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APPLICANT TO FILL IN INFORMATION WITHIN RED LINES -- USE BALL POINT PEN ONLY
BUI LDING PROJECT I DENTI FWATION LLL
APPLICATION & PERMIT
BUILDING — ELECTRICAL— PLUMBING — MECHANICAL
PERMIT NUMBER
9376BUILDINGADDRESS.
n
e l} l
NAMERS /
rle- A%O'i° Co , PHCN% J
O7Y. ELECTRIC PERMIT FEE
PLAN CHECK VALIDATION
d f / f
DATE OrAPPLICATION
CONAME ACTOR'S ^
St /eGfr;C, L]O.NO.Ja
OUTLETS - SWITCHES - RECEP 10.0011. 00 jr, 00
ad LIGHTING FIXTURES 10.0011.00 go,00
DRESSACTOR'S uoyqr -DN
w7AD0 6ral2woc;, PHONEry,33/-3 ,9d2c
PPLIANCES - RESIDENTIAL 4.00 /,?,Oo
PANELS 10.00 0,00
ARCHITECT
on
ENGINEERJIDi.rc, No.
PANELS OVER 200 AMP) 20,00 PLAN CHECK FEE P.C. NO.
ISIGNS TRANS. 3.00
ARCH: OR ENG
ADDRESS SPECIAL CIRCUIT 5.00 VALIDATION
r epOCTriEMP. METER OR POLE INS. 20.00ZIP 1 loss
City of Cuperiluo
ADDRESSPLICANTS
a3_0 - woo Arr, conn Ya
MOTORS - SEE FEE SCH. '] ,00
SERVICE CHANGE 20,00
LICENSED CONTRACTORS DECLARATION TEMP, POLE 30.00
I hereby affirm that I am licensed under provisions of Chapter 4
commencing with Section 7000) of Division 3 of the Business and
Professions Code, )nd license is in full force efSecL.
License Cjass Lic. Number CC!!
ISSUANCE DATE
BLDG. EL PLG. MECH.
Date uu - Contractor s '
BUI
FORMATION
T ' -
FORMATIONOWNER -BUILDER DECLARATION
I 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 cou my which requires a permit to construct, alter,
improve, de olish, 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 FT.
PERMIT ISSUANCE 10,001/0.00
ELEC. CONTR, LIC. NO. ELEC. 00iG8 TOTAL / R T TO
Law (Chapter 9 (commencing with Section 7000) of Division 3 of the
Business and Professions Code) or that he is exempt therefrom and CITY. PLUMBING PERMIT FEE
STORIES TYPE CONSTR. the basis for the alleged exemption. Any violation of Section 7031.5
by any applicant for a permit subjects the applicant to a civil penalty
of not more than five hundred dollars (5500):);
I, as owner of the property, or'my employees with wages as
their sale compensation, will do the work, and the structure is not
ALTER-DRAIN&VENT-WATER (EA.) 5,00
BACK FLOW PROTECT. DEVICE 4.00 Dec. GROUP RE9aUt1N1T5
DRAINS -FLOOR, ROOF, AREA,COND. 5.00intendedOrofferedforsale (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 does such work
himself or through his own employees, provided that such improve-
mentsare not intended oroffered for sale. If, however, the building
FIXTURES -PER TRAP 5.00 SO. FT. FLOOR AREA TOTALACREAGE
GAS -EA. SYSTEM- 1 INC.40UTLETS 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.).
31, 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
to an owner of property who builds or improves thereon. and who
GAS - EA. SYSTEM OVER 4 (EA,) 2.00 BUILDING USE
IND CON Pe Other
INDUSTRIAL WASTE_ INTER. 30.00
LAWN SPRINKLERS - 1 INC 5 V.B. 6.00 ASSESSURS PARCEL NO.
LAWN SPRINKLERS - OVER 5 (EA.) 1.00
contracts for such projects with a contractor(s) licensed pursuant to
the Contractors License Law. SEWER -SANITARY -STORM EA. 200ft/1 O,OD TRACT NO. PARCEL NO.
1 am exempt under See.. 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
I 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.
co PAI e e (Sec. pQ Lab.C.).
Pol' 5
pony
Certified copy is hereby furnished.
Certified p fits yy''ith th city inspection division.
Appicant !_ / /P -r ll C,
FIRE SPRINK
N
ENERGY T-24
Y [:]N MISC. REFER TO ORD.Y
CERTIFICATE OF EXEMPTION FROM WORKERS' PERMIT ISSUANCE 10.00 FLOOD ZONE A-L.U,C.
PLG, CONTR. LIC. NO. PLG.
TOTAL
COMPENSATION INSURANCE
This seetidn need not be completed if the permit is for one
Y N Y N
I TY. MECHANICAL PERMIT FEE FEE SUMMARY
hundred dollars (S 100) or less.)
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
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 [his Certificate Of Ex-
APPLIANCE 5.00 PLAN CHECKemption, 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.
FEE
AIR HANDLING UNIT (TO 10000 C.F.M.) 4.00
AIR HANDLING UNIT (OVER 10000C.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.
3047, Civ.C.).
MICROFILM
HEATING UNIT (TO 100,000 B.T.U.) 8.00
H EATING UNIT (OV ER 100,000 B.T.U.) 9:50 ELECTRIC
Lender's Name
Lender's Address
I certify that I have read this application and state that the above
information is correct, I agree to comply with all city and county
ordinances and state laws relating to building construction, and
VENTILATION FAN (SINGLE) 4.00
PLUMBING
BOILER (3 H.P. or 100,000 B.T.U.) 6.00
BOILER -COMP (Over 100,000 BTU) SEE FEE SCH. MECHANICALherebyauthorizerepresentativesofthiscityt0enteruponthe
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
MECH. CONT. LIC. NO. MECH.
TOTAL
TOTAL
grant' Of this permit.,y -
dt!a r_d ID ;3-,s
Signature of Applicant ontractor Date
OFFICE COPY