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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
PERMIT NUMBER
93843vBUILDINGADDRESS
f /r
CW ERAS
AMNIV/QTY j
JJ ,
PHONES //-/ 7 J /
QTY, ELECTRIC PERMIT FEE
PLAN CHECK VALIDATION
CONTRACTOR'S
NAME Q OUTLETS-SWITCHES-RECEP 10.00/1.00 p D
9VIIIIr/ uD.No.,13,?4 ILIGHTING FIXTURES 10.00/1.00 43.00 j
DATE OF APPLICATION
ADDESS
CONTRACTOR'S
15 9 V,2 leeADDRESS
r - PHONE 3313 7DO
APPLIANCES- RESIDENTIAL 4.00 /.7.D0
PANELS 10.00 .O
ARCHITECT
ORENGINEER
LIC. NO,
PANELS (OVER 200 AMP) 20.00
PLAN CHECK FEE P.G. NO,
SIGNS TRANS. 3.00
ARCH OR ENG. SPECIAL CIRCUIT 5,00 PERMIT VALIDATION
EMP. METER OR POLE INS. 20.00ZIP
p
r`
ADDRESS IMOTORS SEE FEE SCH. OP
SERVICE CHANGE 20.00
LICENSED CONTRACTORS DECLARATION/TEMP, POLE 30.00
1PBLDG.
1 hereby affirm that I am licensed under provisions of Chapter 9
commencing with Section 7000) of Division 3 of the Business and
Professions Codc, d y license is in full force ffg
License Class -" Lie. Number
Date - Contractor
OWNER -BUILDER DECLARATION
1 hereby affirm that I am exempt from the Contractors License
Law for the following reason. (Sec. 703 1.5, BusinessandProfessions
Code: Any city or county which requiresa permit to construct. alter,
Improve, demolish, or repair any structure, prior to its issuance, also
requires the applicant for such permit to fila 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 ofthe
Business and Professions Code) or that he is exempt therefrom and
ISSUANCE DATE
E:]
ELECT. PLG. MECH.
CS •+
DEC BUILDING, PERMIT
INFORMATION
MISC. -- REFER TO - U
PERMIT ISSUANCE d, 00
VALUATION FT,
ELEC. CONTR. LIC. NO.
C;
ELEC.
TOTAL / a
PERMIT TO
QTY. 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 toa civil penalty
of not more than five hundred dollars (S500)J: 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. 5.00intendedorofferedforsale (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
mems are not intended or offered for sale. If, however, the building
IFIXTURES - PER TRAP 5.00 SQ FT. FLOOR AREA TOTALACREAGE
GA5 EA. SYSTEM -1 INCA OUTLETS 6.00
ofimprovement is sold within one year of completion, the owner-
builder will have. the burden of proving that he did not build or Im•
provcfor purpose ofsale.).
I. as owner of the property, am exclusively contracting with
GAS - EASYSTEM -OVER 4 (EA,) 2.00 SUILP[NG USE
RES IND CON Pe Other
El El El 1:1 13INDUSTRIALWASTEINTER. 30.00
LAWN SPRINKLERS - 1 INC 5 V.B. 6.00 ASS ESSORSPARCEL 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 SPA INKLERS - OVER 5 (EA.) 1.00
contracts for such projects with a contractor(s) licensed pursuant to
the Contractor's License Law. SEWER SANITARYSTORM EA. 200ft/10.00 TRACT NO. PARCEL NO.
I am exempt under Sec. B.&P.C. for this WATER HEATER W/VENT 6.00
reason
Owner Date WATER SYSTEM 5.00 ACC. DATE ACC. FILE NO.
WATER TREATING EQUIP. 5,00WORKERS' COMPENSATION DECLARATION
I hereby affirm that I have a eertificatC-of consent to self -insure,
or a certificate of Workers' Compensation Insurance, or a certified ZONING ENG. SITE NO.
copyher gT e t g„L--C.).
PolicyANIddCG+ calnlTfallffy
17 Certified copy
yiishereby
furnished,
y
AppZicanttlfle-
1
f d wir j e ci
l
ppee[ion division.
FIRESPRINK
Y N
ENERGYT-24
Y NoMISC. - REFER TO ORD.
CERTIFICATE OF EXEMPTION FROM WORKERS' PERMIT ISSUANCE 10.00 FLOOD ZONE A.LU.C.
PLC, CONTR. LIC. NO, PLG.
YTOTAL
COMPENSATION INSURANCE
This section need not be completed if the permit is for one
N Y N
QTY MECHANICAL PERMIT FEE FEE SUMMARY
hundred dollars (S 100) or less.)
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 10)00C.F.M.) 4.00
AIRHANDLINGUNIT(OVER10=C.F.M.) 6.00 SEISMIC FEECONSTRUCTIONLENDINGAGENCY
I hereby affirm that there is a construction lending agency for EXHAUST HOOD (WITH DUCT) 5.00
theeConriance of the work for which this permit is issued (Sec. MICROFILM
HEATING UNIT (TO 100,000 B.T.U.) 8.00
H EATI NG UNIT (OV ER 100,000 B.T.U.) 9.50 ELECTRIC
Lender's Name
Lender's Address
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 lover 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
CONST, TAX
PERMIT ISSUANCE 10.00
grant of this permit. MECH. CONT. LIC. N0. MECH.
TOTAL
TOTAL
Signature of App 'cant/Contractor Date
OFFICE COPY