10153u
APPLICANT TO FILL IN INFORMATION WITHIN RED LINES --- USE BALL POINT PEN ONLY
BUILDING PROJECT 113ENTI FICATION
APPLICATION & PERMIT
BUILDING -ELECTRICAL- PLUMBING -MECHANICAL
PERMIT NUMBER
101539Unt1ING - ADDRESS
OWNER'S /
NAME y!S' /
r / uf_U f Gr PHONE /, ` /
QTY, ELECTRIC PERMIT FEE
PLAN CHECK VALIDATION
el
h /
DATE OF APPLICATION
C NTRACTOR'S
NAME .
C,riC_ LIC.NO-a,j ,
OUTLETS -SWITCHES - RECEP 10.00/1.00?6.0
LIGHTING FIXTURES 10.0011.00 O
DOCONTRACTOR'S
ADDRESS i nn %
aD ^esQPHONE15 YI-39
3 APPLIANCES - RESIDENTIAL 4.00
PANELS 10.00 Q. O
ARCHITECT
OR
ENGINEER
LIC. NO,
PANELS (OVER 200 AMP) 20,00
PLAN CHECK FEE P.C. NO.
SIGNS TRANS. 3.00
ADDRESS ENG. SPECIAL CIRCUIT 5,00 PERMIT VALIDATION
TEMP. METER OR POLE INS. 20.00ZIP
APPAOOLRESSTS - ['
3_0 r /' JlLnn
MOTORS e • SEE FEE SCH. 11,061
SERVICE CHANGE 20.00
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 Business and
Professions Code, nmd license is in full force ffect.
QLicenseClass - Lie. Number
Date - Contractor
OWNER -BUILDER DECLARATIONINFORMATION
hereby affirm that I am exempt from the Contractor's License
Law for the following reason. (Sec, 7031.5, Businessand 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 rile a signed statement that
hehe 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 Cade) or that he is exempt therefrom and
ISSUANCE DATEFqBLDG. ELECT. PLG.
EJ
MECH.
DFS, ,1 - 1Qpn BUILDING PERMIT
MISC. - REFER TO ORD
PERMIT ISSUAN lAQ 10,Q0 pd
VALUATION
ELEC. CONTR. LIC. NO. -
ELEC,
TOTAL / -J:
O
PERMIT TO
L jF
QTY. PLUMBING PERMIT FEE
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 ($500).): ALTER -DRAIN &VENT WATER IEA.} 5.00
0 1, 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 RES. UNITS
DRAINS -FLOOR, ROOF, AREA, COND. 5.00intendedorofferedforsale (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 improve-
ments are not intended Or offered for sale. If, however, the building
FIXTURES'- PER TRAP 5.00 SO. FT. FLOOR AREA TOTALACREAGE_
GAS - EA. SYSTEM -1 I N C.4 OUTLETS 6.00
or improvement is sold within one:year of completion, the owner
builder will have the burden Of proving that lie did not build or im-
prove for purpose Of sale.).
1, as owner of the property, am exclusively contracting with
GAS EA. SYSTEM -OVER 4 IEA.} 2.00 BUILDING use
RES IND CON PB Other
El CO ElClElINDUSTRIALWASTEINTER. 30.00
LAWN SPRINKLERS- 1 INC 5 V.B. 6.00 ASSESSORS PARCEL NO. licensed contractors to eonstruct.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 - OVER 5 IEA.) 1.00
contracts for such projects with acontractor(s) licensed pursuant to
the Contractors License Law. SEWER -SANITARY -STORM EA, 200ft110.00 TRACT NO. PARCEL NO.
I am exempt under Sec. B.&P.C. for this WATER HEATER WIVENT 6.00
reason
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 certified ZONING ENG. SITE NO.
copy the Sec. 8Q0 1PolicyN -d a
C1 Certified copy is hereby furnished.
Certified copy i (led with h oily ins}yeclion division.
A plicant I f - frit
FIRE SPRINK
y N
ENERGY T•24
y N misc.- REFER 70 ORD.
CERTIFICATE OF EXEMPTION FROM WORKERS' PERMIT ISSUANCE 10.00 FLOOD ZONE A L.U.C.
PLG. COUR, LIC. NO. PLG,
TOTAL
COMPENSATION INSURANCE
This sccii6n need not be completed If the permit is for one
Y NE] K N
CITY. MECHANICAL PERMIT FEE FEE SUMMARY
hundred dollars (S I OO) or less.)
I 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
BUILDING
become subject to the Workers' Compensation Laws OF California.
Date Applicant
NOTICE, TO APPLICANT: If, after making this Certificate Of Ex.
ALTER OR ADD TO MECH. 5.00
APPLIANCE 5.00 PLAN CHECKemption, you should become subject to the Workers' Compensation
provisions of the Labor Code, you must forthwith comply withFEE
such provisions or this permit shall be deemed revoked. AIR HANDLING UNIT (TO 10=1 .F.M.) 4.00
AIR HANDLING UNIT (OVER IOjulC.F.M.) 6.00 SEISMIC FEECONSTRUCTIONLENDINGAGENCY
1 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.).
EXHAUST HOOD (WITH DUCT) 5.00
MICROFILM
HEATING UNIT (TO 100,000 B.T.U.) 8.00
H EATI NG UN IT (OVER 100,000 B.T.U.) 9.50 ELECTRIC
aLender'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-COMPI3 H.P.oF 100,000 BT.U.) 6.00
BOi LER-COMP (Over 100,000 BTL]) SEE FEE SCH. MECHANICALherebyauthorizerepresentativesofthiscitytoenteruponthe
above-mentioned property for inspection purposes.
MISC. - REFER TO ORD. We) agreeto 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. TAXPERMITISSUANCE10.00
graAing of this Permit ./ MECH. CONT. LIC. NO. MECH.
1
l / / 2e_, /.2_6,- r TOTAL
TOTAL
Signature of Applicant/COntractor Date
OFFICE COPY