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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
9374
BUIL'iNG
AooR1sv
8
OWNER'S
NAME
p
01e 1,76 PHONE f-1 8I
OTY. ELECTRIC PERMIT FEE
PLAN CHECK VALIDATION
DATE OF APPLICATION
rONTRACTORS
NAME
LIC.N0.;7,3
p OUTLETS - SW ITCHES - R ECEP 10.00/1.00 /0-, 01
LIGHTING FIXTURES 10.00/1.00 e23,00
ADDRESTons
SIZ,17 /gale-
Q /+ op PHONE %3 i1-,390
PPLIANCES- RESIDENTIAL 4.00 aDQ
PANELS 10.00 r7 , OD
ARCHITECT
ORENGINEER
LIC. No.
PANELS (OVER 200 AMP) 20.00
PLAN CHECK FEE P.C. NO.
SIGNS TRANS. 3.00
ARCH. OR ENG" SPECIAL CIRCUIT 5,00 PERMIT VALIDATION
PAID, TEMP. METER OR POLE INS. 20.00
ZIP
OCT
APPLICANT'S
AGDRESS w MOTORS `; SEE FEE SCH. ,d
ISERVICE CHANGE 20.00254IY'G Q Sy-nefevit 195
c,yf Q /,r'
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, td m icensc is in'full farce ff [
License Class Lic. Number t
ISSU{FtNCiDT 7`ino
BLDG. EL C PLG. MECH.
Date - Contractor
BUl DING PERMIT"
INFORMATIONOWNER -B U I LDER DECLA RATION
1 hereby affirm that 1 am exempt from the Contractor's License
Law for the fallowing reason. (See. 7031.5, Business and Professions
Cade: 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
MISC. - REFER TO ORD
VALUATION SIFT.
PERMIT ISSUANCE 10.00 Q 00
EL C. CONTR. LIC, NO.
le- / 3
ELEC.
TOTAL 00
TOTAL p TO
CITY. 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 ofSeclion 7031.5 STORIES TYPE CONSTR.
LTER DRAIN &VENT WATER {EA.} 5.00ALTER- by any applicant for a permit subjects the applicant to a civil penalty
of not mo re, than five hundred dollars (S 500).):
1, as owner of the property, or my employees with wages as
their sole compensation, will do the work, and the structure is not
intended or offered for sale (Scc. 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. Ir, however, the building
BACK FLOW PROTECT. DEVICE 4.00 OCC. GROUP RES. UNITS
F*
l
d
DRAINS -FLOOR, ROOF, AREA.COND. 5.00
F I XTUR ES - PER TRAP 5.00 SO. FT. FLOOR AREA TOTAL ACREAGE
GAS EA. SYSTEM -1 INCA 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 a_ r im-
prove for purpose of sale.).
1,. as owner of the property, am exclusively contracting with
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
GAS EA. SYSTEM OVER 4 (EA.) 2.00 f3utLDING USE
R IND CON PB other
ASSESSORS PARCEL NO.
INDUSTRIAL WASTE INTER. 30.00
LAWN SPRINKLERS- 1 INC 5 V.B. 6.00
LAWN SPRINKLERS -OVER 5 (EA.) 1.00
Contracts for such projects with a contractor(s) licensed pursuant to
the Contractors License Law, SEWER -SANITARY -STORM EA. 200ft/10.00 TRACT N0, PARCEL N0.
WATER HEATER W/VENT 6.00lamexemptunderSec. B.&P.C, for this
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 certificate of consent to self -insure.
or a certificate of Workers' Compensation Insurance, or a certified
ZONING ENG. S17E N0.
copy the gQ{BpD„j).
CPolicyN eoi(t
Certified Copy is hereby furnished.
Certified y l[ed'vth th city,i nspection division.
Applicant +C P c ri
FIRE SPR INK
Y H
ENERGY T•24
Y N MISC. - REFER TO ORD.
CERTIFICATE OF EXEMPTION FROM WORKERS' PERMIT ISSUANCE 10.00 FLOOD ZONE A.LU.C.
PLG. CONTR. LIC. NO. PLG,
TOTAL
COMPENSATION INSURANCE
This scclion need not be completed if the permit is for one
Y N Y N
CITY MECHANICAL PERMIT FEE FEE SUMMARY
hundred dollars (S 100) or less.)
I certify that in the performance of the work for which this per-
mit is issued, 1 shall not employ any person in any manner so as to
BUILDING
become subject to the Workers' Compensation Laws of California.
Date Applicant ALTER OR ADD TO MECH. 5.00
NOTICE TO APPLICANT: If, after making this Certificate of Ex-
emption, you should became subject to the Workers' Compensation APPLIANCE 5.00 PLAN CHECK
provisions of the Labor Code, you must forthwith comply with
such provisions or this permit shall be deemed revoked.
FEEAIRHANDLINGUNIT (TO 10,000 C. F.M.) 4,00
AIR HANDLING UNIT (OVER 10MOC.F.M.) 6.00 SEISMICFEECONSTRUCfIONLENDINGAGENCY
I 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.
3097,Civ.C.).
MICROFILM
HEATING UNIT (TO 100,000 B.T.U.) 8.00
H EATING UNIT (OV ER 100,000 B.T.U.) ELECTRIC
Lender's Name
Lender's Address
I certify that 1 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 (OvarI00,000BTU) 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 g of this permlt. MECH. CONT. LtC. N0. MECH.
TOTAL
TOTAL
Signature of Applicant/.Contractor Date
OFFICE COPY