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APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
BUI DDI NG PROJECT IDENTIFICATION yAPPLICATION PERMIT
BUILDING --ELECTRICAL— PLUMBING — MECHANICAL
PERMIT NUMBER
nSUNINGAt1URESs
a
OWNER'
S ,
r 7
7 Y // PHONE
QTY. ELECTRIC PERMIT FEE
PLAN CHECK VALIDATION
DATE OF APPLICATION
CONTRACTOR'
S5
NAME
LIC. No. ,f (,q,
jy OUTLETS -SWITCHES - RECEP 10.00/1,00 97,00
LIGHTING FIXTURES 10.0011.00 ;'Q,O
onEss OR's , Ila le
15-0 PHONE 73-L-Mb0
3 PPLIANCES - RESIDENTIAL 4,00 a, 00
IPANELS 10.00 00
ARCHITECT
ORENGINEER
LIC. NO.
PANELS(OVER 200 AMP) 20,00
PLAN CHECK FEB P.C.NO.
SIGNS TRANS. 3.00
ADDRESS ENG. SPECIAL CIRCUIT S.Qp PERMIT VALIDATION
TEMP. METER OR POLE INS. 20.00ZIP
o r+
ADDRESSTs MOTORS r"'(_r , SEE FEE SCH, 7,00
SERVICE CHANGE 20.00, 0
I
0 /rG [t}pp
a .
1
7
r
r
LICENSED CONTRACTORS DECLARA ON TEMP. POLE 30,00
1 hereby affirm that I am licensed under provisions of Chapter 9
n.. AbAJdt5m
commencing with Section 7000) of Division 3 of the Business and
Professions Code nd m license is in full far of t.
License Class Lic. Number
BLDG. EC - ALG. MECH.
Date Contractor - r# e
BU! E
INORMARMATIONOWNER -BUILDER' DECLARATION
hereby affirm that 1 am exempt from -[he Contractor's License
Law for the following reason. (Sec. 7031.5, Business and Professions
Coder Any city or county which requiresa 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 thai/.'-f-
he is licensed pursuant to the provisions of the Contractor's License
MISC. — REFER TO ORD
VALUATION SFT.
PERMIT ISSUANCE 10.00/0.0,0
ELEC. CONTR. ! LIC. NO. ELEC.
c c.r 3 TOTAL O0 IT TO
CITY. PLUMBING PERMIT FEE
Law (Chapter 9 (commencing with Section 7000) of Division 3 of"'
Business and Professions Code) or that he is exempt therefrom and
STORIES TYPE CONSTR. the basis for the alleged exemption. Any violation Cf Section 7031.5 J
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
1, 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
intended or offered for sale (Sec. 7044, Business and Professions DRAINS -FLOOR, ROOF, AREA,COND. 5,00
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 imprave-
ments are not intended or offered for sale. If, however, the building
FIXTURES - PER TRAP 5.QO Sa FT. FLOOR AREA
I
TOTAL ACREAGE
NGAS - EA. SYSTEM -1 1 NC.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 (Sec. 7044, Business
and Professions Code: The Contractor's License Law does not apply
toan owner of properly who builds or improves thereon, and who
GAS - EASYSTEM -OVER 4 (EA) 200 BUILDING USE
NO CON PB other
ASSESSORSPARCELNO.,
INDUSTRIAL WASTE INTER. 30.00
LAWN SPR INKLERS-11 INC5 V.B. 6.00
LAWN SPR IN KLERS - OVER 5 (EA.) 1.00
contracts for such projects with a coniractor(s) licensed pursuant to
I Contractor's License Law. SEWER SANITARY.STORM EA, 20pft/10.00 TRACT NO. PARCEL NO.
lam exempt under Sec. B.&P.C. for this WATER HEATER WNENT 6.00
reason
Owner Date WATER SYSTEM 5.00 ACC. GATE ACC: FILE N0.
WORKERS`COMPENSATION DECLARATION WATER TREATING EQUIP, 5.00
hereby affirm that 1 have a certificate of consent to self -insure,
or a certificate of Workers' Compensation Insurance, or a certified
ZONING ENG. SITE NO.
copy Cher f ( ec. 3 p,
Policy N C 1rryptf$t'
Certified Copy IS hereby furnished.
Certified pyf js filed tG t
IcLty
inspection division.
A plicant
T i
FIRESPRINK
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.
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.)
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 ALTER OR ADD TO MECH, 5.00
NOTICE TO APPLICANT: If, after making this Certificate of Ex-
APPLIANCE 5.00 PLAN CHECKemption, you should became subject to the Workers Compensation
provisions of the Labor Code, you must forthwith comply with
such provisions or this permit shall be deemed revoked.
FEE
AIR HANDLING UNIT (TO 10=C.F.M.) 4,00
AIR HANDLING UNIT (OVER IOPMC.FM.) 6.00 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 (OVER 100,000 B.T.U.)9.50 ELECTRIC
Lender's Name
Lender's Address
I cerlify that I have read this application and state that the above VENTILATION FAN (SINGLE) 4.00
information is correct. 1 agree to comply with all city and county
ordinances and slate laws relating to building construction, and
PLUMBING
BOILER COMP (3 H.P. Or 100,000 B.T.U.) 6.00
BOILER -COMP (Over 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 which
may in any way accrue against said City in consequence of the
CONST. TAX
PERMIT ISSUANCE 10,00
gra - of this permlt. MECH. CONT. LIC. NO. MECH.
J0-3- TOTAL
TOTAL
SignaureofApplicant/ ontractor Date
OFFICE COPY