10133APPLICANT TO FILL IN INFORMATION WITHIN REDLINES - USE BALL POINT PEN ONLY
BU I LDING PROJECT I DENTIFICATI ON
I
APPLICATION & PERMIT
LDINFr -ELECTRICAL- PLUMBING -MECHANICAL
- PERMITNUMBER
10133
BUILDING
A
WORESNER'
NAME
I1
QTY. ELECTRIC PERMIT FEE
PLAN CHECK VALIDATION
PHONE
OME c*ons
NAME/-,a
UTLETS-SWITCHE -RECEP 10.00/1.00
r
sec. No
LIGHTING FIXTURE 10.00/1.00
ADDDDRESS RESSTRACRs
A
APPLIANCES - REST I 4.00
�p
�-L v PHONE "�/��0
DATE OF APPLICATION
Z PANELS 10,00
AOPRCNITECT
ENGINEER
Lie . NO
PANELS (OVE O 20.00
PLAN CHECK FEE P.C. NO.
SIGNS T .OD
AARCH, R
DDRESS ENO
SPEC A I U 5 O
PERMIT VALIDATION
ZIP
EMP 20.0
PAIL
1CIy
ATS
ADDDREDRESS
MOT S E FEE SCH.
SE ICE CHkqGA MI 20.00
DEC 4 -1985
LICENSED CONTRACTORS DECLARATION
TEMP. POLE141 30.00
I hereby affirm that 1 am licensed under provisions of Chapter 9
(commencing with Section 7000) of Division 3 of the Business and
Professions Cod an y license is full fare d e c
Licens lass- Lic. Number
Dare CoNractmr E'
BL MECH.
❑' ❑ ❑
Q
BUI DING PERMIT
I FORMATION
OWNER -BUILDER DE LARATION
1 hereby affirm that 1 am exempt from the Contractor's License
Law fornycit the following r ountywhih c. 703 requires a permit to and Professions
Code: Any City or county my whiny structur e permit or construct, also
Or repair
improve, e applicant
ester to Its issuance, that
such statement that
h p structure,itofile
requires thedp pursuant
far such permit t0 file a signedContractor's
hews licensed pursuanten the provisions of the License
MISC.- REFER TO ORD
PERMIT ISSUANCE 10.00
VALUATION
$/FT.
ELEQ CONTR. LIC. NO. ELTA
TOTAL
PERMIT TO
)o fDmtorn
of Division 3 of the
Law (Chapter 9 (commencing with Section is exempt
Business and Professions Code) or that he is exempt therefrom and
DTV. PLUMBING PERMIT FEE
STORIES
E CONSTR.
the basis for the alleged exemption. Any violation of Stensen 703
by any applicant for apemrt delta,, $500).he licam macivil penalty
malty
of not mom than five hundred dollars (E500)J:
ALTER-DRAIN-WATER(EA.) 5.00
❑ I, as owner of the property, or my employees with wages ss
their sole compensation, will do the work, and the structure is not
BACK FLOW PROTECT. DEVICE 4.00
DCC. GROUP
RES. UNITS
DRAINS -FLOOR, ROOF, AREA, COND. 5.00
intended or offered I'or sale (Sea 7044, Business and Professions
Code: The Contractor's License Law does not apply to an owner of
FIXTURES - PER TRAP 5,00
GAS - EA. SYSTEM -1 INC.4 OUTLETS 6.00
SD, FT. FLOOR AREA
TOTAL ACREAGE
property who builds or improves thereon. and who does such work
himself or through his own employees, provided that such improve-
mentsarenot intended or offered l'or sale. If, however, the building
Or improvement is sold within one year of completion, the owner-
builder will have the burden of proving that he did not build or im-
of "the.).
prove for 1, as owner
❑ as owner of the property, exclusively contracting with
GAS - EA. SYSTEM -OVER 4 (EA.) 2.00
BUILDING USE
RES IND N PB Omer
Q ❑ Q El
INDUSTRIAL WASTE INTER. 30.00
d
licensed contractors m construct the project (Sec. does Business
he
and Professions Cade: The Contractor's License Law does not apply
to owner of property who builds improves thereon. and who
LAWN SPRINKLERS - 1'INC 5 V.B. 6.00
LAWN SPRINKLERS -OVER 5 (EA.) 1.00
ASSESSD SPA CEL NO.
tr
con tracts for such projects with a conmcmrts) licensed pursuant m
t
the Contractor's License Law.
SEWER -SANITARY -STORM EA. 200ft/10.00
TRACT NO.
PARCEL NO.
❑ lain exempt under Sec. ,B,&P.C. for this
reason
WATER HEATER W/VENT 6.00
Owner Date
WATER SYSTEM 5.00
ACC. GATE
ACC. FILE N0.
WATER TREATING EQUIP. 5.00
WORKERS'COMPENSATION DECLARATION
I hereby affirm that I have a certificate of consent to self -insure,
or a certificate of Workers' Compensation Insurance, or a certified
ZONING
ENG. SITE N0.
copy thereoffSec. 3800, Lab.C.).
P lip cy^. Company
Nr C rtifte y is It b fur 'bed.
ertn' copy n n the city nspecliun division.
pcleant
ov
FIRE SPRINK
Y ❑ N ❑
ENERGY T�34
Y ❑ NE]
MISC. - - REFER TO ORD.
FiRTIFICATF- OF EXEMPTION FROM WORKERS'
PERMIT ISSUANCE 10.00
FLOODZONE
A.L.U.C.
COMPENSATION INSURANCE:
section need not he completed if the permit is for one
Y E] NC]Y
E] NE]
PLG, CONTR. LIC. NO.
TaT.AL
hundred dollars(SIOO) or less.)
I certify that in the performance of the work for which this per,
mit is issued. I shall not employ any person in any mannerso as to
OTY. MECHANICAL PERMIT FEE
FEE SUMMARY
BUILDING
become subject to the Workers' Compensation Laws of California.
Dale Applicant
ALTER OR ADD TO MECH. 5.00
NOTICE: TO APPLICANT: If, after making this Certificate of Ex-
APPLIANCE 5.00
PLAN CHECK
eTp!ion, you should become subject to the Workers Compensation
provisions of the Labor Code, you must forthwith comply with
such provisions or this permit shall be deemed revoked.
AIR HANDLING UNIT (TO 10,D000.F.M.) 4.00
FEE
AIR HANDLING UNIT (OVER 10=C.EM.)6.00
SEISMIC FEE
CONSTRUCTION LENDING AGENCY
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.
3097, Civ.C.).
MICROFILM
HEATING UNIT (TO 100,000 B.T.U.) 8.00
Lender's Name
Lender's Address
HEATING UNIT (OV ER 100,000 B.T.U.)
ELECTRIC
I certify that I have read this application and "Lute that the above
VENTILATION FAN (SINGLE) 4.00
information is correct. 1 agree to comply with all city and county
ordinances and state laws relating to building construction, and
PLUMBING
BOILER- COUP (3 H.P. Or 100,000 B.T.U.) 6.00
BOILER-COMP (0VBr100.000BTU) SEE FEESCH.
MECHANICAL
hereby authorize representatives of this city to enter upon llie
above-mentioned property for inspection purposes.
(We) agree to save, indemnify and keep harmless the City of
Cupertino against liabilities, judgments, costs and expenses which
ma 'n any wa a ru against said City in consequence of the
III ng of this er t
MISC. - REFER TO ORD.
CONST. TAX
PERMIT ISSUANCE 10.00
MECH. CONT. LIC. NO.
MECH.
TOTAL
TOTAL
Ignature d AppwanYcontractor Date
OFFICE COPY