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APPLICANT TO FILL IN INFORMATION WITHIN RED LINES -USE BALL POINT PEN ONLY
BUILDING PROJECT I DENTI.FICATIO
APPLICATION &PERMIT
ELECTRICAL- PLUMBING -MECHANICAL
PERMIT NUMBER
9373NILDING
b.RRR ESS
gam 0-7',BUILDING
OWNER'S Al IS— NAME 7
i j1
7h e e 04 , PHON 7/I / O I
OTY, ELECTRIC PERMIT FEE
PLAN CHECK VALIDATION
Yn
Q h
CONTRACTOR'S
NAME OUTLETS -SWITCHES -RECEP 10,0011,00
6 -ea r;c, LIC,NO.aLIGHTING
DATE OF APPLICATION
FIXTURES 10.0011.00 9,00
CONTRACTOR'S SunsyU e—
ARORESS I
s0 h PHONE - 3 00
3 PPLIANCES- RESIDENTIAL 4.00/,2,00
PANELS 10.00 d47
ARCHITECT
ORENGINEER
tic. No,
PANELS (OVER 200 AMP) 20.00
PLAN CHECK FEE P.C. NO.
AIDSIGNSTRANS. 3.00
ADDRESS ENG.
ZIP
SPECIAL CIRCUIT 5.00 PERMIT VALIDATION
OCT
City of Cupertino
TEMP. METER OR POLE INS. 20.00
APPLICANT'S
ADDRESS
S i zv" n yzz J
MOTORSSEE FEE SCR. 7,00
SERVICE CHANGE 20.00
LICENSED CONTRACTORS DECLARATION I TEMP. 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 Cade ndm ficense is in full force effo t.
License Class — Lic._ Number D
ISSUARICE DATE
SLOG. E E PLG. MECH.
Date — — Contractor
OWNER -BUILDER DECLARATION
1 hereby affum that I am exempt from the Contractor's License
Law far the rollowing reason. (Sec. 7071.5, Business and Professions
Code: Any city or county which requiresa permit to construct, alter,
improve, demolish, or repair any structure, prior to its issuance, also
requires the applicant for such permit t0 file a signed statement that
he is licensed pursuant to the provisions or the Contractor's License
BUILDING PERMIT
INFORMATION
MISC. REFER TO ORD
VALUATION SIFT.
PERMIT ISSUANCE 10.00 elo
ELEC. CONTR. LIC. NO.
a 3
ELEC. ['
TOTAL ,/% • 00
PERMIT TO
GTY. 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
the basis for the alleged exemption. Any violation of Section 7031.5 ti STORIES-- TYIrECONSTR.
by any applicant for a permit subjeels the applicant to a civil penalty
Of not more than five hundred dollars (5500).): ALTER -DRAIN &VENT -WATER IEA,) 5.00
C3 1, as owner of the property, or my employees with wages es
their sale compensation, will do the work, and the structure u not
intended or offered for sale (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
mems are not intended or afrered far salt. If, however, the building
BACK FLOW PROTECT. DEVICE 4.00 OCC.GROUP RES. UNITS
DRAINS -FLOOR, ROOF, AREA,COND. 5,00
F IXTUR ES - PER TRAP 5,00 SO. FT. FLOOR AREA TOTAL ACREAGE
iGAS - EA. SYSTEM 1 INCA OUTLETS 6.00
or improvement is sold within one year a completion, the owner-
builder will have the burden of proving that he 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 (EA.) 2.00 BUILDING USE
IND CON PB Other
I NDUSTR IAL 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
contracts for such projects with a contractor(s) licensed pursuant to
the Contractor's License Law.
LAWN SPRINKLERS- 1 INC 5 V.B. 6.00 ASSESSORS PARCEL NO.
rLAWNSPRINKLERS - OVER 5 (EA.) 1,00
SEWER -SANITARY -STORM EA. 200ft/10.00 TRACT NO, PARCEL NO.
lam exempt under Sec. B.&P.C. for this WATER HEATER WIVENT 6.00
reason
Owner Date WATER SYSTEM 5.00 ACC. GATE ACC. FILE NO.
WATER TREATING EQUIP. 5.00WORKERS' COMPENSATION DECLARATION
hereby affirm that 1 have a certificate of consent to self -insure,
or a certificate or Workers' Compensation Insurance, or a certified
ZONING ENG. SITE N0.
copy lhe1.1 q, .). Policy N.7 ' CC m
114S.
a
Certified copy is hereby furnished.
CerA
licanthfe ,
g/ / rte%thrth', irts ectian division.
P Ryrl LC-
p
FIRE SPRINK
Y N
ENERGY T-24
Y NMISC. - REFER TO ORD.
CERTIFICATE OF EXEMPTION FROM WORKERS'
PERMIT ISSUANCE T0,00 FLOODZONE A.L.U.C.
PLG: CONTR. LIC. NO. PLG,
TOTAL
COMPENSATION INSURANCE
This sectidn need not be completed if the permit is for one
Y N Y N
hundred dollars (5100) or less.)
1 certify that in the performance or the work for which this per- mit is issued. I shall not employ any person in any mannerso as to GTY. MECHANICAL PERMIT FEE FEE SUMMARY
BUILDING
become subject to the Workers' Compensation Laws or Calirornia.
Date Applicant ALTER OR ADD TO MECH. 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 or the Labor Code, you must forthwith comply with
such provisions or this permit shall be deemed revoked,
FEEAIRHANDLINGUNIT (TO 10,0WC.F.M.) 4,00
AIR 14ANDLINGUNIT(OVER10=C.F,M.) 6,00 SEISMIC FEECONSTRUMONLENDINGAGENCY
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 (See.
3091,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 Name
Lender's Address
1 certify that 1 have read this application and stale that the above VENTILATION FAN (SINGLE) 4,00
information is correct. 1 agree to comply with all city and county
ordinancesand state laws relating to building construction, and
PLUMBING
BOILER -COMP (3 H.P. or 100,000 B.T.U,) 6.00
BOILER -COMP (Over 100,000 BTU) SEE FEE SCH. MECHANICALherebyauthorizerepresentativesorthiscitytoenterupon ,the
above-mentioned property for inspection purposes.
MISC. - REFER TO ORD, We) agree to save, indemnify and keep harmless the City or
Cupertino against liabilities, judgments, costs and expenses which
may in any way accrue against said City in consequence or the
CONST. TAXPERMITISSUANCE10,00
gra Ing of this perm( MECH. CONT. LIC. NO. MECH.
kC & A7 3 -AS
TOTAL
TOTAL
Signature of Applicant/Contractor Date
OFFICE COPY