6264OFFICE COPY
APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
BUILDING PROJECT IDENTIFICATION
BUILDING
ADO RE
APPLICATION & PERMIT
PERMIT NUMBER
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OWNER'x1
BUILDING - ELECTRICAL- PLUMBING - MECHANICAL
6264
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CHECK VALIDATION
PHONE
CONTRACTOR'S
NAME 12 S7 - �.,1
� UTLETS - SWITCHES - RECEP 5.00/1.003
LIC. NO. 1 Z/
LIGHTING FIXTURES 5.00/1.00
CONTRACTOR'S
ADDRESS .�8 .Si4�{/Q/0 �:
- RESIDENTIAL 4.00
/� O°I rYS 9.S0 PHONE �7Z7
-APPLIANCES
PANELS
ARCHITECT
OR
5'00
DATE OF APPLICATION
ENGINEER
SIGNS 6.00
PLAN CHECK FEE P.C. NO.
LIC. No.
H. OR ENG.
SIGNS TRANS. 3.00
ESS
SPECIAL CIRCUIT 55.00
PERMIT VALIDATION
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ZIP
ICANT'S
EMP. METER OR POLE INS. 15.00
ESS /
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MOTORS SEE FEE SCH.
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LICENSED CONTRACTORS DECLARATION
SERVICE CHANGE 10.00
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hereby affirm that 1 am licensed under provisions of Chapter 9
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(commencing with Section 7000) of Division 3 of the Business and
Professions Codeand
ISSUANCE DATE
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rwy cense is in full fo�P �ct�'
en 1 Lin. Number
BLDG. ELECT. PLG. MECH.
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Date Contractor
❑ ❑ ❑ ❑
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OWNER - BUILDER DECLARATION
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1 hereby affirm that 1 am exempt from the Contractor's License
Law for the following reason. (Sec. 703 1.5, Business Professions
MISC. - REFER TO ORD
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and
Code: Any city or county which requires a permit to construct, alter,
improve,
PERMIT ISSUANCE 6.00
VALUATION S /FT.
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demolish, or repair any structure, prior to its issuance, also
requires the applicant for such permit to file
ELEC. CONTR. LIC. NO.
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a signed statement that
he is licensed pursuant to the provisions of the Contractor's License
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Law (Chapter 9 (commencing with Section 7000) of Division 3 of the
Business and Professions Code) or that he is exempt therefrom and
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the basis for the alleged exemption. Any violation of Section 7031.5
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by any applicant for a permit subjects the applicant to a civil penalty
STORIES TYPE CONSTR.
of not more than five hundred dollars ($500).):
ALTER -DRAIN &VENT -WATER (EA.) 4.00
❑ 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 2.00
intended or offered for sale (Sec. 7044, Business and Professions
Code: The Contractor's License Law does not apply to
DRAINS - FLOOR, ROOF, AREA,COND. 4.00
OCC. GROUP RES. UNITS
an owner of
property who builds or improves thereon, and who does such work
himself or through his own employees, that
FIXTURES - PER TRAP 4.00
provided such improve-
ments are not intended or offered for sale. If, however, the building
improvement
GAS - EA. SYSTEM -1 1 NC. 4 OUTLETS 4.00
So. FT. FLOOR AREA TOTAL ACREAGE
or is sold within one year of completion, the owner -
builder will have the burden of proving that he did not build or im-
GAS - EA. SYSTEM - OVER 4 (EA.)
prove for purpose of sale.).
1,00
BUILDING USE
❑ 1, as owner of the property, am exclusively contracting with
licensed contractors to
INDUSTRIAL WASTE INTER. 20.00
RES IND CON PB Other
❑
construct the project (Sec. 7044, Business
and Professions Code: The Contractor's License Law
LAWN SPRINKLERS - 1 INC 5 V.B. 5.00
❑ ❑ ❑ ❑
does not apply
to owner of property who builds r improves thereon, and who
LAWN SPRINKLERS - OVER 5 (EA.)
ASSESSORS PARCEL NO.
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contracts for such projects with a contractor(s) licensed pursuant to
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1.00
the Contractor's License Law.
SEWER- SANITARY -STORM EA. 200ft /8.00
❑ 1 am exempt under Sec. B. &P.C. for this
TRACT N0. PARCEL NO.
reason
Owner
WATER HEATER W /VENT 400
Date
WATER SYSTEM 4•00
WORK ERS'COMPENSATION DECLARATION
WATER TREATING EQUIP.
ACC. DATE ACC. FILE NO.
I hereby affirm that I have a certificate of consent to self-insure,
4.00
or a certificate of Workers' Compensation Insurance, or a certified
Polic No.
Policy No. S ' 800, /1y�L /1��
ZONING ENG. SITE NO.
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❑ Certi -' op is her furni
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Certi ied is led a cit Yn a t'on division.
plicant
MISC.
FIRE SPRINK ENERGY T-24
y
REFER TO ORD.
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C IFICATE OF EXEMPTION FROM WORKERS'
PERMIT ISSUANCE 6.00
FLOOD
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COMPENSATION INSURANCE PLG.
CONTR. LIC. NO.
ZONE A.L.U.C.
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hundred section need not be completed if the permit is for one
hundred dollars
PLG.
TOTAL
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($100) or less.)
certify that in the performance of the work for which this per-
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mit is issued, 1 shall not employ any person in manner so as to
any
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become subject to the Workers' Compensation Laws of California.
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Date Applicant
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NOT ICE TO APPLICANT: If, after making this Certificate of Ex-
ALTER OR ADD TO H.
MECH 4 00
BUILDING �O CD
emption, you should become subject to the Workers' Compensation
provisions of the Labor Code, you must forthwith comply with
APPLIANCE 4
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PLAN CHECK
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such provisions or this permit shall be deemed revoked.
AIR HANDLING UNIT (TO 10=C.F.M.) 3.00
FEE
CONSTRUCTION LENDING AGENCY
I hereby affirm that there is
AIRHANDLINGUNIT(OVER 10=C.F.M.) 5.00
SEISMIC FEE
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a construction lending agency for
the performance of the work for which this permit is issued (Sec.
EXHAUST HOOD (WITH DUCT) 0
2.0
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3097,rs Na me ).
Lender's Na
HEATING UNIT (TO 100,000 B.T.U.) 4.00
MICROFILM
Lender's Address
HEATING UNIT (OVER 100,000 B.T.U.)7.50
1 certify that I have read this application and state that the above
information
VENTILATION FAN (SINGLE) 3.00
ELECTRIC
is correct. 1 agree to comply with all city and county
ordinances and state laws relating to building construction, and
BOILER - COMP (3 H.P. or 100,000 B.T.U.) 4.00
PLUMBING
hereby authorize representatives of this city to enter upon the
above - mentioned property for inspection purposes.
BOI LER -COMP (Over 100,000 BTU) SEE FEE SCH.
MECHANICAL
(We) agree to save, indemnify and keep harmless the City of
Cupertino against liabilities, judgments, costs
MISC. - REFER TO ORD.
and expenses which
ma in any way accrue against said City in consequence of the
PERMIT ISSUANCE 3.00
CONST. TAX
an is p
MECH. CONT. LIC. NO. MECH.
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pplicant �Contractor Date
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OFFICE COPY