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APPLICANT TO FILL IN INFORMATION WITHIN RED LINES -- USE BALL POINT PEN ONLY
BUILDING PROJECT IDENTIFICATION
APPLICATION &PERMIT
BUILDING -ELECTRICAL- PLUMBING -MECHANICAL
PERMIT NUMBER
9379AoolWSs
VuOWNER'S
NAME -
y /
e I e,o 01). PHONES//-17
QTY. ELECTRIC PERMIT FEE
PLAN CHECK VALIDATION
7/
v /
DATE OF APP LICATION
CONTRACTOR'S
NAME
j r QQd ,JeCfr1C. LIC. NO. 023 d
Q OUTLETS -SWITCHES - RECEP 10.00!1.00 /044
3 LIGHTING FIXTURES 10.0011.00 ?3,o0
CONTRACTOR'S
ADDRESS S, V4. G
02rCJ 40OD . PHONE 733,?o0
3 PPLIANCES - RESIDENTIAL 4.00 ,?,OD
PANELS 10.00 Q, UO
ARCHITECT
OR
ENGINEER
LIC. No.
PANELS (OVER 200 AMP) 20.00
PLAN CHECK FEE
Rfi nil
P.C. NO.
SIGNS TRANS. 3.00
ARCH O ENG.
ZIP
SPECIAL CIRCUIT 5.00 PERMIT VALIDATION
0CT ,1 11985
city of Cupertino
EMP. METER OR POLE INS. 20.00
ADDRESSA/
2So ire u oo a Ar. u7 va-
MOTORS SEE FEE SCH. oo
SERVICE CHANGE 20.00CHANGE
LICENSED CONTRACTORS DECLARATION TEMP. POLE 30.00
I hereby affirm that 1 am licensed under provisions of Chapter 9
commencing with Section 7000) of Division 3 of the Business and
Professions Code nd r license is in Full fore Bd of bLicenseClassLic. Number
ISSUANCE DATE
BLDG. EL C PLG. MECH.
Date JO Contractor
BU DING PERMIT
FORMATIONOWNER -BUILDER DECLARATION
1 hereby affirm that I am exempt from the Contractor's License
Law forthefollowing reason. (Sec. 7031.5; 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 permit to file a signed statement that
he is licensed pursuant to the provisions of the Contractor's License
MISC. - REFER TO ORD
VALUATION SIFT.
PERMIT ISSUANCE 10.00 IV "DO
ELEC. CONTR. LIC. NO.
eC G $ i
ELEC. G
TOTAL /j PEPIT TO
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 1
the basis for the alleged exemption. Any violation of Section 7031.5 STOR TYPE CONSTR.
by any applicant Fora permit subjects the applicant toacivil penalty
of not more than live hundred dollars (5500).}: ALTER -DRAIN & VENT -WATER (EA.) 5.00
I, as owner of -the property, or my employees with wages as
their sole compensation, will do the work, and the structure is not
IBACK FLOW PROTECT. DEVICE 4.00 OCC. GROUP RES. UNITS
ROOF, AREA, COND. 5.00intendedorofferedforsale (Sec. 7044, Business and ProfessionsDRAINS-FLOOR,
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-
menls are not intended or offered for sale. If, however, the building
FIXTURES - PER TRAP 5,00 SO. FY. FLOOR AREA TOTAL ACREAGE
GAS EA. SYSTEM- 1 I 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
10 an owner of property who builds or improves thereon. and who
GAS EA. SYSTEM -OVER 4 [EA.) 2.00 BUILDING USE
R IND CON P8 Other
ASSESSORS PARCEL NO.
INDUSTRIAL WASTE INTER. 30.00
LAWN SPRINKLERS - 1 INC 5 V.B. 6.00
LAWN SPR INKLERS - OVER 5 (EA.} 1.00
contracts for such projects with a contractor(s) licensed pursuant to
the Contractor's License Law. SEWER -SANITARY -STORM EA. 200ft/10.00 TRACT NO, PARCEL NO.
lam exempt under Sec. B.&P.C. for this WATER HEATER WIVENT 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 1 have a certificate of consent to self -insure,
or a certificate of Workers' Compensation Insurance, or a certified ZONING ENG. SITE NO.
copy theigo Se . flD,J 6C.).
Policy Nig y
Certified copy is hereby Furnished.
JdCertified c ijled vt0tth! c,I ty Gpection division.
A pli et
FIRE SPRINK
Y N
ENERGY T-24
Y NMISC. 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 ($100) or less.)
I certify that in the performance of IIIe work for which this per-
mit is issued, I shall not employ any person in any manner so as to
BUILDING
become subject t0 the Workers' Compensation Laws 0f California.
Date Applicant ALTER OR ADD TO MECH. 5.00
NOTICE TO APPLICANT: If, after making this Certificate of Ex-
emption, you should become subject to the Workers' Compensation APPLIANCE 5.00 PLAN CHECK
provisions of Elie Labor Code, you must forthwith comply with
such provisions or this permit shall be deemed revoked.
FEEAIRHANDLINGUNIT (TO 10=C.F.M.) 4.00
AIR HANDLING UNIT (OVER IOQOOC.F,M.) 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
certify that I have read this application and state 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
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 t0 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. TAXPERMITISSUANCE10.00
gramtlm of this ermi[. MECH. CONT. LIC. NO. MECH. 1ggbp
TOTAL
TOTAL
Signature of Applicant/Contractor Date
OFFICE COPY