10033 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALLPOINT PEN ONLY
• BUILDING PROJECT IDENTIFICATION PERMIT NUMBER
UU'ADDRESc - APPLICATION & PERMIT O 0
gOOREss
BUILDING-.ELECTRICAL-PLUMBING-MECHANICAL ,
NAME33-
/• _ "vi � Mt gAr,i*` k E vl'+A`��d4 j4 I �a%`�•,� § PLAN CHECK VALIDATION
OTYR f 4 9 E LECTHICiPEfiMIT t p * B fE '
PHONE x" i A FS ,.
• CONTRACTORS - OUTLETS-SWITCHES-RECEP 10.00/1.00 -
uc:No. LIGHTING FIXTURES 10.00/1.00
CONTRACTOR'S
Ao/oR s APPLIANCES--RESIDENTIAL '• 4.00air
PHONPANELS 10.00 DATE OF APPLICATION
ARCHITECT - PLAN CHECK FEE P.C.NO.
OR PANELS (OVER 200 AMP) 20.00
ENGINEER ,
LIC.No. SI GNS TRANS: 3.00
ARCH.OR
END, - "SPECIALCIRCUIT - 5.00 vER TION
-T A ZIP EMP.METER OR POLE INS. 20.00 NOV_ - 81985
ADDRESS - MOTORS SEE FEE SCH.
-
SERVICE CHANGE 20.00 Cityof Cupertino
w
02 LICENSED CONTRACTORS DECLARATION', TEMP.POLE 30.00
< oI hereby affirm that I am licensed under provisions of Chapter 9
Z w _ ISSUANCE DATE
w 4 y, (commencing with Section 7000)of Division 3 of the Business and - BLDG. E ECT. PLG. MECH.
H D Z Professions Code,and my license is in full force and effect - i ❑ _❑
oi H o License Class Lic.Number qq -
m r Date Contractor �Y n Q {
or a, or u OWNER-BUILDER DECLARATION Q� L Y BUIING.P,,
w3: , H I hereby affirm that I am exempt from the Contractor's License MISC.- , REFER TO ORD %v ' ,C IN ORM IONy # g
u 0 4 Law for the following reason.(Sea 703 1.5,Business and Professions VALUATION $/FT.
quiets a permit to construct,otter,
Code:Any city or county which re -PERMIT.ISSUANCE 10.00 r
,
improve,demolish,or repair any structure,prior to its issuance,also ELEC.CONTR. LIC.NO. ELEC.
ac or a:o¢ requires the applicant for such permit to file a signed statement that TOTAL ��
6'w m he is licensed pursuant to the provisions of the Contractor's License PERM T TO
HZaLaw(Chapter 9(commencing with Section 700(fiof Division 3 o(thee = vS' w't'- Vt9,14 t
f 4 0 Business and Professions Code)or that he Is exempt therefrom and OTY: s- ' t x a 'PLUMBING PERMIT s m s .b v VFEE 1'
H o the hasis for the alleged exemption.Any violation of Sccflm17031 5 f` ?R" S ES PE CONS
i ;`0 by any applicant for u permit subjects the applicant too civil penalty
ALTER-DRAIN&VENT-WATER (EA.) 5.00
of not more than five hundred dollars(S500).):
❑ 1,as owner of the properly,or my employees with wages as BACK FLOW PROTECT. DEVICE 4.00 Occ. .
their sole compensation,will do the work,and the structure is not GP R UNITS
intended or offered for Sale (Sec. 7044, Business and Professions - DRAINS-FLOOR,ROOF,AREA,COND. 5.00
Code:The Contractor's License Law does not apply to an owner of '
property who builds or improves thereon,and who does such work FIXTURES-PERTRAP5.00 SO.FT.FLOOR AREA TOTAL ACREAGE
himself or through his own employees,provided that such.Improve-
merits are not intended orOffered mor sale.If,however,the building GAS-EA.SYSTEM-111NC.40UTLETS 6.00
or improvement is sold within one year of completion the owner- GAS-EA.SYSTEM-OVER 4 IEA.) 2.00
builder will have the burden of proving that he did not build or im- BUI LOING USE
prove for purpose of sale.). INDUSTRIAL WASTE INTER. 30.00 5 IND CON PB' Other
❑ 1,as owner of the property,am exclusively conducting with - ❑ El
licensed contractors to construct the project(Sec. 7044,Business LAWN SPRINKLERS-I INC 5 V.B. 6.00 ASSESSORS PARNO., El 0
EL
and Professions Code:The Contractor's License Low 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 contractors)licensed pursuant to
' the Contractor's License Law. - SEWER-SANITARY-STORM EA.200ft/10.00 TRACTNO. PARCEL NO.
0_1 am exempt under Sec. ;B.&P.C.for this
on WATER HEATERW/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 I have a certificate of,onsent to self-insure, -
or a certificate of Workers'Compensation Ingrce,or a.certified ,ZONING ENG.SITE NO.
copy thereof(Sce.3800,Lab.0-Iiz /d_Ap��
Policy No. Company l C%O/TJ "
O ❑ Certilie c pyis hereby ' tslled. FIRE SPRINK ENERGY T-24'
z Z - ❑ Certi(ie opy�' filed w11 the'aty sp coon division.
O 'Applicant MISC REFER TO ORD. y ,.N❑ v ❑ N�
H CFiRT GATE O F i PTION F'.ROM WORKERS' PERMIT ISSUANCE 10.00 FLOOD ZDNE q:L.u.C.
LU COMP.NS IONINSURANCE PLG.CONTE. LIC.NO. PLG. [
CL O (This section need not be completed if the permit is for one t TOTAL 1..J V N 0 Y. +❑ NE]Z hundred dollars($100)or less.) a a v -.t
V O I certify that in the performance of the work for which this per + 5 - * fi a sH b ' .a k xda FEE SUMMARY a ay'.N
OTV. . MECHANICALtPERMiT " a-o- v a„
LL F nut is issued,I shall not employ any person in any manner sous to # T y r t t FEE•., y a4 3#,
U become subject to the Workers'Compensation Laws of California. `` `{ '.. w
i Date Applicant ALTER OR ADD TO MECH. 5,00 'BUILDING
. } 0. NOTICE TO APPLICANT: If,after making this Certificate of Ex- -
(•-. Z emption,you should become subject to the Workers'Compensation APPLIANCE T 5.00 PLAN CHECK
provisions of the Labor Code, you must forthwith comply with FEE
V _ such provisions or this permit shall be deemed revoked. AIR HANDLING UNIT(TO 10=C.F.M.) 4.00
CONSTRUCTION LENDING AGENCY - AIR HANDLING UNIT(OVER 10=C.RM.) 6.00 SEI SMIC 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.CJ. HEATING UNIT(TO 100,000 B.T.U.) 8.00
Lender's Name `
Lender's Address - HEATING UNIT(OVER 100,000 B.T.U.)9.50 ELECTRIC
I certify that I have read this application and state that the above VENTILATION FAN (SINGLE) .4.00
information n estreat I agree to comply with all city action, my BOILER-COMP(3 H.P..or 100,000 B.T.U.) 6.00 PLUMBING
ordinances and slate laws relating to building construction,lion, and
hereby authorize representatives ec this city is enter upon the _ BOI LER-COMP (Over 100,000 BTU)SEE FEE SCH. MECHANICAL
above-mentioned property for inspection purposes. .
(We) agree to save, indemnify and keep harmless the City of MISC.- REFER TO -
Cupertino against liabilities,judgments, costs and ORD.expenses which' CONST.,TAX
may in Say way accrue against said City in consequence of the PERMIT ISSUANCE 10.00
ORD.
granting of(]its permit. MECH.CONT. LIC.NO. MECH.
' TOTAL
Stgnaturc of Applicant/Contractor Uatc
' OFFICE COPY