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APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
BUI LDI NG PROJECT I DENTI FICATIDN
APPLICATION &PERMIT
BUILDING - ELECTRICAL --PLUMBING - MECHANICAL
PERMIT NUMBER
9385BUILDINGADDRESSt
DO rn 2r ,e ,
QIRNER'S.`
NAME ' /U
ff
PHDNE%5 /- /.+ `%yJI
QTY. ELECTRIC PERMIT FEE
PLAN CHECK VALIDATION
n
DATE OF APPLICATION
CONTRACTOR'S
NAME,
G LIC,ND..ZLf6 F
97 UTLETS -SWITCHES- RECEP 10,0011,00 Oab/
JD LIGHTING FIXTURES 10.0011.00 0, O
CON CTOR'S ![
qn
ADDRESS /J V z A
PHO14E73 'V[/
PPLIANCES - RESIDENTIAL 4.00
PANELS 10.00 0',pp
ARCHITECT
OR
ENGINEER
LIC. NO.
PANELS (OVER 200 AMP) 20.00
PLAN CHECK FEE P.C. NO.
SIGNS TRANS. 3.00
ADARDCH.
ENG. SPECIAL CIRCUIT 5,00 PERMIT VALIDATION
EMP. METER OR POLE INS. 20.00ZIP
J U/-et APPLICANT'SMOTORS
ADDRESS f. SEE FEE SCH. 700
SERVICE CHANGE 20.00QacGq/ llp
LICENSED CONTRACTORS DECLARATION TEMP, POLE 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 and y license is in full force and eff cl. License lass t' Lic. Number
ISSUANCE DATE
BLDG. ELECT. PLG. MECH.
Date - Contractor
BUILDING PERMIT
INFORMATIONOWNER -BUILDER DECLARATION
I hereby affirm that I am exempt from the Contractor's License
Law for the followingreason.(Sec. 7031.5,Busincssand 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 Contractors License
Law (Chapter 9 (commencing with Section 7000) of Division 3 of the
Business and Professions Code) or that he is exempt therefrom and
MISC, - ) O ORD
VALUATION lFT.
PERMIT ISSUANCE 10.00 49,00
ELEC. CONTR, LIC, NO.
eG• 3
ELEC,
OQTOTAL PERMIT TO
TTQTY. 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 to a civil penalty
of not more than five hundred dollars (5500),): ALTER -DRAIN &VENT -WATER (EA.} 5.00
4 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 awn employees, provided that such improve-
ments are not intended or offered for sale. If, however, the building
FIXTURES - PER TRAP 5.00 FT. FLODR AREA TOTALACREAGE
GAS - EA. SYSTEM -1 I N C.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 Other
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.8- 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. 200ftl10,00 TRACT NO. PARCEL NO.
1 am exempt under Sec. , B.&P.C. for this WATER HEATER WIV ENT 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.
copythere ffSoc.3800 i Jl..).
Policy N e11 12 an
Certified copy is hereby furnished.
Certified co , is Iled t the city inspectlon division.
A pGcant-'a,'2 C / - r
FIRE SPRINK
Y N
ENERGY T•24
Y N MISC. - REFER TO ORD.
CERTIFICATE OF EXEMPTION FROM WORKERS'
PERMIT ISSUANCE 10.00 FLOOD ZONE A.LU.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
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 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' Compensation APPLIANCE 5.00 PLAN CHECK
provisions of the Labor Code, you must forthwith comply with
such provisions or this permit shall be deemed revoked.
FEEAIRHANDLINGUNIT (TO 1000 GF.M 1 4.00
AIR HANDLING UNIT (OVER 10MO C.F.M.) 6.00 SEISMIC FEECONSTRUCTIONLENDINGAGENCY
1 hereby affirm that there 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
H ING UNIT (OV ER 100,000 B.T.U.)9.50EAT ELECTRIC
Lenders Name
Lender's Address
I certify that i have read this application and stale that the above
information is correct. 1 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.
VENTILATION FAN (SINGLE) 4.00
PLUMBING
BOILER-COMP(3 H,P,Or 100,0008.T.U.) 6.00
BOILER COMP IOver 100,000 BTU) SEE•FEE SCH. MECHANICAL
MISC. - REFER TO ORD.
TAX
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 PERMIT ISSUANCE 10.()0JCONST.
gra>4g of this permit. MECH. CONT. LIC. NO. MECH,
J'O
TOTAL
TOTAL
Signature of Apphcan Contractor Date
OFFICE COPY