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APPLICANT TO FILL IN INFORMATION WITHIN RED LINES -USE BALL POINT PEN ONLY
BUI LD1 NG PROJECT I DENTI FICATION
APPLICATION & PERMIT
BUILDING -ELECTRICAL- PLUMBING -MEMECHANICAL
PERMIT NUMBER
101480///QBUILDlhf3lADDRESS
7ys/
OWNER'S
NAME y/S'
r
Q PHQNEV // ''T IJ
QTY. ELECTRIC PERMIT FEE
PLAN CHECK VALIDATION
J0
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CONTRACTOR'S%
N M u jny/vYs e.
LIC. NO. 31j1-3 oa
UTLETS-SWITCHES-RECEP 10.0011,00
LIGHTING FIXTU_ RES 10.00/1.00 ,D
ADDRESS TOR'S PPLIANCES- RESIDENTIAL 4.00 Z,ao
PANELS 10.00 Q. 00PHONE DATE OF APPLICATION
ARCHITECT
ORENGINEER
LIC. No.
PANELS (OVER 200 AMP) 20,00
PLAN CHECK FEE P.C. ND.
SIGNS TRANS. 3.00
ARCH. OR ENG.
ADDRESS SPECIAL CIRCUIT 5.00
PERMIT VALIDATION
TEMP. METER OR POLE INS. 20.00
ZIP
ADDLRESSTS
a2v/Q „jr
MOTORS Via,PrAJIDE FEE SCH. 7,00
SERVICE CHAN 20.00
LICENSED CONTRACTORS DECLARATION TEMP. POLE
t
QQ 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 Code, d gg license is in full force IfpLicenseClassOLic. Number
ISSUANCE DATE
BLDG. BLDG. ELECT. PLG. MECH.
Date - Contractor
BUti
ORM
PERMIT
INF,ORMATIDN_ OWNER -BUILDER DECLARATION
I herebyaffirm that 1 am exempt from the Contractor's Licensep
Law for the following reason. (Sec- 7031.5, Businessand Professions
Code: Any city or county which requirese permit toconstrucl,alier,
improve, demolish, or repair any structure, prior, its issuance, also
requires the applicant for such -permit to file a signed statement that
he is licensed pursuant to the provisions of the Contractors License
Law (Chapter 9 (commencing with Section 7000) o f Division S o f the
Business and Professions Code) or that he is exempt therefrom and
the basis for the alleged exemption. Any violation ofScction 7031.5
by any applicant for a permit subjects the applicant to a civil penalty
of not more than five hundred dollars (3500).):
MISC. - REFER TO ORD
VALUATION JFT.
PERMIT ISSUANCE 10.00
L G. eONTR, LIC. NO.
f
eGfP/G
ELEc.
TOTAL j PERMIT TO
GCL C.`rQTY. PLUMBING PERMIT FEE1 STORIES TYPE CONSTR.
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 FLOW PROTECT. DEVICE 4.00 OCC. GROUP RES. UNITS
DRAINS -FLOOR, ROOF, AR EA, CON D. 5.00intendedorofferedforsale (Sec- 7044, Business and Professions
Code: The Contractor's License Law does not apply to an owner of
properly who builds or improves thereon, and who does such work
himself or through his own employees, provided that such improve-
mcnts are not intended or offered for salt. If, however, the building
FIXTURES - PER TRAP 5.00 50 -FT. FLOOR AREA TOTALACREAGE
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 lie did not build or im-
prove for.purposeofsale.).
1, as owner of the property, am exclusively contracting with
15A5 - EA. SYSTEM OVER 4 (EA.) 2.00 BUILDING USE
RES IND CON PB Other
INDUSTRIAL WASTE INTER. 30.00
LAWN SPRINKLERS- 1 INC 5 V.B. 6.00 ASSESSORS PARCEL NO. 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 LAWN SPR INKLERS - OVER 5 (EA.) 1.00
contracts for such projects with a contractors) licensed pursuant to
the Contractor's License Law, SEWER -SANITARY -STORM EA. 200ft/10.00 TRACT NO. PARCEL NO.
I am exempt under5ec. BAP.C. for this WATER HEATER W/V ENT 6.00
reason
Owner Date WATER SYSTEM 5.00 ACC.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 they S C. 3 Oja,ja}).
Policy N CC,,r 11
FIRESPRINK
Y N
ENERGY T-24
Y N
Certified copy is hereby fumishcd.
Certified copy Glad w rhe +ty 'inspection division.
A picanL ,'/ .4,f MISC.- REFER TO ORD.
CERTIFICATE OF EXEMPTION FROM WORKERS' PERMIT ISSUANCE 10.00 FLOOD ZONE AL.U.C.
PLG. CONTR. LIC. NO. PLG,
TOTAL
COMPENSATION INSURANCE
This section need not be completed if the permit is for one
r N Y N
QTY. MECHANICAL PERMIT FEE FEE SUMMARY
hundred dollars(SI00) 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
BUILDINGbecomesubjecttotheWorkcrs' Compensation Laws of California.
Date Applicant
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 Code, you must forthwith comply with
Such Provisions or this permit shall be deemed revoked.,
FEEAIRHANDLINGUNIT (TO 10MC.F.M.) 4.00
AIR HANDLING UNIT(OVER101000C.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
d
HEATING UNIT LTO 100,000 B.T.U.) 8.00
HEATING UNIT IDV ER 100,000 B.T.U.)950 . ELECTRIC
Lender's No
Lender's Address
1 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 100,000 B.T,U.) 6.00
BOI LER-COMP (Over 100,000 BTU) SEE FEE SCH. MECHANICALherebyauthorizerepresentativesof ,this city to enter upon the
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
MECH. CONT. LIC. NO. MECH. gra g ofthis permit.
JOS
TOTAL
TOTAL
Signature of Applicant/Contractor Date
OFFICE COPY