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APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
BUI LD1 NG PROJECT I DENTI FICAT ON
APPLICATION & PERMIT
BUILDING - ELECTRICAL -PLUMBING - MECHANICAL
PERMIT NUMBER
10143BU,IkOING o
Ap6AE55 _
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ow R'5
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QTY, ELECTRIC PERMIT FEE
PLAN CHECK VALIDATION
DATE OF APPLICATION
CONTRACTOR'S
NAME
LIC. Ko -,234069
OUTLETS -SWITCHES - RECEP 10.0011,00 g5. DD
57 LIGHTING FIXTURES 10.0011,00 ,o'
CONTRAC
ADDRESSTOR'
S /SdLn r 4%/
HONE 3 ',T OO
PPLIANCES-RESIDENTIAL 4.00 a,oa
JPANELS 10.OD0, (J0
ARCHITECTPANELS
ORENGINEER
LIC. NO.
LOVER 200 AMP] 20.00
PLAN CHECK FEE P,C.NO.
SIGNS TRANS. 3.00
ARCH. OR ENG.
ADDRESS SPECIAL CIRCUIT S,QQ PERMIT VALIDATION
TEMP. METER DR POLE INS. 20.00ZIP
APPLICANT'SDDRESSTS
wo,, Qle
MOTORS C SEE FEE SCH. , O U
SERVICE CHANGE 20.00
LICENSED CONTRACTORS DECLARATION TEMP. PO LrIAID 30.00
1 hereby affirm that 1 am licensed under provisions Of Chapter 9
commencing with Section 7000) of Division 3 of the Business and
Professions Cod an my license is in full force n ffe t.DEC
License Class A Lic. Number
ISSUANCE DATE
BLDG. ELECT. PLG.
F-1
MECH,
Date Contractor -
City of Cupertino BUILD PERMIT
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 (commencing with Section 7000) of Division 3 of the
Business and Professions Code) Or that he is exempt therefrom and
INFORMATION
MISC. - REFER TO ORD
VALUATION -
7
SIFT.
PERMIT ISSUANCE 10.00 (T 00
E 6C. ONTR. LIC. NO.
C
ELEC,
TOTAL PERMIT TO
j
L
CITY. PLUMBING PERMIT FEE
STORIES TYPE CONSTR. the basis for the aileged 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-WATER{>A.1 5,00
1, as owner of the property, or my employees with wagesas
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'Ihereon, and who does such work
Wmself or through his own employees, provided that such Improve-
ments are not intended or offered for ssle. If, however, the building
F IXTUR ES - PER TRAP 5.00 1 FT, FLOOR AREA TOTALACREAGE
GAS - EA. SYSTEM -1 INC. 4 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 (EA.} 2,00 BUILDING USE
RES IND CON PB Orher
11 C] El 13 1:1 INDUSTRIAL WASTE INTER. 30.00
licensed contractors to construct the project (Sec. 7044, Business
and Professions Code: The Contractor's License Law docs not apply
toan owner of property who builds or improves thereon, and who
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 contractor(s) licensed pursuant to
the Contractor's License Law. SEWER -SANITARY -STORM EA. 200ft/10.00 TRACT NO.PARCEL NO,.
lam exempt under Sec. B.&P.C. for Ihis WATER HEATER WIVENT 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 N0.
copy [here (Sec. 13WPolicyN . yy
FIRE SPRINK
Y N
ENERGY T-24
Y N
Certified Copy is hereby furnished.
y Certified caps. Tis -Rted wijFj, }h kits irrspeclion division.
plicanY f /L' `rir . 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 El 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 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 (OVER 10=1.F,M.) 6.00 SEISMIC FEECONSTRUCTIONLENDINGAGENCY
1 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 v
MICROFILM
HEATING UNIT (TO 100,000 B.T,U-) 8.00
HEATING UNIT (OVER 100,000 B.T.U.) 9.50 ELECTRIC
e
Lender's Name
Lender's Address
certify that 1 have, read this application and state that the above
information is correct. I 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 loser 100,000 BTU) SEE FET: 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
CONST. TAXPERMITISSUANCE10.00
gra of this permit. MECH. CONT. LIC. N0. MECH,
TOTAL
TOTAL
Signature of ApplicantCOntractor Date
OFFICE COPY