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APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
4
f BUILDING PROJECT IDENTIFICATION
APPLICATION & PERMIT _
BUILDING — ELECTRICAL— PLUMBING — MECHANICAL
PERMIT NUMBER
09525fy1 LDLNGh,V RESS
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OWNER s
NAME QTY, ELECTRIC PERMIT FEE
PLAN CHECK VALIDATION
PHON IYSI
N RAGTOR'S
NAME OUTLETS -SWITCHES - RECEP 10,0011.00
JOE c,NO.
DATE OF APPLICATION
LIGHTING FIXTURES 10.0011,00
DESS OR'sADDRESS -
I
PHONE
PPLIANCES- RESIDENTIAL 4.00
PANELS 10.00
RCfi1TE_CT
ORENGINEER
LIC. NO.
PANELS (OVER 200 AMP) 20.00
PLAN CHECK FEE P.C. NO.
SIGNS TRANS, 3.00
ADDRESS LNG'
ZIP
SPECIAL CIRCUIT 5.00 PERMIT VA I N
Q U
l
fity Of CUp@rriRO I
TEMP. METER OR POLE INS. 20,00
APPLICANT'S
ADDRESS
MOTORS SEE FEE SCH,
SERVICE CHANGE 20.00
LICENSED CONTRACTORS DECLARATION TEMP. POLE 30.00
I hereby affirm that 1 am licensed under provisions of Chapter 9
commencing with Section 7000) of Division 3 of the Business and
Professions Co , an license is in full for
Liccrnse — Lie. Number
ISSUANCE DATE
BLDG,
El
ELECT. PL MECH,
Date Contractor
BUILDING ERMIT
INFORMATIONOWNER -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 Contractors License
MISC. — REFER TO ORQ
VALUATION SIFT,
PERMIT ISSUANCE 10.00
ELEC. CONTR. LIC. NO. ELEC.
TOTAL E M T 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 ail
STORIES T PE 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 (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
ACK 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
7FIXTURES - PER TRAP 5.00 UD S0. FT. FLOOR AREA TOTAL ACREAGE
GAS- EA. SYSTEM -1 1NC.4 OUTLETS 6,OD Ca
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 of sale,),
as owner of,the property, am exclusively contracting with11El
GAS - EA, SYSTEM OVER 4 (EA,) 2,00 BUILDING USE
IND CDN Pa Other
El El El1, INDUSTRIAL WASTE INTER, 30.00
LAWN SPRINKLERS -1 INC3 V.B. 6.00licensedcontractorstoconstructtheproject (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
ASSESSORS PARCEL NO.
LAWN SPRIN KLERS - OVER 5 (EA.) 1.00
contracts for such projects with a contractors) licensed pursuant to
the Contractor's License Law. SEWER -SANITARY -STORM EA. 200ft/10.00 TRACT NO, PARCEL NO,
l am exempt under sec. B.&P.C. for this
reason
WATER HEATER W_IVENT 6.00 G
Owner Date WATER SYSTEM 5.00 D ACC. DATE ACC. FILE NO.
WATER TREATING EQUIP. 5.00WORKERS'COMPENSATION DECLARATION
1 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 N0,
Copy lhereof(Scc. 3800, I.A.C.),
Policy No. Company
FIRE SPRINK
Y No
ENERGY T-24
Y'Q N
Certified copy is hereby furnished.
Ceriifie gopy is filedwith the city inspection division.
pp'cant{+G/i MISC. REFER TO ORD.
CERTIFICATE OF EXEMPTION FROM WORKERS' PERMIT ISSUANCE 10,00 FLOOD ZONE A.L.U,C.
PLG. CONTR. LIC, NO. PLG. (70
TOTAL
COMPENSATION INSURANCE
This section need not be completed if the permit is for one- Y E] NE] Y N
hundred dollars (S 100) or less.)
I certify that in the performance of the work for which this per- reit is issued, I 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 California.
Date Applicant
NOTICE TO APPLICANT: if, afteP 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 with
such provisions or this permit shall be deemed revoked.
FEEAIRHANDLINGUNIT (TO 10A00 C-F.M,) 4.00
AIR HANDLING UNMOVER10)000C:F,M.) 6.00 SEISMIC FEECONSTRUCTIONLENDINGAGENCY
1 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
HEATING UNIT (TO 100,000 B.T.U.) 8.00
HEATING UNIT (OVER 100,000 B.T,U.)9.50 ELECTRIC
Lender's Na me
Lender's Address
I 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
00
BOILER- COMP (3 H,P, or 100,000 B.T.U.) 6.00
BOI LER-COMP (Over 100,000 BTU) SEE FEE SCH. MECHANICALherebyauthorizerepresentativesofthiscitytoenteruponlire
above-mentioned property for inspection purposes.
MISC. - REFER TO ORD.
CONST. TAX rWe) agree to save, indemnify and keep harmless the City of
Cupertino against liabilities, judgments, costs and expenses which
may in an way accrue against said City in consequence of the
gra i o this permit.
PERMIT ISSUANCE 10.00
MECH. CONT, LIC. NO. MECH.
TOTAL
TOTAL
Signature of ApplicafitiContractor Date
OFFICE COPY