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APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
BUILDING PROJECT IDENTIFICATION
APPLICATION &PERMIT
ELECTRICAL— PLUMBING —MECHANICAL
PERMIT NUMBER
ABULDINGADDRESSTd3UlLING
re I
OWNER'S
NAME
e a —7/',/l/ PHONE
QTY. ELECTRIC PERMIT FEE
PLAN CHECK VALIDATION
30f
DATE OF APPLICATION
CONTRACTOR'S
NAME
LIC.NO. a
a OUTLETS - SWITCHES-RECEP 10.0011.00 D
LIGHTING FIXTURES 10.0011.00 0
ONrA ACTOR'S Sir q x/eADDRESS
d irG jLUva(2,iVE73 -,3 ao
PP LIANCES - RESIDENTIAL 4.00 o
PANELS 10.00 %Q.
ARCHITECTPAN
ORENGINEER
LIC, NO.
ELS (OVER 200 AMP) 20,00
PLAN CHECK FEE P.C. NO.
SIGNS TRANS, 3,00
ARCH. OR ENG.SPECIALADDRESS CIRCUIT j,QQ PERMIT VALIDATION
TEMP. METER OR POLE INS. 20,00ZIP
ADDREssrs
1a15'0 IrC hW00 dct
MOTORS Q SEE FEE SCH, Dp
SERVICE CHANGE 20.00
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 Cod ad license is in full force ffectrODECLicenseClassLic. Number .•55
ISSUANCE DATE
BLDG. ELECT.
10
PLG. MECH.
Date — — Contractor
BUILD G PERMIT
INFORMATIONOWNER -BUILDER DECLARATION
1 hereby affirm that I 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, 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. — E TO ORD
VALUATION FT,
PERMIT ISSUANCE 10,00 1f, Op
ELE . CONTR. LIC. NO. ELEC,
3 TOTAL J6,
If
QTY. PLUMBING PERMIT FEE
PERMITTO
r
STORIES TYPE CONSTR. the basis for the alleged exemption. Any violation of Sect ion 7031.5
by any appficant for a permit subjects the applicant to a civil penally
of not more than five hundred dollars (SS00).): ALTER-DRAIN-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
DRAINS -FLOOR, ROOF, AREA, GOND, 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-
mems are not intended or offered for sale. If, however, the building
FIXTURES - PER TRAP 5.00 SD. F.T. FLOORAREA TOTALACREAGE
GAS -1 A. SYSTEM -1 1 NC.4 OUT LETS 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 lm-
prove.forpurpose Of sale.).
0 1, as Owner of the property, am exclusively contracting with
GAS - EA. SYSTEM -OVER 4 (EA.) 2,00 BUILDING USE
RES IND CON PB Other
1 11 1:1licensed
INDUSTRIAL WASTE INTER, 30,00
LAWN.SPRINKLERS- 1 INC 5 V.B. 6.00 ASSESSORS PARCEL NO. 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 LAWN SPRINKLERS - 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, 200ft110,00 TRACT NO. PARCEL NO.
1 am exempt under Sec. B.&P.C. for this WATER HEATER WIVENT 6.00
reason
Owner Date WATER SYSTEM 5.00 ACG. DATE ACC, FILE NO.
WATER TREATING EQUIP, 5.00WORKERS' COMPENSATION DECLARATION
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. SITE NO.
copy there f(S8lPolicyF„
FIRE SPRINK
Y N
ENERGY T-24
Y N
O Certified copy is hereby furnished-
Q Certified copy, }s filerty y+ilh tlY ee aty inspection division.
AAplicant /1+/S 7//G 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.)
I certify that in the performance of the work for which this per-
mil'is issued. I shall not employ any person in any manner so as to
BUILDING
become so bject to the Workers' Compensation Laws of California.
Date Applicant
NOTICE TO APPLICANT: If. after making this Certificate Of Ex-
ALTER OR ADD TO MECH. 5,00
JAPPLIANCE 5,00 PLAN CHECKemption, you should become 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 10=12 F.M.) 4,00
AIR HANDLING UNIT (OVER 10,000 C. F. M.) 6.00 SEISMIC FEECONSTRUCTIONLENDINGAGENCY
I -Ir Iiereby 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.).
Lenders Name
MICROFILM
HEATING UNIT (TO 100,000 B,T,U.) 8.00
HEATING UNIT (OVER 100,000B.T.U.)9.50 ELECTRIC
h
Lender's Address
certify that I have read this application and state that the above
information is correct. 1 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 100,0008.7 U.) 6.00
BOI LER-COMP (Over 100,000 BTU) SEE FEE SCH.1 MECHANICALherebyauthorizerepresentativesofthiscity, to enter upon the
above-mentioned property for inspection purposes.
miss, - REFER TO ORD. We) agree to save, indemnify and keep harmless the City Of
Cupertino against liabilities, judgments, costs and expenses which
mayin any way accrue against.said City in consequence Of the
CONST. TAX
PERMIT ISSUANCE 10,00
gran ' of this permit. MECH, CONT. LIC. NO. MECH,
s TOTAL
TOTAL
Signature of Applicant(Contractor Date
OFFICE COPY