.).
LI 1, as owner of the property, am exclusively contracting with
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
contracts for such projects with a contractor(s) licensed pursuant to
the Contractor's License Law.
1 am exempt under Sec. B.&P.C. for this
reason
TEMP. POLE 30.00
t
BLDG. ELECT, PLG. MECH.
l 7 uryp et't1n0n'tV
13UILDING PERMIT
INFORMATION
MISC. - REFER TO ORD
VALUATION lFT,
PERMIT ISSUANCE 10-00 Q O
ELEC. CONTR. LIC. NO. ELEC.
TOTAL j of
QTY. PLUMBING PERMIT FEE
PERMiT TO
f
STORIES TYPE CONSTR.
ALTER-DRAIN(EA.) 5.00
BACK FLOW PROTECT. DEVICE 4.00 OCC. GROUP RES. UNITS
DRAINS -FLOOR, ROOF, AREA,COND, 5.00
FIXTURES - PER TRAP 5.00 sa FT. FLOOR AREA TOTALACREAGE
GAS - EA. SYSTEM- 1 INC.4 OUTLETS 6,00
GAS EA. SYSTEM -OVER 4 {EA.) 2.00 BUILDING USE
RES IND CON PB Other
INDUSTRIALWASTE INTER. 30.00
LAWN SPRINKLERS - 1 INC 5 V.B. 6.00 ASSESSORS PARCEL NO.
LAWN SPRINKLERS - OVER 5 (EA.) 1.00
SEWER -SANITARY -STORM EA. 200ft/10,00 TRACT NO. PARCEL NO.
WATER H EATER W/V ENT 6.00
Owner Date
WORKERS -COMPENSATION DECLARATION
I hereby affirm that I have a certificate of consent to self -insure,
or a certificate, of Workers' Compensation Insurance, or a certified
copy then f Sec. 3 0Q b:
Policy N orma
Certified copy is hereby furnished.
Certified copy is tiled with the city inspection division.
Applicant
WATER SYSTEM 5.00 ACC_. OATE ACC. FILE NO.
WATER TREATING EQUIP, 5.00
ZONING ENG. SITE No-
FIRE SPRINK
Y [:] N
ENERGY T-24
Y N[:] MISC. - REFER TO ORD.
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
This sectidn need nor be, completed if the permit is for one
hundred dollars ($100) or less.)
I certify that in the performance of the work for which this per-
mit is issued, 1 shall not employ any person in any manner so as to
become subject to the Workers' Compensation Laws of California.
Date Applicant
PERMIT ISSUANCE 10.00 FLOOD ZONE
Y N
A.L.U.C.
Y N
PLG; CONTR. LIC. NO. PLG.
TOTAL
QTY. MECHANICAL PERMIT FEE FEE'SUMMAAY
BUILDINGALTERORADDTOMECH. 5.00
NOTICE TO APPLICANT:, If, after making this Certificate of Ex-
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,
CONSTRUCTION LENDING AGENCY
I hereby affirm that there is a construction lending agency for
the performance of the work for which this permit is issued (Sec.
3097,Civ.C.).
Lender's Name
APPLIANCE 5.00 PLAN CHECK
FEEAIRHANDLINGUNIT (TO 10=11F.M.) 4.00
AIR HANDLING UNIT (OVER 10MC.F.M.) 6.00 SEISMIC FEE
EXHAUST HOOD (WITH DUCT) 5.00
MICROFILM
HEATING UNIT (TO 100,000 B.T.U.) 8.00
HEATING UNIT (OVER 100,000 B.T,U.)9.50 ELECTRICLender's Address
1 certify that I have read this application and state that the above
information is correct. 1 agree to comply with all city and county
ordinances and state laws relating to building construction, and
hereby authorize representativesof 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
Lg;anting of thiS permit.
1 _ O
of ffv0 QV] .
VENTILATION _ FAN (SINGLE) 4.00
PLUMBING
BOILER -COMP (3 H.P. or 100,000 B.7 U.) 6.00
BOILER -COMP (Over 104,000 BTU) SEE FEE SCH. MECHANICAL
MISC. - REFER TO ORD.
CONST, TAXPERMITISSUANCE10.0011
MECH. CONT. LIC.NO, MECH.
TOTAL
TOTA...
rgnature of Applicant] ntractor Date
OFFICE COPY