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APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE B'POINT PEN ONLY
BUILDING PROJECT IDENTIFICATION
APPLICATION & PERMIT
BUILDING - ELECTRICAL -PLUMBING -MECHANICAL
PERMIT NUMBER
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9J 372
BUILDING
OWNER'S-/
NAME !t
PHONE5-'% u I
QTY. ELECTRIC PERMIT F££
PLAN CHECK VALIDATION
DATE OF APPLICATION
CONTRACTOR'S
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11 LIC.NOfJ 4FI> f
UTLETS -SWITCHES - REC£P 10,001.1,00
LIGHTING FIXTURES 10.0011.00
CADDRESSON RACTOR'S hH
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L3 -4,A 1pfJ PHONE ajl-3P}
APPLIANCES - RESIDENTIAL 4.00
PANELS 10.00 d
ORENGINEER
LOC. No.
PANELS PANELS (OVER 200 AMP) 20.00
PLAN CHECK FEE P.C. NO.
SIGNS TRANS. 3.00
AARCH.
ORDDRESS ENG.
ZIP
SPECIAL CIRCUIT 5,00 PERMITVALIDATION
P+JD
a7S
Cit of mertino5ANCEATE
EMP. METER OR POLE INS. 20.00
APPLICANT'SMOTORS
ADDRESS
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SES FEE SCH.
SERVICE CHANGE 20.00
LICENSED CONTRACTORS DECLARAtt6N
1 hereby affirm that I am licensed under provisions of Chapter 9
commencing with Section 7000) of Division 3 of the Business and
Professions Cade• d y license is in full fort fre
License Class f
ce
Lic, Number
Date
1Z 01_;?_
Contractor
OWNER -BUILDER DECLARATION
1 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 cou my 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 Cade)' or that he is exempt therefrom and
the basis for the alleged 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 ($500),);
1, as owner of the property, or my employees with wages as
their sole compensation, will do the work, and the structure is not
intended or offered for sale (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 sale, If, however, the building
or improvement is sold within one year of completion, the owner-
builder will have the burden of proving that he did not build or iin-
prove for purpose of sale.).
El 1, 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
contracts forsuch projects with a contractor(s) licensed pursuant to
the Contractors License Law.
0 1 am exempt under Sec. ,S.&P.C.for this
reason
TEMP. POLE 30.00
BLDG, ELE T. PLG. MECH.
BUIL PERMIT
N RMATION
MISC. - REFER TO ORD
VALUATION lFT.
PERMIT ISSUANCE 10.00 Q"
ELE . CONTR. L[G. NO.
1 y
GUf
ELEC.
TOTAL ER I7 7
KQTY. PLUMBING PERMIT FEE
STORIES TYPE CONSTR.
ALTER-RAIN&VENT-WATER{EA.) 5.00
BACK FLOW PROTECT. DEVICE 4.00 OCC. GROUP RES. UNITS
DRAINS -FLOOR, ROOF, AREA, COND. 5.00
FIXTURES -PER TRAP 5.00 SO. FT. FLOOR AREA TOTALACREAGE
GAS- EA. SYSTEM -1 INC.4 OUTLETS 6.00
GAS - EA. SYSTEM - OVER 4 (EA.) 2.00 BUILDING USE
R IND CON PB Other
INDUSTRIAL WASTE INTER, 30.00
LAWN SPR INKLERS-1 INC5 V.B. 6.00 ASSESSOR5PAHCELNO.
LAWN SPRINKLERS - OVER 5 (EA.) 1.00
SEWER -SANITARY -STORM EA. 2001tl10.00 ACT NO. PARCEL NO.
WATER HEATER WJVENT 6.00
Owner + %
j(
Date
5JM%6/PL4t6'1%C9 NSATION DECLARATION
1 hereby affirm that ! have a certificate of consent to self -insure,
ora certificate of workers' Compensation Insurance, or a certified
copy thereof (Sec. 3600, Lab.C.)•
Policy No. Company
0 Certified copy is hereby furnished.
pf Cerilfi P l with therc nspection division,
Applicant y , 1
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
This sec[ion need not be completed If the permit is for one
hundred dollars (S 100) or less.)
I certify that in the performance or ihe.work for which this per-
mit is issued, 1 shall not employ any person in any manner so as to
become subject to the Workers Compensation Laws of Catifotni:i.
BUILDINGDateApplicant
WATER SYSTEM r 5.00 ACC. DATE ACC. FILE NO.
WATER TREATING EQUIP 5.00
ZONING ENG. SITE NO,
FIRE SPRINK
Y N
ENERGY T-24
Y N MISC. REFER TO ORD.
PERMIT ISSUANCE 10.00 FLOOD ZONE
Y N
A.L.U.C.
Y t, 11
PLG. CONTR, LIC. NO. PLG,
TOTAL
QTY. MECHANICAL PERMIT FEE FEE SUMMARY
ALTER OR ADD TO MECH. 5.00
NOTICE TO APPLICANT: If, after making this Certificate of Ex-
emption, you should become subject to the Workers' Compensalion
provisions of the Labor Code, you must forthwith comply with
such provisloris or this permit shall be deemed revoked.
CONSTRUCTION LENDING AGENCY
hereby affirm drat there is a construction lending agency for
the performance of the work for which this permit is issued (Sec.
3097, Civ.C.).
Lender's Name
APPLIANCE 5.00 PLAN CHECK
FEEAIRHANDLINGUNIT (TO 10A00QF, NQ 4.00
AIR HANDLING UNIT (OVER 10p00C•F.M.) 6.00 SEISMIC FEE
EXHAUST HOOD (WITH DUCT) 5.00
MICROFILM
HEATING UNIT (TO 100,000 B.T.U.) 8•00
H EATING UNIT (OV ER 100,000 B.T.U.) 9.50 ELECTRICLender's Address
I certify that 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
hereby authorize representatives of this city to enter upon the
above-mentioned property for inspection purposes.
We) agree to save, ' demnify and keep harmless the City of
Cupertino against Iia 'ties, judgments, costs and expenses which
may in any way erste againdpid City in consequence of the
grant' it. (%ECH.
VENTILATION FAN (SINGLE) 4,00
PLUMBING
BOILER-COMP(3 H.P,or 100,000 B.T.U,) 6.00
BOILER -COMP (Over 100,0017 BTU) SEE FEE SCH. MECHANICAL
MISC. - REFER TO ORD,
CONST. TAXPERMITISSUANCE10.00
CONT. LIC. NO. MECH,
TOTAL
TOTAL
Signa o Applicant/Contractor to
OFFICE COPY