12091 APPLICANT TO FILL IN INFO ATION WITHIN RED LINES - USE W&L POINT.PEN ONLY
BUILDING PROJECT IDENTIFICAPERMIT NUMBER
BUILDING APPLICATION & PEWIT
IT 0
REa
BUILDING-ELECTRICAL-PLUMBING-MECHANICAL
q'S 91
PLAN CHECK VALIDATION
NAME OTV. ELECTRIC PERMIT FEE -T � 7
J s o2 / ^
Gr PNDNE �14b - 5
CONTRACTORS
NAME $ UTLETS-SWITCHES-RECEP 10.00/1.00
NAME
LIC.No. o� LIGHTING FIXTURES 10.00/1.00
f.ONTfl ACTOR's
A^DORE55 tr�'� /-� APPLIANCES 4.00
V Cr NONE '44(9-194 PANELS 10.00 DATE OF APPLICATION
ARCHITECT PANELS (OVER 200 AMP) 2000 PLAN CHECK FEE P.C.NO.
Ofl
ENGINEE ff����Ir.
$ I /7 UC.rvoClS/(oa SIGNS TRANS. 3.00
ADR. END. - SPECIAL CIRCUIT 5.00 P [DnnoN
ADDRESS
ss /�
zIPQLt(p EMP.METER OR POLE INS. 20.00 MAR 5 _ 1987
APPLICANT'S MOTORS SEE FEE SCH. JO
ADDRESS
SERVICE CHANGE 20.00 CRY ofCapWidno
woo LICENSED CONTRACTORS DECLARATION s"
<u u I hereby affirm that 1 am licensed under provisions of Chapter 9 ISSUANCE DATE
a y (commencing with Section 7000)of Division 3 of the Business and DWT
MUCH
F D i Professions C and my license is in full fur O Licenu la Lic.Number0wrwDate Contractor_re ¢ OWNER.BUILDER DECLARATION N
Boa" MISC- - REFER TO ORD
u r I hereby affirm Thal I am exempt from the Confmctor's License
IL O< Lawforthe following reason.(Sec.7031.5,Businessand Professions PERMIT ISSUANCE 10.00 /vyL�UATION S/FT.
jww� Code:Any city or county which requires a permit to construct, r y)
a <p improve.demolish,or repair any Structure,prior to its issuance,also ELEC.CONTR. U17-NO. ELEC. ./ ✓/
O= requires the applicant for such permit to file a signed statement that TOTAL 3 PERMIT TO
A. a.m he is licensed pursuant to the provisions of the Contractor's License -
C z¢
Law(Chapter 9(commencing with Section 70001 of Division 3 ofthe
i c Business and Professions Code)of that he is exempt therefrom and OTY. PLUMBING PERMIT -FEE
s H$ the basis for the alleged exemption.Any violation of Section 7031.5 STORIES TYPE ON;}t�
by any applicant for a permit subjects the applicant to a civil penalty ALTER-DRAIN&VENT-WATER (EA.) 5.00
m
of not oon than five hundred dollars(S500).):
❑ I,as owner of the property,or my employees with wages as BACK FLOW PROTECT. DEVICE 4.00 O UP 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. 5.00
Code:The Contractor's License Law docs not apply to an owner of
property who builds or improves thereon,and who does such work Q FIXTURES-PER TRAP 5.00 sa P .F ao Afl A TOTAL 4CREAGE
himself or through his own employees,provided that such improve-
rents are not intended oroffered for Sale.If,however,the budding GAS-EA.SYSTEM-11 NC.4 OUTLETS 6.00
or improvement is Sold within one year of completion,the Owner-
builderBUILDING will have the burden of proving that he did not build or im . .
' IND CON PB Omar
prove for purpose of sale.). INDUSTRIAL WASTE INTER. 30.00
❑ 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. 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 IEA.) 1.00
contracts for such projects with a contractor(s)licensed pursuant to SEWER-SANITARY-STORM EA.200ft/10.00 TRACT NO. PARCEL NO.
the Contractor's License Law.
❑ I um exempt under Sec.-,BAP.C.for this WATER HEATER W/VENT 6.00
reason
Owner Date WATER SYSTEM 5.00 ACC.DATE ACC,FILE NO.
WORKF.RS'COMPENSATION DECLARATION WATER TREATING EQUIP. 5.00
1 hereby affirm that I have a certificate of consent to self-insure. ZONING ENG.SITE NO.
or a certificate of Workers'Compensation Insurance,or a certified
copy thereof(Sec.3600,Lab.C.). (5p.4-C'7
Policy No. Company
Q Q Certified copy is hereby furnished. FIRE SPHINK ENERGY T 24
Z Z •tQ Certifie coy is f •d with the city inspection division. MISC.- REFER TO ORD. y ❑ N❑ y ❑ No
O APPlicant
CC I2 PERMIT ISSUANCE 10.00 FLOOD ZONE A.LU.C.
LU - CERTIFICATE OF EXEMPTION FROM WORKERS'
CL >_ COMPENSATION INSURANCE PLG.CONTR. LIC.NO. PLG.
CL O (This Section need not be completed if the permit is for one TOTAL Y❑ No , V❑ N❑
D Z hundred dollars($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. H mil is issued,I shall not employ any person in any manner so as 1.
U become subject to the Workers Compensation,Laws of California.
Date cant BUILDING
0 W Appli
a ALTER OR ADD TO MECH. 5.00
} IA NOTICE TO APPLICANT: If,after making this Certificate Ex
F Z eruption,you should become subject to the Worken'Compensato tion APPLIANCE 5.00 PLAN CHECK
provisions of the Labor Code, you must forthwith comply with FEE
U AIR HANDLING UNIT(TO.10,000GF.NL) 4.00
such provisions or this permit shall be deemed revoked. /1
CONSTRUCTION LENDING AGENCY AIR HANDLING UNIT(OVER 10=C.EM.) 6.00 SEISMIC FEE 01
I hereby affirm that there is a construction lending agency for EXHAUST HOOD (WITH DUCT) 5.00
the performance f the wor far which this permit is issued(Sec. MICROFILM
3097,Civ.CJ. ��cm HEATING UNIT ITO 100,000 B.T.U.) 8.00
Lender's Name / HEATING UNIT MER 100,000 B.T.U.)9.50 ELECTRIC
Lender's Addre
I certify that I have read this application and state that the above VENTILATION FAN (SINGLE) 4.00 ZEE
information is correct. I agree to comply with all city and county BOILER-COMP(3 H.P.or 100',000 B.T.U.) 6.00 PLUMBING
ordinances and stale laws relating to building construction, and
hereby authorize representatives of this city to enter upon the BOILER-COMP (Over 100,000 BTU)SEE FEE SCM. MECHANICAL 3
above-mentioned property for inspection puiposes.
(We) agree to save, indemnify and keep harmless the City of MISC.- REFER TO ORD.
Cupertino against liabilities,judgments, Costs and expenses which PERMIT ISSUANCE 10.00 1 rCONST.TAX
may in any way accrue,against said City in consequence of the
gmnli oft 's per _ - MECH.CONT. I.C.N0. TOTA� ! / TOTAL I I I
Signa um of Meant/Contractor Date I�
OFFICECOPY 1