09839 APPLICANT TO FILL IN INFORMATION.WITHIN RED LINES - USE BALL POINT PEN ONLY
BUI LDI NG PROJECT I DENTI FICAT16N - PERMIT NUMBER
.-IJuoi APPLICATION & PERMIT
ADORES$ 09839
Q ✓��� �� BUILDING -ELECTRICAL-PLUMBING-MECHANICAL
OWNER'S - ;ri, n - ', PLAN CHECK VALIDATION.
- NAME ELECTRIC PERMIT_ 'FEE '
• 6&J rrea Cniv5>PRONE
NA.E crOR's UTLETS-SWITCHES-RECEP 10.00/1.00
NAME
1r'q c.NO. LIGHTING FIXTURES 10.00/1.00
CONTRACTOR'S' -
AOORrsss � PPLIANCES-RESIDENTIAL 4.00
-" 6✓ {�.���Gl/ 44/ PROry a*29, 0_10 PANELS - 10.00 DATE OF APPLICATION
ARCHITECT - '
.
on PANELS (OVER 200 AMP) 20.00 PLAN CHECK FEE P.C.NO.
ENGINEER, .
SIGNS TRANS. � 3.00. '
'
ADDRESS SPECIAL CIRCUIT 5.00 PERMIT VALIDATION
nP EMP.METER OR POLE INS.' 20.00 PND '
' -AooA ssT S
/Ice MOTORS ' - SEE FEE SCH. - f� +dee(
G.rr IAT�,w 4WSERVICE CHANGE - 20.00 -OCT 9 - I98S
0 ¢i
o o LICENSED CONTRACTORS DECLARATION TEMP.-POLE 30.00 'VIE�'no
a v u 1 hereby affirm that I am licensed under provisions of Chapter 9 S A C DATE
n a vuwi (commencingiwith Section 7000)of Division 3 of the Business and
Professions Code,and my license is in full fort and a ec - BLDG. ELECT. PLG. CH.
o i m o License Clams Lic.No er -
v, H w Date Contrec El ❑
¢ o
OWNER-BUILDER DECLARATION BUILDINGIPERMI
n T..
X g;u♦- 1 hereby affirm that I am exempt from the Contractor's License MISC.- REFER TO ORD • - - .INFORMATION
u0¢ Law forthe followingreason.(Sec.7031.5;Boomessand Professions VALUATION
' y.Ha Code:Any city or county which requires a permit to construct,alter, - PERMIT ISSUANCE 10.00
¢ ¢Q 0 improve,demolish,or repair any structure,prior to its issuance,also ELEC.CONTR. LIC.NO,
u requires the applicant for such permit to file a signed statement that ELED.
esRMIT TO
n w m m he is licensed pursuant to the provisions of the Contractor's License TOTAL
Hz >
Law(Chapter 9(commencing with Section 7000)of Division 3 ofthe "_ '
_ 4 o Business and Professions Code)or that he is exempt therefrom and QTY'.` ;PLUMBING`PERMIT a-FEE
¢E_ es the basis for the alleged exemption.Any violation of Section 7031.5 .-P - STORI TYPE CONBTR.
a3_ by any applicant for a.permit subjects the applicant to a civil penalty ALTER-DRAIN -WATER (EA.) 5.00
of not more than five hundred dollars(5500).):
❑ 1,as owner of the property,or my employees with wages as BACK FLOW PROTECT.DEVICE 4.00 OCC.GROUP RES.UNITS
/heir sole compensation,will do the work,and the structure¢not
intended or offered for sale(Sec. 7044, Business and Professions DRAINS-FLOOR,ROOF,AREA,CON D. 5.00
Code:The Contractor's License Law does not apply m an owner of - -
property who builds or improves thereon,and who docs such work FIXTURES-PER TRAP 5.U0 50.FT.FLOOR AREA TOTAL ACREAGE
• himself or through his own employees,provided that such improve-
ments are not intended or offered for sale.If,however,the building' GAS-EA.SYSTEM-11NC.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- GAS-EA.SYSTEM-OVER 4(EA.) 2.00 BUILDING USE
prove for purposemf sale.). INDUSTRIAL WASTE INTER- 3000 E 1❑ ❑N Ps E-1 El❑ 1,as owner of the property,am exclusively contracting with .
licensed Contractors to construct the project(Sec. 7044,Business LAWN SPRINKLERS-1 INC 5 V.B. 6.00 ASSESSORS PARCEL NO.
.and Professions Code:The Contractor's License Law does not apply - -
to an owner of property who builds or improves thereon,and who LAWN SPRINKLERS-OVER 5(EA.) 1.00
contracts for such projects with a contmetod s)licensed pursuant to
the Contractor's License Law. - SEWER SAN ITAR Y-STORM EA.200ft/10.00 - RACT NO. PARCEL NO.
' ❑ lam exempt under Sec. ,B.&P.C-forthes
reason WATER HEATER W/VENT, 6.00
Owner Date WATER SYSTEM 5,00
ACC.DATE ACC FILE NO.
WORKERS'COMPENSATION DECLARATION, WATER TREATING EQUIP. 5.00
I 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 thereof(See 3800,Lab_Cr)
. -
Policy No. Company SCG'((
O ❑ Certified copy is hereby furnished.�J 0 FIRE SPRINK ENERGY T-14
Z Z ��'' Ce fie copy filed with}pe city msp- Pee on"div as
p AQplicant�- . '_( 1� - - MISC.- REFER TO ORD. YE] N� - y � N�
- UJ CERTIFICATE OF EXEMPTION FROM WORKERS' - PERMIT ISSUANCE 10.00 'FLOOD ZONE A.L.U.C.
W
COMPENSATION INSURANCE PLG.CONTR. .uC.NO. PLG.
tl (This section need not be completed if the permit is for one TOTAL Y NE Y - N
_ Z hundred dollars(5100)or less-) - - ' _
L)-O. I certify,that in the performance of the work for which this per, 'FEESUMMARY''a•*++
W I- mit is issued,I shall not employ any person in any manner so as t QTY. MECHANICAL PERMIT 'FEE • ,
O become subject to the Workers'Compensation Laws of California. " -
ED Date Applicant ALTER OR ADD TO MECH. 5.00 BUILDING
} ' NOTICE-TO APPLICANT:If,after making this Certificate of Ex-
Z -
F _ emption,you should become subject to the Workers'Compensation APPLIANCE 5.00 PLAN CHECK '
provisions of the Labor Code, you must forthwith comply with ,
U such provisions or this permit shall be deemed revoked. _ AIR HANDLING UNIT(TO 10=C.RIA) 4.00 - FEE -
CONSTRUCTIONLENDINGAGENCY AIR HANDLING UNIT(OVER 10MC.F.M.16.00 SEISMIC FEE
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. MICROFILM
3097,Civ. HEATING UNIT(TO 100,000 B.T.U.) 8.00 _
Lender's Name
e
' Lender's Address HEATING UNIT(OVER 100,000 B.T.U.)9.50 ELECTRIC
I certify that I have read this application and stale that the above VENTILATION FAN (SINGLE) 4.00
•. information is correct.1 agree to comply with all city and county PLUMBING.
ordinances and State laws relating to building construction;and BOILER-CONIP(3H.P.D11(Y0,000B.T.U.) 6.00
hereby authorize representatives of this city to enter upon the BOILERCOMP IOver 100,1)00 BTU)SEE FEE SCH.
above-mentioned property foMECHANICAL
r.inspection purposes.
(We) agree to save, indemnify and keep harmless the City of MISC.- REFER TO ORD.
Cupertino against liabilities,judgments, costs and expenses which CONST.TAX
may in any way accrue against said City in Consequence of the •PERMIT ISSUANCE - 10.00 _
granting of this permit. qq MECH.CONT. LIC NO. MECH.
TOTAL51
y,/^J j -`TOTAL "
Signature of Applicant/ tractor Date
OFFICE COPY -