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APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
BISI LDI NG PROJECT I DENTI FICATIO
APPLICATION & PERMIT
BUILDING — ELECTRICAL— PLUMBING — MECHANICAL
PERMIT NUMBER
9394BUILDINGADDRESS ,
jIO9G •vC IIGrn S e r 40 P_
OWNER'S
NAME
4
r
T-LJCr 1y i . PHONE 6 1 1-\ A
QTY, ELECTRIC PERMIT FEE
PLAN CHECK VALIDATION
Q n
f
DATE OF APPLICATION
CONTRACTOR'S
NAM
L- LIC.NO. 11 *\3p6
l OUTLETS -SWITCHES -RECEP 10.0011.00 ,0a
Q LIGHTING FIXTURES 10.0011.00
CAOOTRRA TORIS S,y..l'31%3C&C, ( TfSSQ50 Bl PHONE ']3y3g0o
JAPPLIANCES -RESIDENTIAL 4.00
PANELS 10.00 p()
ARCHITECTPgNELS
ORENGINEER
LIc.ND.
OVER 200 AMP) 20.00
PLAN CHECK FEE P.C. NO.
SIGNS TRANS. 3.00
ADDRESS
ENG' SPECIAL CIRCU IT 5,00 PERMIT VALIDATION
EMP. METER OR POLE INS. 20.00ZIP
APPLICANT'S
l p -Q pakwWo k) p,L-e
rl MOTORS t--(;Vc C . SEE FEE SCH. rl ,0o
SERVICE CHANGE 20.00
LICENSED CONTRACTORS DECLARATION TEMP. POLE AVE)
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 forte and effect. License ClasC-- Lic. Numbe 7
Date NaContractor. t - -c—
ISSUANCE DATE
c 1DEC SLOG. ELECT.1
El
PLG.
El
I MECH.
CI Of Cupe finoOWNER-BUILDER DECLARATION
I hereby affirm that I am exempt from the Contractor's License
Law for the fotlowingreason. (Sec. 703 1.5, 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 file a signed statement that
he is licensed pursuant to the provisions of the Contractor's License
Law (Chapter 9 (commencing with Section 7000) ofPivision 3 of the
Business and. Professions Code) or that he is exempt therefrom and
BUILDING PERMIT
INFORMATION
MISC. — REFER TO ORD
VALUATION SIFT.
PERMIT ISSUANCE 10.00 - a0
EL`EC. CONT R. LIC. NO.
t't=IGCZe G 09318 1
ELEC. 00
TOTAL i ' PERMIT TO
E[r
QTY. PLUMBING PERMIT FEE
STORIES TYPE CONSTR. the basis for the alleged exemption. Any violation of5ection 7031.5
by any applicant for a permit subjects the applicant toacivil penalty
of not more than rive hundred dollars (S500)J: gLTER-DRAIN &VENT -WATER (EA.) 5,00
l7 1, as owner of the property, or my employees with wages as
their sole compensation, will do the work, and The structure is not
SACK FLOW PROTECT. DEVICE 4.00 Dec. GROUP RES. UNITS
DRAINS -FLOOR, FtOOF, 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-
ments are not intended or offered for sale. If, however, the building
FIXTURES - PER TRAP 5,00 SO 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.).
1, as owner of the property, am exclusively contracting with
licensed contractors to construct the project (Sea 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,OD BUILDING USE
RES IND CON PS Other
1:1 ElEl I NDUSTR IAL 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 contmetor(s) licensed pursuant to
the Contractor's License Law. SEWER -SANITARY -STORM EA. 20DR/1 D.OD TRACT NO. PARCEL NO.
am exempt under Sec. B.&P.C. for this
reason
WATER HEATER WJVENT 6.00
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 NO.
copy lltcr, e 3B,1I!
n1TI.,
ab.CJ.
Policy N] nl any
Certified copy is hereby furnished.
N1 Certified coy is f led with the city inspection division.
Applicant ti c G-C t_`[
FIRE $PRINK
Y N
ENERGY T•24
Y N MISC.- REFER TO ORD.
CERTIFICATE OF EXEMPTION FROM WORKERS' PERMIT ISSUANCE lo.001 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
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, I shall not employ any person in any manner so as to
BUILDING
become subject to the Workers' Compensation laws of Califomi3.
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 10=C.F.M.) 4.00
AIRHANDLINGUNIT (OVER 10p00C.F.M.) 6.00 SEISMIC FEECONSTRUCTIONLENDINGAGENCY
I hereby affirm that there is a construction lending agency for EXHAUST HOOD (WITH DUCT) 5.00
3097eCo.
C).
of the work for which this permit is issued (Sec. MICROFILM
HEATING UNIT (TO 100,000 B.T.U.) B.00
H EATING UNIT (OV ER 100,000 B,T.U.)9.50 ELECTRIC
Lender's Name
Lender's Address
I certify that I have read this application and state that the above VENTILATION FAN (SINGLE) 4.00
information is correct. l agree to comply with all city and county
ordinances and state laws relating to building construction, and
PLUMBING
BOILER- COMM H.P. or 100,000 B.T,U.) 6.00
BOILER -COMP ,(over 10D,000BTU) SEE FEESCFt. MECHANICALherebyauthorizerepresentativesofthiscitytoenteruponthe
above-mentioned properly 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 rue against said City in consequence of the
tin f this pe it.
L?= q _5&e,
CONST. TAX
PERMIT ISSUANCE 10.00
MECH, CONT. LIC. NO. MECH.
TOTAL
TOTAL
Signatu Applicant[ontractor Date
OFFICE COPY