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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
PERMITNUMSER
10146ACREpSsoT
r rO.Se— LJ /
OWNER'S
NAME
PHONr
f /-
Jh, n
E'
a
QTY. ELECTRIC PERMIT FEE
PLAN CHECK VALIDATION
a
DATE OF APPLICATION
CONTRACTOR'S
LIC. ND. e 3
OUTLETS-SWITCHES-RECEP 10.0011.00 ,00
Q LIGHTING FIXTURES 10-0011-00,2,9,00
CONTRACTOR'S
ADDRESS J
PHONE 3 Q
APPLIANCES 4.00
SOU
PANELS 10.00 119100
ARCHITECT
ORENGINEER
LIC. No.
PANELS (OVER 200 AMP) 20,00 PLAN CHECK FEE P.C.-NO.
SIGNS TRANS. 3.00
AARCH
OR
DDRESS SPECIAL SPECIAL CIRCUIT 5,00 PERMIT VALIDATION
TEMP. METER OR POLE INS. 20.00ZIP
ANT'S
DDRESDRESSAD
8u}po 1,
MOTORS SEE FEE SCH. i L90r'a.
SERVICE CHANGE 20,00
LICENSED CONTRACTORS DECLARATIO TEMP, POLE 30.00
I hereby affirm that l am licensed under provisions of Chapter 9
commencing with Section 7000) of Division 3 of the Business and
Professions Code, d rr}ylicense is in full fort ff DLicensessCVLic. Number
Date— Contractor
OWNER -BUILDER DECLARATION
I 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 (commencingwith Section 7000) of Division 3 of the
Business and Professions Code) or that he is exempt therefrom and
the basis for the alleged exemption. Any violation of Section 7031.5
ISSUANCE DATE
DEC I- - 35 BLDG. ELECT. PLG. MECH.
City of Cupertino BUILDING PERMIT
INFORMATION
MISC. — REFER TO ORD'
VALUATION SIFT.
PERMIT ISSUANCE 10.00 D, Oo
E C. CONTR. LIC. NO.
G ' 3
ELEC. r
TOTAL/J 0 PERMITTO
L -EC-[,
QTY. PLUMBING PERMIT FEE1 STORIES TYPE CONSTR_
by any applicant for a permit subjects the applicant to a civil penalty
of not more than five hundred dollars (5500).): ALTER DRAIN & VENT -WATER (EA.) 5.00
1, as owner of Ike 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. 5.00intendedorofferedforsale (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
mimprove-
mes are not intended or offered for sale. If, however, the building
FIXTURES - PER TRAP 5.00 S(L FT, FLOOR AREA TOTAL ACREAGE
GAS EA. SYSTEM -1 1 NC. 4 DUTL ETS 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.).
111, as owner of the property, am exclusively contracting with
GAS EASYSTEM -OVER 4 (EA,) 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
to 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 - OV ER 5 (EA.) 1.00
contracts for such projects with a contractor(s) licensed pursuant to
the Contractors License Law. SEW ER -SAN 1TARY-STORM EA, 200k/10.00 TRACT NO. PARCEL NO.
El 1 am exempt under Sec. B.&P.C. for this
reason
WATER HEATER W/VENT 6.00
Owner Date WATER SYSTEM 5.00 ACC. DATE ACG. FILE NO.
WATER TREATING EQUIP, 5.00WORKERS'COMPENSATION DECLARATION
I 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 S c. 38O jtl.
Policy N .aji-
FIRE SPRINK
Y N
ENERGY T•24
Y N
Certified copy Is hereby furnished„
Certified coTTc i1ction division.
plican
REFER TO ORD. MISC.A
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-
mit is issued, 1 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 Ibis 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.
FEE
AIR HANDLING UNIT (TO 10=QF.M.) 4,00
AIR HANDLING UNrr(OVER10=CF,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.) 6.00
HEATING UNIT (OVER 100,000B.T.U,)9.50 ELECTRIC
Lender's Name
Lender's Address
1 certify that I have read this application and slate that the above
information is correct. 1 agree to comply with all city and countyPLUMBING
ordinances and state laws relating to building construction, and
VENTILATION FAN (SINGLE) 4.00
OILER- COMP O H.P, Dr 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. 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
g of this permit..
CONST. TAX
PERMIT ISSUANCE 10,00
MECH. CONT. LIC. NO. MECH. ,
4=4LMd 6" -ov /a-4 - ?.i TOTAL
TOTAL
SiOftrure of Applicant!, ontractor Date
OFFICE COPY