09606 (2)APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
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BUI LDI NG PROJECT I DENTI FICAT10N
APPLICATION & PERMIT
BUILDING - ELECTRICAL -PLUMBING -MECHANICAL
PERMIT NUMBER
09606BUILDINGADDRESS
X .6~
OwNER'S
NAME
QTY, ELECTRIC PERMIT FEE'
PLAN CHECK VALIDATION
HON -/
Car•IrRAcrDH's
NAME OUTLETS - SW ITCHES - R ECEP 10.00/1.00
LIGHTING FIXTURES 10.0011.00LIC.NO. -R -s7/_449
CONTRACTOR'S
ADDRESS
PPLIANCES- RESIDENTIAL 4.00
PANELS 10.007N /, 9 DATE OF APPLICATION
ARCHITECT
i
ORENGINEER
LIC. No.
PANELS (OVER 200 AMP) 20.00 Pt-ANCHECKFEE P.C. NO.
SIGNS TRANS. 3.00
AARCH.
OilDDRESS ENG SPECIAL CIRCUIT 5,00SERM IOATION
EMP. METER OR POLE INS. 20.00ZIP SEP a 1985APPLICANT'S
AOORESS
MOTORS SEE FEE SCH.
SERVICE CHANGE 20.0037A91 Of Cupertino
LICENSED CONTRACTORS DECLARATION TEMP. POLE 30.00
I hereby affirm that I am licensed under provisions of Chapter 9
commencing with Section 7000) of Division 3 of the Business and
Professions Code, and m license is in full force and eff et.
Licenst Jac 6 c. Number Q
ISSUANCE DATE
BLDG, ELECT.
I
PLG. I PUC
Nfi
Date ontractar
BUILDING PERMIT
OWNER -BUILDER DECLARATION
I hereby affirm that 1 aexempt from the Contractor's Licensem
Law for the following reason. (Sec. 7031.5, Business and Professions
Code: Any city or counly which requires permit to Construct, alter,
improve, demolish, or repair any structure, prior to its issuance, also
requires the applicant for such permit to rile a signed statement that
he is licensed pursuant to the provisions of the Contractors License
INFORMATION
MISC. - REFER TO ORD
VALUATION SIFT.
PERMIT ISSUANCE 10.00
ELEC. CONTR, LIC. NO, ELEC,
TOTAL IT T
CITY, PLUMBING PERMIT FEE
Law (Chapter 9 (commencing with 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 STORIES TYPE CONSTR.
ALTER -DRAIN &VENT WATER IEA.) 5.00byanyapplicantforapermitsubjectstheapplicanttoacivilpenalty
of not more than five hundred dollars (S500).):
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 (See. 7044, Business and Professions
Code: The Contractor's Licensc 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 sale. If, however, the building
F IXTUR ES - PER TRAP 5.00 50, 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 contracting with
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
GAS EA. SYSTEM -OVER 4 (EA.) 2.00 BUILDING USE
INP CON PB Other
3 INDUSTRIAL WASTE INTER. 30.00
LAWN SPRINKLERS - 1 INC 5 V.B. 6.00 ASSESSORS PARCEL NO.
LAWN SPR INKLERS - OVER 5 (EA.) 1.00
contracts for such projects with a contractor(s) licensed pursuant to
the Contractor's License Law. SEWER SAN ITARYSTORM EA, 200ft/_ 10.00 TRACT ND. PARCEL NO.
l am exempt under Sec. BAP.C. for this WATER HEATER WIVENT 6.00
reason
Owner Date WATER SYSTEM 5.00 ACC. DATE AGC. F [LE N0.
WATER TREATING EQUIP. 5:00WORKERS'COMPENSATIONDECLARATION
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 NO.
copy thereD Sea 3800 Lab -C
Polic o.mpany.
V'/Certified copy is hereby famished.
ertitied copy is fled with the city inspection division.
Applicant
FIRESPRINK
Y N
ENERGY T-24
Y N 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 Y N
MECHANICAL PERMIT FEE FEE SUMMARY
hundred dollars (S 100) or less.)
1 certify that in the performance of the work for which this per -QTY.
mit is issued, i shall not employ any person in any manner so as to
become subject to the Workers Compensation Laws of California.
Date Applicant
NOTICE TO APPLICANT: if, after making this Certificate of Ex-
BUILDING
ALTER OR ADD TO MECH. 5.00
APPLIANCE 5.00 PLAN CHECK
FEE
emplion, you should become subject to [he Workers' Compensation
provisions of We Labor Code, you must forthwith comply with
such provisions or this permit shall be deemed revoked. AIR HANDLING UNIT (TO 10DWC F.M.) 4.00
AIR HANDLING UNIT (OVER 10PIX)C.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 .g oD
MICROFILM
HEATING UNIT (TO 100,000 B.T.U.) 8.00 pv
HEATINGUNIT(OVER100,000H.T.U.)9.50 ELECTRIC
Lend"" Name
Lender's Add.' ,
1 certify that 1 have rc ffi app ILation 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 p-va
PLUMBING
rBOILER -COMP (3 H.P. or 100,000 e,T.U.) 6.00
BOI LER-COMP (Over 100,000 BTU) SEE FEZ: 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 p.dd
granting of this permit. MECH. CONT. LIC. NO. MECH.
TOTAL a o TOTAL
13ignbture of ApplicantlContractor Date
OFFICE COPY