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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
10152S,uILoiNG - ADDRESS
7 ' / r
NAME 1/S'
a/ IX/ PHC,1,S/, / / (p
QTY. ELECTRIC PERMIT FEE
PLAN CHECK VALIDATION
1100l/ 41 #-:Z
DATE OF APPLICATION
CONTRACTOR'S
NAME
LIC. NO. a
UTLETS-SWITCHES -RECEP 10,0011.00
LIGHTING FIXTURES 10.0011.00 0,
CONTRACTOR'Sf,{ n a rano /G
ADDRESSa55 PHONE
APPLIANCES- RESIDENTIAL 4.00 op
PANELS 10.00 Q, D
ARCHITECT
ORENGINEER
LLC. ND.
PANELS (OVER 200 AMP) 20,00 PLAN CHECK FEE P.C. NO.
SIGNS TRANS. 3.00
ARCHEOss ENG.
ADDzip
SPECIAL CIRCUIT 5.00 PERMIT VALIDATION
TEMP. METER OR POLE INS. 20.00
kADDRESSTS
0 a)2 LOCO / 42 1/
MOTORS G _ SEE FEE SCH. 7 DO
SERVICE CHANGE 20.00
LICENSED CONTRACTORS DECLARATIO TEMP. POLE 30.00
PAID
1 hereby affirm that 1 am licensed under provisions of Chapter 9
commencing with Section 7000) of Division 3 of the Business and
Professions Codc, d m license is in full Farce an a t.
License CI ss Lic. Number
ISSUANCE DATE
BLDG. ELECT. PLG. MECH.
Date Contractor
CTBUILD '
INFORMATION
PERMIT
OWNER -BUILDER DECLARATION
1 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) of Division 3 of the
Business and Professions Code) or that he is cKcmpt therefrom andQTY.
IMISC. — O
VALUATION fFT.
PERMIT ISSUANCE 10.00 O, PO
E E CO TR. LIC. NO.
4c, '06
ELEC.
TOTAL s O D
PERMIT 70
Z
PLUMBING PERMIT FEE
STORIES TYPE CONSTR. the basis for the alleged exemption. Any violation of Seclioo 7031.5
by any applicant for a permit subjects the applicant toa civil penally
of not more than five hundred dollars ($500).): ALTER DRAIN &VENT WATER {EA.) 5.D0
1, as owner of the properly,or my employees with wages asBACK
their sole compensation, will do the work, and the structure is not
FLOW PROTECT. DEVICE 4,00 OCC.GROUP RES. UNITS
intended or offered for sale (Sec; 7044, Business and Professions DRAINS -FLOOR, ROOF, AREA,COND. 5.00
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-
menti are not intended or offered for sale. If, however, file building
FIXTURES - PER TRAP 5.00 SO. FT. FLOOR AREA TOTALACREAGE
GAS EA. SYSTEM 1 INCA OUTLETS 6.00
or Lmprovement is sold within one year of completion, the owner-
builder will hare, the burden of proving that h e did not build or im-
prove for purpose of sale.).
as owner of the property, am exclusively contracting with
GAS - EASYSTEM -OVER 4 (EA.) 200 BUILDING USE
RES IND CON Pa other
0 11INDUSTRIALWASTEINTER. 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 ASSESSORS PARCEL NO.
LAWN SPRINKLERS - OVER 5 (EA.) 1.00
contracts for such projects with a conlractor(s) licensed pursuant to
the Contractor's License Law. SEWER -SANITARY -STORM EA. 200ftl10.00 TRACT NO. PARCEL NO.
1 am exempt under Sec. B.&P.C. for this
reason
WATER HEATER WIVENT 6,00
Owner Date WATER SYSTEM 5.00 ACC. DATE ACC. FILE NO.
WATER TREATING EQUIP. 5.00WORKERS'COMPENSATION DECLARATION
I hereby affirm that I have a certificate of consent to self -insure.
or a certificate of Workers' Compensation Insurance, or a ccrlified ZONING ENG. SITE NO.
copy the (Sec. 3 0 y
Policy
Certified copy is hereby furnished.
Certified copy is fled with 1 lty Lnspe r, division.
p' e r I 6,1
FIRE SPRtNK
Y N
ENERGY T•24
Y N MISC. - REFER TO ORD.
CERTIFICATE OF EXEMPTION FROM WORKERS' PERMIT ISSUANCE 10.001 FLOOD ZONE A.L.U.C.
PLG, CONTR. LIC. NO. PLG,
TOTAL
COMPENSATION INSURANCE
This section need not be completed if the permit is for one
Y N Y N
QTY. MECHANICAL PERMIT FEE FEE'SUMMARY
hundred dollars (5100) or less.)
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
become subject to the Workers' Compensation Laws Of California.
BUILDINGBateApplicantALTERORADDTOMECH. 5.00
NOTICE TO APPLICANT: If, after making this Certificate of Ex-
APPLIANCE 5.00 PLAN CHECKemption, 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.
FEEAIRHANDLINGUNITITOIOXDQF.NL) 4,00
AIR HANDLING UNIT(OVER 10MC.F.M.) 6.00 SEISMIC FEECONSTRUCTIONLENDINGAGENCY
I hereby affirm that there is a construction lending agency for EXHAUST HOOD (WITH DUCT) 5.00
the
097er
performance of the work for which this permit is issued (Seca MICROFILM
HEATING UNIT (TO 100,400 B.T.U.) 8.00'
HEATING UNIT (OVER 100,000 B.T.U.)9.50 ELECTRIC f `
Lender's Name
Lender's Address
1 certify that I have read this application and state that the above
information is -correct. I agree to comply with all city and county
Ordinances and state laws relating to building construction, and
VENTILATION FAN (SINGLE) 4,00
PLUMBING
BOILER - COMP (3 H.P. or 100,000 B.T.U.) 6.00
BOILER -COMP iOver t00000BTu) SEE FEEscH. MECHANICALherebyauthorizerepresentativesofthiscitytoenteruponthe
above-mentioned property for inspection purposes.
MISC.- REFER TO ORD. 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
CONST. TAX
PERMIT ISSUANCE 10.00
gr "gg Of this permit. MECH. CONT, LIC. NO. MECH.
TOTAL
TOTAL
Signature of Applicant/Contractor D/ate
OFFICE COPY