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APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
BU LDING PROJECT 1 DENT] FICATION
APPLICATION & PERMIT
BUILDING - ELECTRICAL - PLUMBING - MECHANICAL
JPERMIr NUMBER
J v .7
^' 5597
BUILDING
ADDRESS -
_lo ,fy 5 c �j
J vr�--
OW EH'S
��HDONE
OTY.
ELECTRIC PERMIT
FEE
PLAN CHECK VALIDATION
gs ya
yy
C.�
•,1
C
INZNAME
R's
UTLETS - SWITCHES - RECEP 10.00/1.00
Ate O LION . 7912
•` �M
�
GAT E OF APPLICATION
LIGHTING FIXTURES 10.00/1:00
CONTRACTORS 65z
A PHONE3� oq0
APPLIANCES - RESIDENTIAL 4.00
PANELS O.00
ORcHlrecr
ENGINEER
LIC. NO.
PANELS (OVER 200 AMP) 20.00
PLAN CHECK FEE p.C.`N0.
SIGNS TRANS. 3.00
ADDRESS
ZIP
SPECIAL CIRCUIT. 5.00
PERMIT VALIDATION
P A f
TEMP. METER OR POLE INS. 20.00
A
ES
ADDRESS
MOTORS SEE FEE SCH.
SERVICE CHANGE '20.00
c a 8 .
LICENSED CON "TRACTORS DECLARATION
(sr,L
I hereby affirm that I am licensed underpmvisionsof Chapler9
Icommencing will, Section 7000) of Division 3 of the Business and
Professions Cp a`d f y icense is in full f c f
License Class d LIE. Numhcr
Ur
I 1+(/ - DATE -
BLDG. ELECT. LG. MECH.
❑ ❑
_
Date Conlmdor_ _Qeg7_,,�
BUILDING PERMIT
INFORMATION
OWNER- IIUILDF-R DECLARATION
I hereby affirm that I am exempt from the Contractor's License
Law for the followingresson.( Sec. 7031.5. Businessand Professions
Code: Any city or county which requires a permit to construct, alter,
MISC. - FE ORD
PERMIT ISSUANCE
VALUATION
$ /FT.
ELEC. CONTR. LIC. NO. LE /11C.
TAL .
OTY. PLUMBING PERMIT EE
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 10 the provisions Of the Contractor's License
Law (Chapter 9 (commencing with Section 7000) of Division 3 of the
Vastness and Professions Code) or that he is exempt therefrom and
PERMIT TO
-
t is hasis for One alleged exemption. Any violation of Sectior1 7031.5
by any applicant for a permit subjects the applicant ma civil penalty
of not more than five hundred dollars ($500)):
STORIES
'
TYPE CONSTR,
ALTER -DRAIN &VENT-WATER IEA.) 5.00
❑ Las owner of the property, or my employees with wages as
their sole compensation, will do lite work, and the structure is not
BACK FLOW PROTECT. DEVICE 4.00
OCC. GROUP
RES. UNITS
DRAINS- FLOOR, ROOF, AREA, COND. 5.00
intended or offered for sale (Sec. 7044, Business and Professions
Code: The Contractor's License Law does not apply to an owner of
FIXTURES - PER TRAP 5.00
GAS- EA.SYSTEM- 1 1NC.40UTLETS 6.00
properly who builds or improves thereon, and who does such work
himself or through his own employees, provided that such improve-
mentsarenet intended or offered for sale. if, however, the building
S0. FT, FLOOR AREA
TOTAL ACREAGE
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-
GAS - EA. SYSTEM - OVER 4 (EA.) 2.00
BUILDING
USE
prove for purpose 0fsale.).. -
❑ I, as owner of the property, am exclusively contracting with
RES IND CON
❑ 0
PB -Other
0 ❑ ❑
INDUSTRIAL WASTE INTER. 30.00.
LAWN SPRINKLERS - 1 INC 5 V.B. 6.00
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
ASSESSORS PARCEL NO.
LAWN SPRINKLERS - OV ER 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
TRACTNO.
PARCEL NO.
❑ Iamexemptunder Sec. ,BAP.C. for this
reason
WATER HEATER W /VENT 6.00
Owner Date
WATER SYSTEM 5.00
ACC. DATE
ACC. FILE N0.
N'ORKERS'COMPENSATION DECLARATION -
WATER TREATING EQUIP. 5.00
1 hereby affirm that I hove o certificate of consent to sCINIIsllre,
or a certificate of Workers' Compensation h,surana, or a certified
ZONING
ENG. SITE NO.
copy thereof (Sec. 3800, Lah.C.).
Policy No. Company-
❑ Certified copy is Filed famished i
Cl ant Certified copy is filEJ with JM city inspection division.
Applicant
MISC. - REFER TO ORD.
FIRESPRINK
y [:) NEI
ENERGY T -24
y [-] N[]
CER TIFICATE OF EXEMPTION FROM WORKERS'
PERMIT ISSUANCE 10.00
-
FLOOD ZONE
A.L.U.C.
COAIPF:NSATION INSURANCE
(This section need not be Completed if the permit is for one
Y 0 N
Y CD NE].
PLG. CONTR, LIC. NO.
PLG.
TOTAL
hundred dollars (51001 or IesyJ
I 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
OTY.
MECHANICAL PERMIT
FEE
FEE SUMMARY
BUILDING
become subject to the Workers' Compensation Laws of California.
Dale Applicant
NOTICE '1'O APPLICAN'T': If, after making this Certificate of Ex-
ALTER OR ADD TO MECH. 5.00
APPLIANCE 5.00
AIR HANDLING UNIT (TO 1000C.F.M.) 4.00
PLAN CHECK
FEE
emption, 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 .
AIR HANDLING UNIT (OVER 10=C.F.M.) 6.00
SEISMIC FEE
CONS'TRUCT'ION LENDING AGENCY
I hereby affirm that there -is i construction lending agency for
the performance of the work for which this perant is issued'(See.
3097, CN.C).
EXHAUST.HOOD (WITH DUCT) 5.00
-
MICROFILM
HEATING UNIT (TO 100,000 B.T.U.) 8.00
Lender's Name
Lender's Address
HEATING UNIT (OVER 100,000 B.T.U.)
ELECTRIC
I certify that I have read thisapplicatum 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.
MECHANICAL
heathy enthoritc representatives of this city m enter upon the
ubovo- mentioned property Ibr inspection for, es.
• (We)-agree to save, indemnify and keep harmless the City of
MISC. - EFER TO ORD.
Cupertino against liabilities, judgments, costs and expenses which
may in any way accrue against said City in consequence of the
ra Dg t11is ermit,
PERMIT ISSUANCE 10.00
CONST. TAX
M_ ECH. CONT. LIC. NO.
MECH.
XJ,(PI - 2_ / _Q
/�
TOTAL -.
T
S�,at re of Applicant/Contractor ]Tire
OFFICE COPY