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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
1014 9
all''LDLNG v743
ADDRESS '
13 e,
OWNER'S
d1NA
fCi~
CEJ iale-10? /l
QTY. ELECTRIC PERMIT FEE
PLAN CHECK VALIDATION
GATE OF APPLICATION
0PHONES/
NANRAcroRs
uc.NO.430b6p
UTLETS- SWITCHES -RECEP 10,0011.00 DO/
LIGHTING FIXTURES 10,0011.00 9.0
CONTRACTOR'S hQle,
ADDRESS
aPHONE 73%/'38996pO
y PPLIANCES- RESIDENTIAL 4.00
a00
PANELS 10.00 Q 0 a
ARCHITECTPANELS
ORENGINEER
LIC. na
OVER 200 AMP) 20.00
PLAN CHECK FEE P.C. NO.
ISIGNS TRANS. 3.00'
SSENG. ADDREOR
SPECIALCIRCUIT 5.0Q PERMIT VALIDATION
EMP, METER OR POLE INS- 20.00ZIP
APPLICANT'S
ADDRESS
a (J sw/)q va
MOTORS SEE FEE SCH, OZle,Z C r
SERVICE CHANGE 20.00
LICENSED CONTRACTORS DECLARA ON TEMP, POLE 30.00
TIECw - 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, apd my i ense is in full force effecL
License ss ! Lic. Number //66
Date f2 - , Contractor
ISSUANCE DATE
BLDG. ELECT.
I
PLG. MECH.
lr ubercit f
BUILDING PERMIT
INFORMATIONOWNER -BUILDER DECLARATION
I hereby affirm that 1 am exempt from the Comractor'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 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
MISC. - REFER TO ORD
VALUATION
PERMIT ISSUANCE 10.00 Q 00
E C. CONTR, LIC. NO.
e
ELEC
TOTAtr -Y 0-0PE IT r0
CITY. 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 five hundred dollars (S500).): 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 F LOW'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
FIXTURES - PER TRAP 5.00 SO. FT. FLOOR AREA TOTALACREAGE
GAS-EA.SYSTEM-1INC.4'OUTLETS 6,00
or improvement is sold within one year of completion, the owner-
builder will have the burden of proving [hat he did not build or im-
prove for purpose of sale.).
1. as owner of the property, am exclusively contracting with
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 BUILDING USE
REs IND CON PB Other
1:1 El EJ 1:3 1:1licensed
INDUSTRIAL WASTE INTER. 30,00
LAWN SPRINKLERS • 1 INC 5 V.B. 6.00 ASSESSORS PARCEL NO.
LAWN SPRINKLERS - OVER 5 (EA.) 1.00
contracts for such projects with a contractors) licensed pursuant to
the Contractor's License Law, SEWER -SANITARY -STORM EA. 200(t/10.00 TRACT NO. PARCEL NO.
Lam exempt under Sec. B.&P.C. ror this WATER HEATER W/VENT 6.00
reason
Owner Date WATER SYSTEM 5.00 ACC. PATE ACC, FILE NO.
WATER TREATING EQUIP. 5.00WORKERS'COMPENSATION DECLARATION
1 hereby affirm that 1 have a certificate of consent to self -insure,
or a certificate of Workers' Compensation Insurance, or a certified ZONING ENG. SITE NO.
f e . S
icppp.). PolyNr
FIRESPRINK
Y N
ENERGYT-24
Y N
Certified copy Is ereby furnished.
CeRified copy i t e wrt y c cit inspection division.
Ajppicant /; riC. MISC.- REFER TO ORD.
CERTIFICATE 017 EXEMPTION FROM 1VORKERS'
PERMIT ISSUANCE 10,00 FLOOD ZONE A,L.U,C.
COMPENSATION INSURANCE
This section need not be completed if the permit is for one
Y N Y N
PLG. CONTR. LIC. NO. PLG.
TOTAL
QTY 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, I shall not employ any person in any manner so as to
BUILDING
become subject to the Workers' compensation Laws of California.
BUlDateApplicant
NOTICE TO APPLICANT: if, after 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 Cade; you must forthwith comply with
such provisions or this permit shall be deemed revoked.
FEEAIRHANDLINGUNIT (TO 10MOC.F.M.I 4.00
AIR HANDLING UNIT (OVER 110=1 .F,M.) 6.00 SEISMIC FEECONSTRUCTIONLENDINGAGENCY
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 (Sec.
3097, Civ.C,).
MICROFILM
HEATING UNIT (TO 100,000 B.T.U.) 8.00
HEATING UNIT (OV ER 100,000 B.T,U.)9.50 ELECTRIC
Lender's Name
Lendcr'sAddresa
I certify that I have read this application and state that the above V ENTI LAT ION 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
PLUMBING
BOILER -COMP (3 H,P,or 100,000 B.T.U.) 6.00
BOI LER-COMP (Over 100,000 BTU) SEE FEE SCH, MECHANICALherebyauthorizerepresentativesofthiscitytoenteruponthe
above-mentioned property for inspection purposes.
MISC. - REFER TO ORD,
CONST. TAX
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 PERMIT ISSUANCE 10,00
Ing of this permit. MECH.,CONT. LIC, N0. MECH.
IP -6 .5`
TOTAL
TOTAL
ature of AppBcant/Contractor Date
OFFICE COPY