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APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
BUILDING.PROJECT IDENTIFICATIO
APPLICATION & PERMIT
BUILDING - ELECTRICAL- PLUMBING - MECHANICAL
PERMITNUMBER
10147BUILDING- ADDRESS
R S ' NAMEL h.s'
J
Irle e PHONE / %
QTY. ELECTRIC PERMIT FEE
PLAN CHECK VALIDATION
4(
DATE OF APPLICATION
CONTRACTOR'S%
NAME
LIC. NO, .3
Q OUTLETS-SWITCHES-RECEP 10.0 0/1.00 Q/
LIGHTING FIXTURES 10.0011.00
CONTRACTOR'S ceanr a GADDRESS
j
AZ3tJ r" - PHONE ~,DO
3 PPLIANCES-RESIDENTIAL 4.00 OC9
PANELS 10.00 Q 00
ARCHITECT
pRENGINEER
uc. NO.
PANELS (OVER 200 AMP) 20.00
PLAN CHECK FEE P.C. NO.
SIGNS TRANS. 3.00
ADDREORSS ENG. SPECIAL CIRCUIT 5.00 PERMIT VALIDATION
TEMP. METER OR POLE INS_ 20.00ZIP
APPLICANT'S
ADDRESS,f 2-5_0 vU/}'G
MOTORS de- . SEE FEE SCH. Op
SERVICE CHANGE PAID 20.00
LICENSED CONTRACTORS DECLARA ION TEMP. POLE 30.00
DEC^ 1herebyaffirmthat1amlicensedunderprovisionsofChapter9
commencing with Section 7000) of Division 3 of the Business and
Professions Code, a 1d my 'cense is in full force fee
License Class Lie. Number
Date - - Contractor
ISSUANCE DATE
BLOC. ELECT. PLG. MECH.
City of Cupertino
BUILDING PERMIT
INFORMATIONOWNER -BUILDER DECLARATION
hereby affirm that i am exempt from the Contractor's License
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 Contractors 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 SIFT.
Lawrorthefollowingreason.(Sec. PERMIT ISSUANCE 10.00 e, O
L C. CONTR. LIC. NO.
23 FO
ELEC. 1 TOTAL DO
PERMITTO
ELSmoi%
IQTY, 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 civil penalty
of not more than five hundred dollars ($500),); 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, AREA, COND. 5.00intendedorofreredforsale (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-
eare not intended or offered for sale. If, however, the buildingmms
FIXTURES'- PER TRAP 5.00 SO. FT. FLOOR AREA TOTALACREAGE
GAS EA. SYSTEM - ]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 or im-
prove for purpose of sale,).
1, as owner of the property, am exclusively contracting with
GAS - EA. SYSTEM OVER 4 IEA.) 2.00 BUILDING use
RES IND CON PB Other
INDUSTRIAL WASTE INTER. 30.00
licensed contractors to construct the project (Sec. 7044, Business
and Professions Code: The Contractor's License Law does not apply
I,)an owner of property who builds or improves thereon, and who
LAWN SPRINKLERS - 1 INC 5 V.B_ 6.00 ASSESSORS PARCEL NO.
LAWN SPR INKLERS - OVER 5 (EA.) 1.00
contracts Cor such projects with a contractor(s) licensed pursuant to
the Contractor's License Law. SEWER-SANITARY STORM EA. 200ft/1 O.OD TRACT NO. PARCEL NO.
I am exempt under Sec. B.&P.C. for this
reason
WATER HEATER W/VENT 6.00
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 seirinsure,
or a certificate of Workers' Compensal ion insurance, or a certified ZONING ENG. SITE N0.
copy there f Sec. O,Y.
Policy N C¢
FIRE SPRINK
Y N
ENERGY T•24
Y N
Certified copy is hereby furnished.
Certified co is. ft1 d the ty inspection division.
App ican[ -1 r -4c, MISC. - REFER TO ORD,
CERTIFICATE OF EXEMPTION FROM WORKERS' PERMIT ISSUANCE 10.Ool 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 E] V N
MECHANICAL PERMIT FEE FEE SUMMARY
hundred dollars (S 100) or fess.)
I certify that in the performance of the work for which this perQTY.
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.
Date Applicant -
NOTICE TO APPLICANT: If, after making this Certificate of Ex-
ALTER OR A D TO MECH. 500
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. AIR HANDLING UNIT (TO 10J000C.F,M.) 4.00 FEE
AIR HANDLING UNIT (OVER 10=C.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.
MICROFILM
HEATING UNIT (TO 100,000 B.T.U.) 8.00
HEATING UNIT (OV ER 100,000 B.T.U.) 9.50 ELECTRIC o
Lender's Name
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
BOILER -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 liabililies, judgments, costs and expenses which
may in any way accrue against said City in consequence of the
ting of this permit.
PERMIT ISSUANCE 10.00
MECH. CONT. LIC. NO.'MECH,
J
TOTAL
TOTAL
Signature ofApplican onlractor Date
OFFICE COPY