1535 ,APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN.ONLY
i- ' BUILDINGPROJECT-IDENTIFICATION - ERM FR
BUILDING APPLICATION & PERMIT [
ADDRESS J J
BUILDING - ELECTRICAL-PLUMBING-MECHANICAL ,
OWNER'5 PLAN CHECK VALIDATION
NAME QTY. ELECTRIC PERMIT FEE.
Q{ PHONE
CONTRACTORS _
NAME UTLETS-SWITCHES;RECEP 5.00/1.00
W i 'y LIGHTING FIXTURES 5.00/1.00
ADDRESS R's [APPLIANCES-RESIDENTIAL 4.00
ADDRESS
%1 Li �, PHON :5=E�CPgfi G. PANELS 5.00 Q DATE OF APPLICATION
ARCHITET SIGNS 6.00 "PLAN CHECK FEE P.C.NO.
OR
ENGINEER
I.C.No, SIGNS TRANS. - ' ,3.00
ADDRESS ENG' SPECIAL CIRCUIT 5,00 PERMIT VALIDATION
ZIP TEMP.METER OR POLE INS. 15.00
ADDRESS MOTORS SEE FEE SCH.
ADDRESS
SERVICE CHANGE CUprusTIMA 10.00
Ws.iona,
o O LICENSED CONTRACTORS DECLARATION '
<u 1 hereby affirm that I am licensed under provisions of Chapter 9 FEB A ISSUANCE DATE
H G (commencing with Section 7000)of Division 3 of the Business and BLDG. ELECT, PLG. MECH.
H D Professions Cq� m be nse is in full lorce n effect.
Z, O 6 1982
�, - License Class�^c� �y1Lic.Numbe ❑ ❑ ❑ ❑
9 z F w Date 2I sit a COntracmr t_{..kgi.r�ys,�_
al y E ���-�
¢ 4 - OWNER-BUILDER DECLARATION PAIL BUILDING PERMIT
"- MISC.- REFER TO ORD INFORMATION
w 3 e. y I hereby affirm that I am exempt from the Contractor's License VALUATION $/FT.
F u 0 a Law for the following reason.(Sec.7031.5,Businessland Professions PERMIT ISSUANCE 6.00 ,
Code:Any city or county which requires a permit to construct,alter,
Q R ¢ improve,demolish,or repair any SIroclum,prior to its hotmoce,also ELED,CONTR, LIC.NO. ELEC. /'�
o 0 requires the applicant for such permit to file a signed sale...on,Ihai ` ) t• TOTAL - PERMIT TO
A w mohe is licensed pursuant to the provisions of the Contractor's License
H t i Law(Chapter 9(cummencingwith Section 7000)of Division 3 of the
a Business and Professions Code)or that he is exempt therefrom and CITY. PLUMBING PERMIT FEE
21=- D the basis for the alleged exemption.Any violation of SectMm703L5 STORIES TYPE CONSTR.
a ; by any applicant for a permit subjects the applicant to a civil penalty ALTER-DRAIN& VENT-WATER (EA.) 4.00.
of not more than five hundred dollars(55000.):
❑ I,as owner of the property,or my employees with wages as BACKFLOW PROTECT. DEVICE 2.00 OCC.GROUP RES.UNITS
their 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 F IXTURES-PER TRAP 4.00 SO,FT,FLOOR AREA TOTAL ACREAGE ,
himself or though his own employees,provided Dem such improve-
ments
mprove- -
rentserenotintendcdaroffcredfoesale.Tided that such
building GAS-EA.SYSTEM-11NC.40UTLETS 4.00
or improvement is sold within one year of completion,the owner- GAS-EA.SYSTEM-OVER 4 (EA.) 1.00 BUILDING USE
builder will have the burden of proving that he did not build or im-
prov e forpurp000fsale.). - INDUSTRIAL WASTE INTER. ' 20.00
❑ 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. 5.00 ASSESSORS PARCEL NO,
and Professions Code:The Contractor's License Law does not apply
to an owner of property who builds of improves thereon,and who LAWN SPRINKLERS-OVER 5(EA.) 1,00 '
Contracts for such projects with a contractor(sl licensed pursuant to '
the Contractor's License Law. SEWER-SANITARY-STORM EA.200ft/6.00 TRACT NO. - PARCEL NO.
❑ I no exempt under Sec. - ,R&RC.for this WATER HEATER W/VENT 4.00
re.
son
Date Owner WATER SYSTEM 4.00 ACC.DATE ACC.FILE NO.
WORKERS'COMPIiNSATION DI:CLARATION WATER TREATING EQUIP. 4.00
I hereby affirm that I have a certificate of Consent 1.self-insure, ZONING ENG.SITE NO.
or a certificate of Workers'Compensation Insurance,or a Certified ,
copy thereof(Sec.3800,Lab.C.).FA s Tl�b N-J�
PtN'mr�yI�NO. Company
0 l�Certified Copy ishereby furnished. ' '- FIRE SPRINK ENERGY T 24
Z Z ❑ Cerl y ie-libel wir, City inspection division. MISC.- REFER TO ORD.
Applicant O� ✓ Y ❑ N❑ Y.F] N❑
into PERMIT ISSUANCE 6.00 FLOOD ZONE A.L.U,C.
LU > CERTIFICATE EXEMPTION FROM WORKERS'W COMPENSATION INSURANCE PLG.CONTR. LIC.NO. PLG.
CL O (This section need not be completed if the permit is 1'or one TOTAL Y❑ Ni Y ❑ N
Z) Z hundred dollars IS 100)or less.)
U O 1 certify that in the performance of the work for which this per- CITY MECHANICAL PERMIT FEE FEE SUMMARY
U. mit is issued,I shall not employ any person in any manner so as to
U become subject to the Workers'Compensation Laws of California.
ED Date ApplicantALTER OR ADD TO MECH, q,pp BUILDING ,
} m NOTICE TO APPLICANT: If,after making this Certificate of Ex-
F,-. ? emption,you should become subject to the Workers'Compensation APPLIANCE 4.00 PLAN CHECK
provisions of the Labor Code, you roust forthwith comply with FEE
V such provisions or this permit shall be deemed revoked AIR HANDLING UNIT(TO 10=C.F.M.) 3.00
CONSTRUCTION LENDING AGENCY AIRHANDLING UNIT(OVER 10=C.F.M.) 5.00 SEISMIC FEE
I hereby affirm that there Era construction lending agency for EXHAUST HOOD (WITH DUCT) 2.00
the performunce of the work for which this permit is issued(Sec. HEATING UNIT(TO 100,000 B.T.U.) 4.00 MICROFILM
3097,Civ.C.).
Lenders Name HEATING UNIT(OV ER 100,000 B.T.U.)7.50
Lender's Address ELECTRIC
I certify that I have read this application and state that the above VENTILATION FAN (SINGLE) 3.00
information n correct I agree to comply with all city unJ county PLUMBING
ordinances and state laws relating to building construction,co and BOILER-COMP(3,H.P.or 100,000 B.T.U.) 4.00
hereby authorize representatives of this city to enter upon the BOILER-COMP(Over 100,0000TU)SEE FEESCH. MECHANICAL
above-mentioned property for 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 3.00 ,
�mnli is mil. MECH.CONT. LIC.NO. MECH. '
7 TOTAL TOTAL
'Signature of A Iicant/C mlrac or Jat
. . . OFFICE COPY