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APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
BUILDING PROJECT I DENTI FICATIONPERMIT
PERMIT
BUILDING — ELECTRICAL—PLUMBING — MECHANICAL
NUMBER
93939UILDINGr __5APPLICATION
ADDRESS
SS 01 IjCr ,Q
OWNER'S
7/s' NAME
Awe- PHONEk571_/ /
OTY. ELECTRIC PERMIT FEE
PLAN CHECK VALIDATION
P/q,
DATE OF APPLICATION
CONTRACTOR'S
NAME
e r' LIC.NDaj gfIG
OUTLETS - SWITCHES - RECEP 10.0011.00 0 O
7 LIGHTING FIXTURES 10.00/1.00 O
DYRESSTDRs
SL44,71u Ile-PPLIANCESAD
ut% WO ?..NEZ-943(?OQ
RESIDENTIAL 4.00 40
PANELS 10,00 00
ARCHITECT
ORENGINEER
LIC. NO,
PANELS (OVER 200 AMP) 20,00 PLAN CHECK FEE P,C,NO,
ISIGNS TRANS. 3.00
ARCH, OR ENG'
SPECIALADDRESS CIRCUIT 5OD PERMIT VALIDATION
EMP. METER OR POLE INS. 20,00ZIP
ADDRESSTs
I
a?.SO Ir' w S f
MOTORS r SEE FEE SCH. 00
SERVICE CHANGE 20.00
LICENSED CONTRACTORS DECLARATION 30,00TEMP. POLEP.A-1
I hereby affirm that 1 am licensed under provisions or Chapter 9
commencing with Section 7000) of Division 3 of the Business and
Professions Code nd license is in full farce nd MBEG. ClaLicense ss Lic. Number
ISSUANCE DATE
BLDG.
El
ELECT. PLG.
1:1 I
MECH.
Doti Contractor
ri
OWNER -BUILDER DECLARATION'tyINFORMATION
hereby affirm that I am exempt from the Contractor's License
Law for the following reason. (Sec. 7031,5, Business and Professions
Code: Any city or county which requiresapermit to construct,altcr,
improve, demolish, or repair any structure, prior to its issuance, also
requires the applicant for such permit to file a signed statement thatr!GheislicensedpursuanttotheprovisionsoftheContractor's License
MiSC, — RTO ORD
BUILDING PERMIT
VALUATION SIFT.
PERMIT ISSUANCE 10.00 Q. 06,
ELEC, CONTR. LIC, NO. ELEC.
TOTAL j 0 PERMITTO
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 IeL
STORIES TYPE CONSTR. the basis for the alleged exemption. Any violation of Section 7031.5
by any applicant for a permit subjects the a plicanttoacivilpenalty
of not more than rive hundred dollars (55011).): 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 ofrered for sale (See. 7044, Business and Professions DRAINS -FLOOR, ROOF, AREA, COND. 5.00
Cade: 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 -
merits amnot intended orOffered for sale. If, however. the building
FIXTURES - PER TRAP 5.00 SO. FT. FLOOR AREA TOTAL ACREAGE
GAS - EA. SYSTEM -I INC.4OUTLETS 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.).
D 1, as owner of the property, am exclusively contracting with
GAS - EA. SYSTEM OVER 4 (EA.) 2.00 BUILDING USE
RES IND CON Pe Other
INDUSTRIAL WASTE INTER, 30.00
licensed contractors t0 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 Ihercon. and who
LAWN SPRINKLERS- 1 INC,5 V.B. 6,00 ASSESSORS PARCEL NO.
I LAWN SPRINKLERS - OVER 5 (EA.) 1.00
contracts for such projects with a contraetor(s) licensed pursuant to
the Can tractor's License Law, SEWER -SANITARY -STORM EA. 200ft/10.00 TRACT NO. PARCEL NO.
am exempt under Sec. BAP.C. for this
reason
WATER HEATER W/VENT 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.
copythere f (Se . 31 p C,), Policy Ifji
FIRE SPRINK
Y N
ENERGY T•24
Y N
0 Certified Copy Is hereby furnished.
Cerlife op Js f Cd with Ijle city inspection division.
A p.cant .0 /--Y-' MISC. - REFER TO ORD.
CERTIFICATE OF EXEMPTION FROM WORKERS' PERMIT ISSUANCE 10,00 FLOOD;ONE XL-U,C.
PLG. CONTR, LIC. NO. PLG.
TOTAL
COMPENSATION INSURANCE
This sectidn 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.)
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 Workcre 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'Compcnsation
Provisions of the Labor Code, you must forthwith comply with
s[tch provisions or this permit shall be deemed revoked.
FEEAIRHANDLINGUNIT (TO 10=QF.M.) 4.00
AIR HANDLING UNIT(OVER 10,000C.F.M.) 6.00 SEISMIC FEECONSTRUCTIONLENDINGAGENCY
1 hereby affirm that there is a construction lending agency for EXHAUST HOOD (WITH DUCT) 5.00
the perfortnance of the work far which this permit is issued (Sec.
3097,Civ.C.).
MICROFILM
HEATING UNIT (TO 100,000 B.T.U.) 8.00
HEATINGUNIT(OVER100,000B.T.U.)9.50 ELECTRIC
Lender's Name
Lender's Addressddr
1 certify that I have read this application and slate that the above VENTILATION FAN (SINGLE) 4.00
information is correct. [ agree to comply with all city and county
ordinances and state laws relating to building construction, and
PLUMBING
BOILER-COMPI3 H.P. or 100,000 B.T.U.) 6.00
OMP (Over 100,0.00 BTU) SEE FEE SCH, MECHANICALherebyauthorizerepresentativesofthiscitytoenterupontheBOILER-C
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
grand orthis perml
3_S
MECH, CONT. LIC, NO. MECH,
TOTAL
TOTAL
Signature of Ap 11Conoa Date
OFFICE COPY