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APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
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BU,I LDI NG PROJECT I DENTI FICATION
APPLICATION & PERMIT
BUILDING - ELECTRICAL- PLUMBING - MECHANICAL
PERMITNUMBER
09608
BUILDING
A4ORESS378
OYUNER's -
NAME
GX/ LA PHONE
QTY. ELECTRIC PERMIT FEE
PLAN CHECK VALIDATION
CONTRACTOR'S
NAME OUTLETS -SWITCHES -RECEP 10.0011.00
LIGHTING FIXTURES 10.0011.00I_qC a LIC. NO./3D
CONTRACTOR'S
ADDRESS APPLIANCES - RESIDENTIAL 4.00
PANELS 10,00HONE. DATE OF APPLICATION
ARCHITECT -
Gfl '
ENGINEER
LIC. NO.
PANELS (OVER 200 AMP) 20,00 PLAN CHECK FEE P.C. NO_.
SIGNS TRANS. 3.00
ADDRRESS ENG. SPECIAL CIRCUIT 5,00 PERMIT VALID IQNID
EMP. METER OR POLE INS. 20.00ZIP
n SEP 0 4198
APPLICANT'S
ADDRESS
MOTORS SEE FEE SCH.
SERVICE CHANGE 20.00
City- of CupertinoLICENSEDCONTRACTORSDECLARATIONTEMP, 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
Professions Code, and my !cease is in full force and effect.
Licens Classd'Y _ ic. Number
Date ' 294-'A-a-A,eif-Contractor
ISSUANCE DATE
BLDG- ELECT- PLG. M
R.
99- V-3-4 f`
OWNER -BUILDER DECLARATION
I hereby affirm that I am exempt from the Contractor's License
Law for the following reason. (Sec. 703 1.5, Business and Professions
Code: Any city or coup ty wh ich 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
BUILDING PERMfT
INFORMATION
MISC. - REFER TO ORD
VALUATION IFT.
PERMIT ISSUANCE 10.001
ELEC. CONTR. LIC. NO. ELEC.
TOTAL PE IT TO
QTY. PLUMBING PERMIT FEE
Law (Chapter 9 (commencing with Section 700D) of Division 3 of the
Business and Professions Code) or that he is exempt therefrom and
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 ($900).): ALTER -DRAIN &VENT -WATER (EA,) 5,00
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
intended or offered for sale (Sec. 7044, Business and Professions DRAINS -FLOOR, ROOF, AREA, COND. 5.00
Code: The Contractor's License Law docs not apply to an owner of
property who builds or improves thereon, and who docs such work
himself or through hisnwn employees, provided that such improve-
ments are not intended or offered for sale. If, however, the building
FIXTUR ES - PER TRAP 5.00 SO. FT. FLOOR AREA TOTALACREAGE
GAS - EA. SYSTEM -1 INC.4 OUTLETS 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-
proveforpurposeofsaleJ.
1, as owner of the property, am exclusively contracting with
GAS EA. SYSTEM -OVER 4 (EA.) 2.00 BUILDING USE
IND CON PS Other
INDUSTRIAL WASTE INTER.30,00
licensed contractors to construct the project (Sec. 7044, Business
and Professions Code: The Contractor's License. Law docs 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 SPRIN KLERS - OVER 5 (EA.) 1.00
contracts for such projects with a contractor(s) licensed pursuant to
the Contractor's License Law, SEWER -SANITARY -STORM EA. 200ft1i 0.00 1RACT 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'COMPENSATIONDECLARATION
1 hereby affirm that I have a certiticale of consent io self -insure.
or a certificate of Workers' Compensation Ins ura ce, ar a certified ZONING ENG. SITE NO.
copy thereo Sec. 380 Lab.C.).
Policy No.8 ompany
Certifred copy is hereby furnished.
Certified copy is filed with the city inspeerion division.
Applicant
FIRE SPR INK
Y N
ENERGY T-24
Y N MISC. - REFER TO ORD.
CERTIFICATE OF EXEMPTION FROM WORKERS' PERMIT ISSUANCE 10.00 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 (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
BUILDING
become subject to the Workers' Compensation Laws of California.
Date' Applicant
I
ALTER OR ADD TO MECH: 5.00
NOTICE TO APPLICANT: If, after making this Certificate of Ex-
APPLIANCE 5.00 PLAN CHECKemption, you should became 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 10P00 C.F.M.) 4.00
AIR HANDLING UNIT (OVER 10=C.F,M.) 6.00 SEISMIC FEECONSTRUCTIONLENDINGAGENCY
hereby affirm that there is a construclion lending agenpy for
the performance of the work for which this permit is issued (Sec.
3097. Civ.C.).
EXHAUST HOOD (WITH DUCT) 5.00 _r. Did
MICROFILM
HEATING UNIT (TO 100,000 B.T.U.} 8.00 * VO
HEATING UNIT (OVER 100 000 B.T_.U.)9.50 ELECTRIC
Lender's Name
Lender's Address
I certify that 1 have read this application an sttatethat the above VENTILATION FAN (SINGLE) 4.00 8.00
information is correct. 1 agree to comply with all city and county
ordinances and state taws relating to building construction, and
PLUMBING
BOILER COMP{3 H.P. or 100,000 B.T.U.) 6.00
BOILER -COMP (Over 100,000 BTW SEE FEE SCH. MECHANICALherebyauthorizerepresentativesof ,this city to enter upon the
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, casts and expenses which
many in any way accrue against said City in consequence of the
CONST. TAXPERMITISSUANCE10.00
gra fin f this permit.)
9 _q-
MECH. CONT. LIC, NO, MECH,
TOTAL,
ov TOTAL
Signat reer-Applicant/Contractor Date
OFFICE COPY