9375O
ZZ
O
CO
LU 7
O..
D Z
UO_
U_ I"
Ow
m
z
A
APPLICANT TO FILL IN INFORMATION WITHIN RED LINES— USE BALL POINT PEN ONLY
BUI LDI NG PROJECT I DENTI FICATION
APPLICATION & PERMIT
B ILDING — ELECTRICAL— PLUMBING —MECHANICAL
PERMIT NUMBER
9375BUILDINGADDRESS
7 !lL
nG
OWNER's
NAME
J J/'y
s{/S'
fC CFe l PHONE L!5-7/
CITY, ELECTRIC PERMIT FEE
PLAN CHECK VALIDATION
DATE OF APPLICATION
NaMea
1 .0 1eGfrrC LIC.N6.,;?8 6
O OUTLETS -SWITCHES -RECi=P 10.00/1.00/01/00
d73 LIGHTING FIXTURES 10.0011.00 .23-a
CONTRACTOR'S
ADDRESS StG/!/JI%CL t<
LSD //'G LUaa / PHONE c3
PPLIANCES- RESIDENTIAL 4.00
PANELS - 10,00 DO
ARCHITECT-
ORENGINEER
LIC. No.
PANELS (OVER 200 AMP) 20.00
PLAN CHECK FEE P.C, ND.
SIGNS TRANS. 3.00
ARCH. ORENG_
AADDRESS SPECIAL CIRCUIT 5.00 PF VALIDATION
tPAID,'
IT
TEMP., METER OR POLE INS. 20.00ZIP
fi
VrOcr, 11985
CRY of Gooertino
APPLICANT'S
ADDRESS
q?.SCi /.. stZ ,4 V ga
p MOTORS ;-QG , SEE FEE SCH. 00,
SERVICE CHANGE 20.00
LICENSED CONTRACTORS DECLARATION If TEMP. POLE 30,00
I hereby affirm that I am licensed under provisions of Chapter 9
commencing with Sc.CtiDn 7000) of Division 3,of the Business and
Professions Code nd m r license is in full for eff
License Class Lie. Number
ISSUANCE DATE
SLOG. ELECT PLG. MECH.
Date Contractor e
OWNER -BUILDER DECLARATION
I hereby affirm that ! am exempt from the Contractor's License
Law.for the following reason: (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 permil to file a signed statement. that pGheislicensedpursuanttotheprovisionsoftheContractorsLicense
BU LDING PERMIT
4 FORMATIONMISC. — REFER TO ORD
VALUATION SIFT:
PERMIT ISSUANCE 10.00 7, Op
ELEC. CO NTH. LIC, NO.
r •
ELEC. TOTAL
QTY. PLUMBING PERMIT FEE
Law (Chapter 9 (commencing with Section 7000) of Division 3 0"h'
Business and Professions Code) or that lie is exempt therefrom and
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-WA7ER(EA,) 5.00
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-
meats are not intended or offered for sale. If, however, the building
BACK FLOW PROTECT. DEVICE 4.00 OCC. GROUP RES. UNITS
DRAINS -FLOOR, ROOF, AR EA,COND. 5,00
FIXTURES - PER TRAP 5.00 SO" FT. FLOOR AREA1 TOTALACREAGE
GAS-EA.SYSTEM-1 INC.40UTLETS 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 Pe ocher
1:1 1:1 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- I INC 5 V.B, 6,00 ASSESSORS PARCEL NO. '
LAWN SPRINKLERS - OVER 5 (EA.) 1.00
contracts for such projects with a con tractor(s).licensed pursuant to
the Contractor's License Law. SEWER -SAN ITARY-STORM EA, 200ft110.00 TRACT NO. PARCEL NO.
lam exempt under Sec. B.&P.C. for this WATER HEATER W/VENT 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 conscnl to self -insure,
or a certificate of Workers' Compensation Insurance, or a certified ZONING ENG. SITE NO.
copyhe f(Sec. $pWaW ). Po ]ic ]It[e 7jCCadlffnn a rr
Q Cerci ted copy is}hereby furnished.
Cet o, t py "s filcd lllh city inspection dirision.
Applicant i-./ -!Pv
FIRESPRINK
y N
ENERGYT-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.
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($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 California.,
Date • Applicant
NOTICE TO APPLICANT: If, after making this Certificate of Ex-
emption, you should become subject to the Workers' Compensation
ALTER OR ADD TO MECH. 5,00
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 10pAOGF.M.) 4.00
AIR HANDLING UNIT (OVER 10)000C.F.M.)'6.00 SEISMIC FEECONSTRUCTIONLENDINGAGENCY
Ihereby 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 k.
MICROMLM
HEATING UNIT (TO 100,000 B.T,U,) 8.00
HEATING UNIT (OVER 100,000 B.T,U.)9.50 LECTRIC
Lender's Name
Lender's Address
I certify that I have read this application and stale that the above VENTILATION FAN (SINGLE} 4.00
information is correct. I agree to comply with all city and county
ordinances and state laws relating to building construction, and
PLUM811VG
BOILER -COMP (3 H.P. ar 100,000 B.T.IJ.) 8.00
lover 100,000 BTU) SEE FEE SCH. MECHANICALherebyauthorizerepresentativesofthiscitytoenterupon [heBOILER-COMPabove-mcnlioned property for inspection purposes.
MISC. - REFER TO ORD,
CONST. 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 10.00
grant'yN of this permit. G MECH.CONT. LIC. NO. MECH.
tC-10-??-til _[/ %D –3 -1p,-<
TOTAL
TOTAL
Signature of Applicant/Contractor Date
OFFICE COPY
f_