4846 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT,PEN ONLY
.d�61 PER M I T.NUM a ER
BVD "°/02 O N B APPLICATION & PERMIT /�
PDD as - `t `F 46
BUILDING-ELECTRICAL-PLUMBING-MECHANICAL
OWNER'S - - - - PLAN C i', DATION
NAME QTY. ELECTRIC.PERMIT FEE '
PN°ry ..
NAMER °R$ OUTLETS-SWITCHES-RECEP 5.00/1.00 "FJAN 23 19$5
rjezg. 6 uc.No LIGHTING FIXTURES 5.00/1.00
CONTRACTORS 7 - PPLIANCES-RESIDENTIAL • 4.00 City Of Cupertino,
ADDRESS - _ _ _-
- "T -Mg-� • ,�-• S DRIINE�r1-T"/ ! Lr PANELS ._:.1.:..w. x' 5.00 DATE OF APPLICATION
ORcwTECT -- t'.' - $IGNS+ 6.00 PLAN CHECK FEE P.C.NO.
OR
ENGINEER `/
JL uc.NO g • ' SIGNS TRANS. 3.00
ADDR.SS ENG. SPECIAL CIRCUIT 5.00 PERMIT VALIDATION
A/ / V O zlpfy Q EMP.METER OR POLE INS. 15.00 PAID
ADDRESS ADDRESS MOTORS SEE FEE SCH. '
SERVICE CHANGE T 10.00 „
w UAN 2 3 198;
00 LICENSED CONTRACTORS DECLARATION
mo U I hereby affirrti that I am licensed under provisions of Chapter 9 n• UANCE DATE
y st w (commencing with Section 7000)of.Division 3 of the Business and
r w i Professions C c,and m lice a is in full for< ff t ✓�el[I• EC
oO m a License Cla� s,ia Number_�9
¢ Contractor-;tj_,q,y_rk* -
¢ IC w ¢ OWNER-BUILDER DECLARATION ,BUILDING PER IT '
o a u INFORMATION
E
; N I hereby affirm that I am exempt from the Contractor's License MISC.- REFER TO ORD '
u. O'a Law the followingreason.(Sec.7031.5,Business and Professions VALUATION $/FT.
H _ PERMIT ISSUANCE
Code:Any city or county which requires permit to construct alter. 6,00
Q M ¢ 0 'Improve,demolish,or repair any structure,prior to its issuance,also ELEC.CONTR. LIC.N0. I ELEC.
o ¢ requires the applicant for such permit to fil...igned sLuctuent that TOTAL
° wm'u PERMIT TO
he is licensed pursuant to the provisions of 100 ).[Dictor's License
H z r Law(Chapter and
Professions
ode)or
is exempt
the of o of the • �.
ca E o Business and Professions Code)or that he is exempt therefrom and QTY. PLUMBING.PE RNIIT FEE
Ix I- $ the basis for the alleged exemption.Any violation of Section 7031.5 5 RI T ST .
o ; by any applicant fora permit subjects the applicant to a civil penalty ALTER-DRAIN&VENT-WATER (EA,14.00
Iffof not more than five hundred dollars($500).):
0 1,as owner of the property;or my employees with wages as BACK FLOW PROTECT. DEV ICE 2.00 OCC.GROUP RES.UNITS
sole compensation,will do the work,and the structure is not
intended or offered for sale (Sec. 7044, Business and Professions DRAINS-FLOOR,ROOF,AREA,COND. 4.00
Code:The Contractor's License Law does not apply to an owner of
property who builds or improves thereon,and who docs such work FIXTURES-PER TRAP - 4.00 SO.FT.FLOOR AREA TOTAL ACREAGE
himself or through his own employees,provided that such improve-
menuarenetintendedorofferedforsale.If,however,the building, GAS-EA.SYSTEM-1'INC.40UTLETS 4.00
or Improvement is sold within one year of completion,the owner GAS-EA.SYSTEM-OVER 4 IEA.) 1.00 BUILDING USE
builder will have the burden of proving that he did not build or ire- - RES' IND CON PB Omer
prove for purpose of sale J' INDUSTRIAL WASTE INTER. 120.00
❑ d ;
as owner of the property, e exclusively contacting with
licensed contractors 'construct the project(Sec.7044,Business LAWN SPRINKLERS- 1 INC 5 V.B. 5.00 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,contraatuds)licensed pursuant to
the Contractor's License Law, SEWER-SANITARY-STORM EA.200ft/8.00 TRACT No. PARCEL NO.
❑ lam exempt under Sea BAP.C.for Ibis WATER HEATER W/VENT _ '4.00
reason
Date Owner WATER SYSTEM • 4.00 Ace.DATE ACC.FILE NO.
WORK ERS'CONIPE NSATION DECLARATION WATER TREATING E I ., B
hereby affirm that I have a certificate of consent 10 sell'-insure, 20NING
or o Certificate of W°rkors'Compensation Insurance,or a certified ENG.SITE N0,
copy thereof(Sec,3800,Lab.C.). .
P�oI No. Compmsy
Z � ]Pj Certified copy is hereby furnished.
Z - Certified copy t fled with the city inspection division. FIRE SPRINK ENERGY T2C
0 plicum MISC.- REFER TO ORD. Y❑ N[ Y Q N[]
~ to PERMIT ISSUANCE 6.00
LU CER'I'I FICCOMPV I ATION INS FROM WORKERS' FLOOD ZONE A.L.U.C.
W COMPIiNSAT10N INSURANCE - PLG.CONTR. LIC. PLG. �O ts0 ❑ ❑ ❑ N❑
j Z flfus section need not be completer) if the permit is far one r TOTA Y N Y
hundred dollars($100)or less.)
U O I certify that in the performance of the work for which this per- GTY. MECHANICAL PERMIT FEE FEE SUMMARY
LL F mit is issued, I shall not employ any person in any manner so as to
Wbecome subject to the Workers'Compensation Laws of Calititrnia.
Q. Date Applicant _ ALTER OR ADDTO MECH. 4.00 BUILDING
} N NOTICE TO APPLICANT: If,after making this Certificate of Ex-
'� ? Creation,you should become subject to the Workers'Compunsatimt APPLIANCE 4.00 PLAN CHECK-
provisions of the Labor Code, you must forthwith comply with FEE
C.1 such provisions or this permit shall be deemed revoked. AIR HANDLING UNIT(TO 10=r-F.M.) 3.00
CONSTRUCTION LENDING AGENCY AIR HANDLING UNIT IOVh`.l .F.MJ 5.00 SEISMIC FEE
I hereby affirm that there is a construction lendin,agency for EXHAUST HOOD (WITH DUCT) 2.00 0
the performance of Ne work for which this permit is issued(Sec. MICROFILM
3097,Civ.C.L - HEATING UNIT( 4.00
Lender's Name HEATING UNITI V 00,0 OB.T.U.17.50
Lender's Address - ELECTRIC
I certify that I have read this application and state that the above VENTILATION FAN' f' 3.00
information is rotate[. 1 agree to comply with all city and county - PLUMBING -.
ordinances and state lows relating comply
consvuainn, and BOILER-COM M H.P.of 100,000 B.T.U.) 4.00
hereby above-mentioned
property forms of on city to enter upon the BOILER-COMP IOVer 100,000 BTUI SEE FEE SCH. MECHANICAL
above-;authored property forinsp ofth i purposes.
(We) agree to save, indemnify and keep harmless the City of MISC.- REFER TO ORD.
Cupertino against times,judgments, costs and expenses which PERMIT ISSUANCE 3,00 CONST.TAX
ny ac rue ago said Ci tN�qnee of the
gran ti cr L MECH.CONT. LIC.NO, i - MECH.
gn as;can[/Canlnctor _ "/G !` Toy/ TOTAL
7�tc,E�-� C'a�ly�GE.✓�.eiRG CayT.e. FFlc�coY