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APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
BUI LDING PROJECT I DENTI FICATI
APPLICATION &PERMIT
BUILDING - ELECTRICAL- PLUMBING -MECHANICAL
PERMIrNun1BER
n n
r r
BUILDING
ADDRESS '/
7^ eQ n -1
OwNER'S r _
NAME T
PHONL, {I -I t3I
QTY. ELECTRIC PERMIT FEE
PLAN CHECK VALIDATION
DATE OF APPLICATION
CONTRACTOR'S
NAMEWNAME + /
ec_Ar71Cn. LIc.NO.dJ QQ6
Lqy OUTLETS - SWITCHES -RECEP 10,0011.00 d A0
LIGHTING FIXTURES 10-0011.00,..,73.02.3
CONTRACTOR'SORf6TORS S sgn 2 G
dso AlrGXubge> PHONE / 3 1.30006
PPLIANCES-RESIDENTIAL 4.00 OD
PANELS 10.00 Q•
ARCHITECT
OnENGINEER
LIC. NM
PANELS (OVER 200 AMP) 20.00
PLAN CHECK FEE P.C. NO.
ISIGNSTRANS. 3.130
ADnR'ESSs ENG. SPECIAL CIRCUIT 5.00 PW uR DATION
TEMP. METER OR POLE INS. 20.00ZIP
OCTI119855
Cif1 Of Cupertino
APPLICANTSDDRESSTS
r , San ya
MOTORS r G, , SEE FEE SCH. , 00
SERVICE CHANGE 20.00
LICENSED CONTRACTORS DECLARATION TEMP, POLE 30.00
I hereby affirm that I am licensed under provisions of Chapter 9
commencing with Section 70(10) of Division 3 of the Business and
Professions Code n y license ism full fore of ct
License lass Lic. Number
ISSUANCE DATE
BLDG. ELE PLG. MECH.
Dafe P Contractor
BI1 LD G PERMIT
INFORMATIONOWNER -BUILDER DECLARATION
1 hereby affirm that i am exempt from the Contractor's License
Law for the following reason. (Sec. 703 1.5, Businessand Professions
Code: Any city or county which requires 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
MISC. - REFER TO ORD
VALUATION SIFT.
PERMIT ISSUANCE 10.00 Q, oD
ELEC, CONTR. LIC, LA0.
1/ ,
ELEG.
TOTAL 7 ' D
p MIT 70
QTY. PLUMBING PERMIT FEE
Law (Chapter 9 (commencing with Section 7000) of Division 3 of the
Business and Professions Code) or that he is exempt therefrom and
STORIES TYPE CONSTR. the basis for the alleged exemption. Any violation ofSection7031.5
by any applicant fora permit subjects the applicant toaeivilpenalty
of not more than five hundred dollars (S500).): ALTER•DRAIN&VENT-WATER(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 We (Sec_ 7034, Business and Professions
BACK FLOW PROTECT. DEVICE 4,00 OCG GROUP RES. UNITS
DRAINS-FLC)OR, ROOF, AREA, COND. 5.00
Code: The Contractor's License law docs 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 -
mems 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 I N C. 4 OUTL ETS 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 Cor purpose of sate.).
LI1, as owner of the property, am exclusively contracting with
GAS - EA. SYSTEM -OVER 4 IEA.} 2.130 suILOING USE
RES IND CON Pe Otner
I NDUSTR IA L WASTE I LATER. 30.00
LAWN SPRINKLERS 1 INC 5 V.B. 6.00 ASSESSORS PARCEL NO. 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 - OVER 6 IEA.) 1.00
contracts for such projects with a conlraclor(s) licensed pursuant to
the Contractor's License Law.TRACTSEWER -SANITARY -STORM EA. 200h110.00 NO. PARCEL NO.
I am exempt under Sec. BA P.C. for this WATER HEATER WNENT 6.00
reason
Owner Date WATER SYSTEM 5.00 ACC. DATE ACC. FILE NO.
WATER TREATING EQUIP, 5.00WORKERS'COMPENSATLON DECLARATION
I hereby affirm that I have a cerlificate of consent to self -insure,
or a certificate of Workers Compensation Insurance, or a certified ZONING ENG. SITE LA0.
copytbSgi f
uhp
r
nyPoliny
Certified copy is hereby furnished.
Certified Ep pnyy is led wr q the city. inspection division.
Applicant rrr,z-V r r -C •
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.L.U.C.
ALG. CONTR, LIC, NO. PLG.
TOTAL
COMPENSATION INSURANCE
This section need not be completed if the permit is for one
Y NE] Y N
QTY. MECHANICAL PERMIT FEE FEE SUMMARY
hundred dollars (S 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
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 10SWC.F.M.1 4,00
AIR HANDLING UNIT (OVER 10=C.F.M.) 6.001 SEISMIC FEECONSTRUCTIONLENDINGAGENCY
I 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
HEATING UNIT (OV ER 100,000 B.T.U.}9.50 ELECTRIC
Lender's Name
Lender's Address
I certify that 1 have read this application and state that the aboveVENTILATION
information is correct. I agree to comply with ail city and county
ordinances and state laws relating to building construction, and
FAN (SINGLE) 4.00
PLUMBINGBOILERCOMP (3 H.P. or 100 000 B.T.U.) 6.00
BOILER -COMP (Over 100,0013 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 which
may in any way accrue ainst said City in consequence of the
grantin of this permit.
a 3.8S
CONST. TAX
PERMIT ISSUANCE 10.00
MECH. CONT. LIC. NO. MECH.
TOTAL
TOTAL
Signature of ApplicantTContractor Date
OFFICE COPY