9383a
APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
SUI LD1 NG PROJECT I DENTI FICATION
APPLICATION & PERMIT
BUILDING - ELECTRICAL- PLUMBING --MECHANICAL
PERMIT NUMBER
9383
su owe
ADDgI=.ss
r`
NAME 'YNAME
ade PHDN S"7i_/y
QTY. ELECTRIC PERMIT " . . FEE
PLAN CHECK VALIDATIONPLAN
DATE OF APPLICATION
CONTRACTOR'S
NAME // `
1 Z/eG//'! LIC.No,5,23?
W/OUTLETS -SWITCHES - RECEP 10.0011.00 ?(6.00
LIGHTING FIXTURES 10.00/1.00 490
AODRESsroRs //
un•r ua e
a Q y!',f7/Lr
PPLIANCES- RESIDENTIAL 4.00 a,QO
PANELS 10.00 /,9.00
ARCHITECT
OR
ENGINEER
LIC. NO.
PANELS (OVER 200 AMP) 20,00 PLAN CHECK FEE P.C. NO.
SIGNS TRANS. 3.00
ADURCSS ENG. SPECIAL CIRCUIT 5.00 PERMIT VALIDATION
TEMP. METER OR POLE INS. 20.00ZIP
APPLICANT'S
ADDRESS /
jQ l G iGjop An fm4 ? vea /
MOTORS SEE FEE SCH. !JO
SERVICE CHANGE 20.00
LICENSED CONTRACTORS DECLARATIOW TEMP. POLE 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 m license is in full farce arid effec
License lass Lie. Number
ISSUANCE DATE
BLDG. ELECT. PLG.
El
MECH.
Date ContractorD
OWNER -BUILDER
I hereby affirm that i am exempt from the Contractor's License
Law for the following reason. (Sec. 7031.5, Businessand 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 applicinl for such permit to file a signed statement that
he is licensed pursuant to thep 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
DECn 9 1085CUILB ING.-PERMIT"
INFORMATION
MISC. - REFS TO ORD,
PERMIT ISSUANCE /D OU
VALUATION" FT.
fLEC. CONTR. LIC. NO.
G f
ELEC,
TOTAL
D D
PERMIT TO
s='
OTY. PLUMBING PERMIT FEE `
the basis for the alleged exemption. Any violation of Section 7031.5 STORIES TYPE CONSTR.
by any applicant for a permit subjects the applicant to aeivil penalty
of not more than five hundred dollars ($500).):
1, is, owner of the property, or my employees with wages as
their sole compensation, will do the work, and the structure is not
ALTER -DRAIN &VENT WATER {EA.) 5.00
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 improve-
ments are not intended or offered for safe. If, however, the building
FIXTURES -PER TRAP 5.00 SQL FT. FLOOR AREA TOTAL ACREAGE
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.).
as owner of the property, am exclusively contradling with
GAS - EA. SYSTEM OVER 4 (EA) 200 BUILDING USE
RES IND CON PB Other
I--] IN El1. 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 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 STORM EA. 200ft110,00 TRACT NO. PARCEL NO.
1ani exempt under Sec. B.&P.C.for this
reason
WATER HEATERW/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 1 have a certificate of consent to self -insure
or a certificate of Workers' Compensation. Insurance, or a certified ZONING ENG. SITE NO.
copyher of Sec ,(16
PolicyL` yl
Certified copy is hereby furnished.
Certified ca is +]ed vr'th the ei y inspection division.
7 p icant- I
fJ [aC
FIRE SPRINK
Y 0 NE]
ENERGY T-24'
Y NQMISC. - 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 sectidn need not be completed if the permit is for one Y N Y[] N
OTY. MECHANICAL PERMIT FEE FEE"SUMMARY
hundred dollars ($100) 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
BUILDING
become subject to the Workers' Compensation Laws Of California.
Date Applicant ALTER OR ADD TO MECH. 5.00
NOTICE TO APPLICANT: If, after making this Certificate of Ex-
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 10m011F.M.) 4.00
AIR HANDLING UNIT (OVER 10pWCRM.) 6.00 SEISMIC FEECONSTRUCTIONLENDINGAGENCY
I hereby 'affirm that tlhcre 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.) 8.00
Lender's Name HEATING UN ELECTRIC LL dCjLender's Address
I certify that I have read this applicationand state that the above VENTILATION FAN (SINGLE) 4.00
information is correct. I agree to comply with all.city and county
ordinances and state laws relating to building construction, and -
PLUMBING
BOILER-COMP(3 H.P.Or 100,000 B.T.U.) 6.00
BOILER -COMP (Over 100,000 BTU) SEE FEE SCH. MECHANICALherebyauthorize, representatives of this city to enter upon the
above-mentioned property for inspection purposes.
We) agree to save, indemnify and keep harmless the City of MISC. - REFER TO ORD.
Cupertino against liabilities, judgments, costs and expenses which--
may in any way accrue against said City in consequence of the
CONST. TAXPERMITISSUANCE10.00
gran ' f this permit. MECH. CONT. LIC. NO. MECH.
r TOTAL
TOTAL
Signa re of Applicant ntractor Date
OFFICE COPY