09533 (2)APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
oirz Foo
cr wUF2 W
0
N z_
yew
Lr R Wa0
F W O QyNJ
Cc M O 0
a X o u¢ w m N
zr
fie
ir r o
a $
W,
i'
11 , BUI LSI NG PROJECT I DENTI FICATION
APPLICATION & PERMIT
BUILDINGMAW - ELECTRICAL- PLUMBING -MECHANICAL
PERMIT NUMBER
09533
BUILDING
ADDR s
a. IAS
NAME `
4 C/g' CITY. ELECTRIC PERMIT FEE
PLAN CHECK VALIDATION
PHONEv r
CONTRACTOR'S
N E OUTLETS -SWITCHES - RECEP 10.0011.00
LIGHTING FIXTURES 10.0011.00ae.No.
CONTRACTOR'S
ADDRESS- Daess APPLIANCES- RESIDENTIAL 4.00
PANELS 10.00PHONE DATE OF APPLICATION
acHITECTPANELS
RRENGINEER
LIC. NO.
OVER 200 AMP) 2000
PLAN CHECK FEE P.C. NO.
SIGNS TRANS. .3,00
ARCH
ESS ENG,
ZIP
SPECIAL CIRCUIT 5,00 PERMIT VALIDATION
PAID
AUGSERVICE
TEMP. METER OR POLE INS. 20.00
APPLICANT'S
AUDREss
MOTORS SEE FEE SCH,
CHANGE 20.00 G 2 a y
v;
I S
ISSUJQ 6IFT limpffnif
LICENSED CONTRACTORS DECLARATION
1 hereby affirm thal i am licensed under provisions of Chapter 9
TEMP. POLE 30.00
commencing with Section 7000) of Division 3 of the Business and
Professions Co , an license is in full force apJj f t90LicenseassLie. Number ca] L-
Date '" Contractor
BLDG. ELECT. PL .
INFORM TION
BUILDING @ [MIT
OWNER -BUILDER DECLARATIONREFERenIherebyaffirmthatIamexemptfromtheContractor's Licse
Law. for the following reason. (Sec. 7031.5, Business and 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 Fide a signed statement that
he is licensed pursuant to [lie provisions of the Contractor's License
MISC. - TO ORD
VALUATION
PERMIT ISSUANCE 10.00
ELEC. CONTR. LIC. NO. ELEC.
TOTAL PERM TO
QTY. PLUMBING PERMIT FEE
Law (Chapter 9 (commencing with Section 7000) of Division 3 oft he
Business and Professions Code) or that he is exempt therefrom and
the basis for the alleged exemption. Any violation of Section 7031.5 STORIES TYP NSTR.
by any applicant fora permit subjects the applicant toacivilpenalty
of not more than five hundred dollars (5500).): ALTER -DRAIN &VENT -WATER (EA.) 5.00
1, as owner of the property, or my employees with wages asBACKFLOW
their sole compensation, will do the work, and the structure is not
PROTECT. DEVICE 4.00 OCC. GROUP RES. UNITS
DRAINS -FLOOR, ROOF, AREA,COND. 5.00intendedorofferedforsale (See. 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-
mentsare not intended oroffered for sale. If. however, the building
IF IXTURES - PER TRAP 5.0D 50, FT. FLOOR AREA TOTALACREAGE
GAS-EA.SYSTEM-11NC.40UTLETS 6.00
or improvement is sold within one, year of completion, the owner- wner
builder will have the burden of'proving that he did not build or im- builder
prove for purpose of sale;).
O 1, as owner of the property, am exclusively contracting with
GAS EA. SYSTEM OVER 4 (EA.} 2.00 BUILDING USE
R IND CON PB Other
INDUSTR IAL WASTE INTER. 30.00
LAWN SPRINKLERS- 1 INC 5 V.B. 6.00licensedcontractorstoconstructtheproject (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
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. 200ft/10.00 a
TRACT No: PARCELNO.
am exempt under Sec. B.&P.C. for this WATER HEATER WJVENT 6.00 00
reason
Owner Date WATER SYSTEM 5.00 Viz ACC. DATE ACC. FILE N0.
WATER TREATING EQUIP. 5.00WORKERS'COM PENSATION DECLARATION
I hereby affirm that I. have a certificate of consent to selFinsure.
or a certificate of Workers' Compensation Insurance, or a certified ZONING ENG. SITE NO,
copy thereof (Sec. 3800, Lab.C.),
Policy No. Company
FIRE SPRINK
Y N
ENERGY T-24
Y No
Sertified copy is hereby furnished.
plidhertified
s rled wi the city inspection division.
Apphc
cr
l1r tF-1
MISC. - REFER TO ORD.
CERTIFICATE OF EXEMPTION FROM WORKERS' PERMIT ISSUANCE 10.00 FLOOD ZONE A.L.U.C,
PLG: CONTR. LIC. NO. PLG. (
OTALTv
COMPENSATION INSURANCE
This seclion need not be completed if the permit is for one
hundred dollars ($100) or less.)
1 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
Y N Y N
QTY. MECHANICAL PERMIT FEE FEE SUMMARY
BUILDING
become subject to the Workers' Compensation Laws of California.
Date Applicant
NOTICE TO APPLICANT: If, after making this Certificate of Ex-
ALTER OR ADD TO MECH. 5.00
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 1OX0C.F,M.) 4.00
AIR HANDLING UNrr(OVER 10JMC.F.M.) 6.00 SEISMIC FEECONSTRUCTIONLENDINGAGENCY
I hereby affirm that there is a construction lendingagency 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 LTO 100,OD0 B:T.U_} 8.00
HEATING UNIT (OVER 100,000 B.T.U.19.50 ELECTRIC
Lender's Name
Lender's Address
I certify that I 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
VENTILATION FAN (SINGLE) 4,00
PLUMBING Q
BOILER- COMPO H.P. or 100,000 B.T.U.) 6.00
BOILER -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 whichCONST.
may in any way accrue ainst said City in consequence of the
grant' of I permit.
TAX
PERMIT ISSUANCE 10.00
MECH, CONT. LIC. NO, MECH.
TOTAL
TOTAL
Si o K pK rant/ ontracto Dat
OFFICE COPY