9418 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT P NLY
BUILDING PROJECT 1 DENTI FICATI ONPERMIT NUMBER
�( aUILDING APPLICATION & PERMIT , 9 418
a Dfl Ea� 3 n
Cj Id BUILDING-ELECTRICAL-PLUMBING-MECHANICAL
OWNER'S PLAN CHECK VALIDATION
" OTY. ELECTRIC PERMIT FEE
• eA4Ne &00AP NONE 6- S 3�'�G�/;�
NAMERacroRS OUTLETS-SWITCHES-RECEP 10.00/1.00
LIC.NO, LIGHTING FIXTURES 10.00/1.00
CONTRACTOR'S
ADDPPLIANCES-RESIDENTIAL 4.00
AO
PHONE PANELS 10.00 DATE OF APPLICATION
ARCHITECTPANELS'(OVER 200 AMP) 20,00 PLAN CHECK FEE P.C.NO.
ENGINEER _ LIC,NO SIGNS TRANS. 3.00
EOR ENT SPECIAL CIRCUIT 5.00 PERMIT VALIDATION
ZIP TEMP. METER OR POLE INS, 20.00 PAID
APPLICANT SMOTORS SEE FEE SCH.
ADDDRESSDRESS
SERVICE CHANGE 20:00 AUG - 5 1985
woo LICENSED CONTRACTORS DECLARATION TEMP.POLE 30.00 �N
<wa
cU I hereby af0mt that Lam licensed under provisions of Chapter 9 U E pAIV. 1110
y "' (commencin with Section 7000)of Division 3 of the Business and
a ,AA 8 BLDG. T. PL MECH.
r h z Professions Code,and my license is in full force and effect. ElE] ❑
o i u, en
W Licse Class Lic.Number IN
. r w H J Date Contractor
a Y s BUILDING PERMIT
¢ ¢nOWNER-BUILDER DECLARATION INFORMATION
xN I hereby affirm that I am exempt from the Contractor's License MISC.- REFER TO ORD
FUOes Law forthe following reason,(Sec.7031.5,Business and Professions PERMIT ISSUANCE 10.00 VALUATION $/FT.
Cade:Any city or county which requires a permit to construct,alter,
¢ ¢ ¢ D improve,demolish,or repair any structure,prior to its issuance,also ELEC.CONTR. LIC.NO. ELEC.
n -A c a requires the applicant for such permit to file a signed statement that TOTAL PERMIT TO
w m he is licensed pursuant to the provisions out the Contractor's License !�-
ei z aLaw(Chapter 9(commencingwith Section 7000)of Division 3 ofthe �e W1a7U
Business and Professions Code)or that he is exempt therefrom and QTY- PLUMBING PERMIT FEE
0C r$ the basis for the alleged exemption.Any violation Of Section 7031.5 STORIES TYPE CONSTR.
d ; by any applicant for a permit subjects the applicant toa civil penalty 'ALTER-DRAIN -WATER IEA.) 5.00
of not more than five hundred dollars(S5001.)'.
❑ 1,as owner of the property,or my employees with wages as BACK FLOW PROTECT.DEVICE 4.00 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,GOND. 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-PER TRAP 5.00 50.FT.FLOOR AREA TOTAL ACREAGE
• himself or through his own employees,provided that such improve-
mems are not intended or offered for sale.If,however,the building GAS-EA.SYSTEM-1 INC.4 OUTLETS 6.00
or improvement is sold within one year of completion,the owner- GAS-EA.SYSTEM-OVER 4(E!1) 2.00 BUILDING USE
builder will have the burden of proving that he did not build or im- RES IND CON PB Omer
prove For purpose ofsnleJ, INDUSTRIAL WASTE INTER. 30.00
I,as owner of the property,am exclusively contracting with 11 13 El 1:1 1:1li sea 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 Lawdoes 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 contractoos)licensed pursuant to SEWER-SANITARY-STORM EA.200ft/10.00
the Contractor's License Law. TRACT NO. PARCEL NO.
❑ I um exempt under See,.,BAP.C.for this WATER HEATER W/VENT 6.00
reason
Owner Uate - WATER SYSTEM 5.00 ACC.DATE ACC.FILE NO.
WORKERS'COMPENSATION DECLARATION WATER TREATING EQUIP. 5.00
1 hereby affirm that I have a certificate of consent to self-insure, ZONING ENG,SITE N0.
or a certificate of Workers'Compensation Insurance,or a certified
copy thereof(See.3800,Lab.C.). i
Policy No. Company
Q ❑ Certified copy is hereby furnished. FIRE SPRINK ENERGY T.24
Z 2 ❑ Certified copy is filed,with the city inspection division.
0 Applicant MISC.- REFER TO ORD. - y ❑ N❑ Y ❑ N❑
~ in PERMIT ISSUA CE 10.00 FLOOD ZONE A.L.U.c.
Lu - CERTIFICATE PE EXEMPTION PROM WORKERS'
W � COMPENSATION INSURANCE L .CONT NO. PLG. eI w
0- 0 (This section need not be completed if the permit is for one TOTAL OGY Y❑ N❑ Y E] ❑
N
hundred dollars IS 100)cur Tess.)
U 0 I certify that in the performance of the work for which this per- OTY MECHANICAL PERMIT FEE FEE SUMMARY
LL U mit is issued.I shall not employ any person in any nanner so as to
become subject to the Workers'Co npensalion Laws of California.
ED Datc Applicant ALTER OR ADD TO MECH. 5.00 BUILDING
} to NOTICE TO APPLICANT: If,after making this Certificate of Ex-
r Z emption,you should become subject to the Workers'Compensation APPLIANCE 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 10SWC.F.M.) 4.00
CONSTRUCTION LENDING AGENCY AIR HANDLING UNIT(OVER 10MC.F.M.) 6.00 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 ISec. MICROFILM
3097,Civ C.). HEATING UNIT(TO 100,000 B.T.U.) 6.00
Lender's Name
Lender's Address HEATI NG 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 is correct. I agree to comply with all city and county PLUMBING LT
ordinances and store laws relating to building construction, and BOILER-OOMP(3 H.P.Or 100,000 B.T.U.1 6.00
.hereby authorize representatives of this City to enter upon the BOILER-COMP IOver 100,000 BTU)SEE FEE SCH. MECHANICAL
above-mentioned property for inspection purposes.
(We) agree to save, indemnify and keep harndess'the City of MISC.- REFER TO ORD.
Cupertino against liabilities,just ts, costs and expenses which PERMIT ISSUANCE 10.001CONST.TAX
may in any way accrue agains , City in nsequence of the
g
=his LIC.NO. MECH.
TDTAL. . TOTAL
gnature of Appl ant o tractor ate
OFFICE COPY' -