10150APPLICANT TO FILL IN INFORMATION WITHIN RED LINES —USE BALL POINT PEN ONLY
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JBUI LDING PROJECT 1 DENTI FICATION
APPLICATION & PERMIT
BUILDING — ELECTRICAL— PLUMBING — MECHANICAL
PERMIT NUMBER
5V10150BUILDINGADDRESS/731
71?5p
OWN ER'S
NAME 7J J
CQ PHONk ','
JJoo
CITY, ELECTRIC PERMIT FEE
PLAN CHECK VALIDATION
CONTRACTOR'S
NAMENAME UTLETS-SWITCHES-RECEP 10.0011.00 G
LIGHTING FIXTURES 10.0011.00
U
yl•G "• LLC,NO. p(
DATE OF APPLICATION
CONTRACTORS
ADDRESS Sinn 4.)e—
PHONE 3•S 3c 0
PPLIANCES-RESIDENTIAL 4.00 ,
PANELS 10.OD CD
ARCHITECTPANELS(OVER200AMP)
ORENGINEER
LIC. NO.
2000 PLAN CHECK FEE P.C. NO.
SIGNS TRANS. 3.00
ARCH. OR ENG.SPECIALADDRESS CIRCUIT SQQ PERMIT VALIDATION
TEMP. METER OR POLE INS. 20.00ZIP
APPUCANTS MOTORS wry SEE FEE SCH, 00ADDRESS
SERVICE CHANG 20.0042. -To &n 0,Qe1old4
LICENSED CONTRACTORS D CLARATID TEMP. POLE 30.00
f•, C1herebyaffirmthatIamlicensedunderprovisionsofChapter9
commencing with Section 7000) of Division 3 of the Business and
Professions Code nd license is in full fore p f
License Class ic. Number
Date — Camractor
ISSUANCE DATE
BEG 9M BLDG. ELECT. PLG. MECH.
City Of CuDertin0 BUILDINGRERMIT
INFORMATIONOWNER -BUILDER DECLARATION
I hereby affirm that 1 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, alley,
improve, demolish, or repair any struCLure, 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
Law (Chapter 9 (commencing with Section 7000) of Division 3 of the
Business and Professions Code) or that he is exempt therefrom and
I
MISC. — REFER TO ORD
VALUATION SlFT.
PERMIT ISSUANCE 10.0000
ELEC. CONTR. LIC. NO,
E'G J'JC
E LEC. OOTOTAL PERMIT TO
L
fCITY. 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 rive hundred dollars (5500).): ALTER -DRAIN Bt VENTWATEA(EA.) 5.00
p 1, as owner of the property, or my employees with wages as
their sale compensation, will do the work, and the structure is not
1BACK FLOW PROTECT. DEVICE 4.00 OCG. GROUP RES. UNITS
DRAINS -FLOOR, ROOF, AREA, GOND. 5.00IntendedorofferedforWe (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-
mcnts are not intended at offered for sale. If, however, the building
FIXTURES - PER TRAP 5.00 SO. FT. FLOORAREA TOTAL ACREAGE
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 un-
provefor purpose orsale.).
p 1, as owner of the property, am exclusively contracting with
GAS - EA. SYSTEM -OVER 4 (EA.) 2.00 BUILDING USE
RES IND CON PS Omer
INDUSTRIAL WASTE INTER. 30.00
licensed contractors to construct the project (See. 7044, Business
and Professions Code: The Contractor's License Law does not apply
10 an owner of property who builds or improves therean, and who
LAWN SPRINKLERS - 1 INC 5 V.B. 6.00 ASSESSORS PARCEL NO.
LAWN SPR IN KLERS - OVER 5 (EA.) 1.09
contracts for such projects with a contractor(s) licensed pursuant to
the Contractor's License Law, EWER -SAN ITARY-STORM EA, 200RI1 D.OD TRACT NO. PARCEL NO.
p 1 am exempt under Sec. B.&P,C. for this
reason
WATER HEATER W/VENT 6.00
Owner Dale 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 selPinsure,
or a certificate of Workers' Compensation Insurance, or a certified ZONING ENG. SITE NO.
copy thereof Sec. 38 0 lb
Policy NzM-
S&C' 31
r a*
FIRE SPRINK
Y N
ENERGY T-24
Y NC]
Certified Copy is hereby umishcd.
i Certified copy is riled with the city inspection division.
Applicant 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 section need not be completed if the permit is for one
Y N Y N
CITY, MECHANICAL PERMIT FEEI FEE SUMMARY
hundred dollars (5100) or less.)
I certify that in the performance or the work for which this per-
mit is issued, 1 shall not employ any person in any manner s0 as to
BUILDING
become subject to the Workers' Compensation Laws of California.
Date Applicant
NOTICE TO APPLICANT: If, after making this Certificate of Ex-
I
ALTER OR ADD TO MECH. 5.00
APPLIANCE 5.00 PLAN CHECKemption, you should become subject to the Warkers Compensation
provisions of the Labor Code, you must forthwith comply with
such provisions or this permit shall be deemed revoked. FEEAIRHANDLINGUNIT (TO 10ADOC.F.M.) 4.00
AIR HANDLING UNIT (OVER 10X0C.F,M.) 6.00 SEISMIC FEECONSTRUCTIONLENDINGAGENCY
I 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.) 6.00
Lender's Name
Lender's Address HEATING UNIT (OVER 100,000 B.T.U.)9.50 ELECTRIC d p
1 certify that I have read Ihis application and stale that the above VENTILATION FAN (SINGLE) 4.00
information is correct. I agree to comply with all city and county
ordinances and state laws relating to building construction, and
hereby authorize representatives of this city to enter upon the
above-mentioned property for inspection purposes.
PLUMBINGBOILER -COMP (3 H.P. or 100,000 B.7U,) 6.00
BOl LER-COMP 10vor 100,000 BTU) SEE FEE SCH. MECHANICAL
MISC. - REFER TO ORD. We) agree to save, indemnify and keep harmless the City of
Cupertino against liabilities, judgments, costs and expenses which
ma in any way accrue ogainst said City in consequence or the
n g of this permit.
PERMIT ISSUANCE 10.001CONST. TAX
MECH. CONT. LIC, NO. MECH.
TOTAL
TOTAL
Signature of Applican o.tractor Date
OFFICE COPY