8529 A0,P„L4CANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
BU I LDING PROJECT I DENTIFICATI ON PERMITNUMBER
aDILDING APPLICATION & PERMIT
noon
Iei I BUILDING - ELECTRICAL-PLUMBING-MECHANICAL 8529
OWNER'S PLAN CHECK VALIDATION
NAME QTY. ELECTRIC PERMIT FEE
eONE
NAMen Toms OUTLETS-SWITCHES-RECEP 10.00/1.00
•� _m . LIGHTING FIXTURES 10.00/1.00
CONTRACTOR1 PPLIANCES-RESIDENTIAL 4,00
ADDRE
NE - PANELS 10.00 DATE OF APPLICATION
RCHI T ECT PLAN CHECK FEE P.C.NO.
OR PANELS (OVER 200 AMP) 20.00
ENGINEER
uC.ii SIGNS TRANS. 3.00
aoo iss eNa SPECIAL CIRCUIT 5.00 PE ATION
ZIP EMP.METER OR POLE INS. 20.00
ADDDRESS T's MOTORS SEE FEE SCH. JUN 5 1J198!,
SERVICE CHANGE 20,00
woo LICENSED CONTRACTORS DECLARATION TEMP. POLE 30.00 City of l;u�ertino
a u w I hereby affirm that I an,licensed under provisions Of Chapter 9 ISSUANCE DATE
z (commencing with Section 7000)of Division 3 of the Business and
BLDG. ELECT. PLG. ME
G 2 i Prufessiuns Co littnse is in full fort off ❑ ❑ ❑
Z O(6' - License Ca It Lic.Numbc /�
o z F D Uam Comrvctor
w a OWNER ILDER DECLARATION BUILDING PERMIT
O n O INFORMATION
X ; LL y I hereby affirm that I am exempt from thr Contractor's License MISC.- REFER TO ORD
u0a Law for the following reason. 7031.5,Businessand Professions PERMIT ISSUANCE 10.00 VALUATION S/FT.
H -0 Code:Any city or county which mquiresa permit to construct,after,
¢ ce< improve,demolish,or rtpair any structure,prior to its issuance,also ELEC.CONTR. LIC.NO. ELEC.
wO LL requires the applicant for such permit to Glc a signed statement that TOTAL PERMIT T
m he u licensed pursuant to the provisions of the Contractor's License
Hz � Law(Chapter 9(commencing with Section 7100)of Division 3 ofthe _
4 o Business and Professions Ci or that he is exempt therefrom and OTY. PLUMBING PERMIT FEE
w H the basis for the allrged exemption.Any violation nCS,cti.G 7031.5 STORE TYPE CONSTR.
by any applicant for a permit subjects the applicant to a civil penally
of not more than five hundred dollars(5510).1: ALTER-DRAIN& VENT-WATER (EA.) 5.00
❑ 1,as owner of the property,or my employee;with wages as BACK F LOW PROTECT.DEV ICE 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,COND. 5.00
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 5.00 sa FT.FLOOR AREA TOTAL ACREAGE
himself or through his own employ,,,,Provided that such'in
prove-
meetserenot intended orOffered for sale.If,however,the building GAS-EA.SYSTEM-1 1 NC.4 OUTLETS 6.00
or improvement is sold within one year of completion,the owner- GAS-EA.SYSTEM-OVER 4 (EA.) 2.00
builder will have the burden ofproving film he did not build or im- BUILDING USE
prove for purpose ofsale.). INDUSTRIAL WASTE INTER. 30.00 E IND CON PB Other
❑ I,as owner of the property,am exclusively contracting withEl El 0 11
licensed contractors to construct the Project(Sec 7044,BusinessI LAWN SPRINKLERS-1 INC 5 V.B. 6.00 ASSESSORS PARCEL NO.
and Professions Code:The Contractor's License Law docs 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 contractorls)licensed parmant to SEWER-SANITARY-STORM EA.ZOOft/10.00
the Contractor's License law. TRACT NO. PARCEL NO.
❑ l am exempt under Ser..,L&P.C.for this WATER HEATER W/VENT 6.00
rtason
Owner Date WATER SYSTEM 5.00 ACC.DATE ACG FILE NO.
WORK ERS'COMPIiNSAI'ION DECLARATION WATER TREATING EOUIP. 5.00
1 hereby affirm that I have a certificate of consent to self-insure,
or a Certificate of Workers Compensa1 io 1 rance,or a e mined ZONING ENG.SITE NO.
cop Pol' th Vj$eQ t ny.l� /)�i/ / - �( _
U ❑ Citified dopy is hereby Prones ed FIRE SPRINK ENERGY T]a
Z Z �(Crrrifivd copy f d with the city inspection division. ❑ E] ❑ ❑
Atp licant � / misc.- REFER TO ORD. Y N v N
LU~ TPERMIT ISSUANCE 10.0 ��rp���
> CERTIFICCOMP"NSATON INSURAONCEr EXEMPTION FRucORKIiRS' PLG.CONTR. LIC.NO. PLG eW FLOOD ZONE A.L.U.C.
S D ('This section need not be completed if the permit is for one TOTAL / Y❑ N[D Y E3 NEJ
::I Z hundred dollars IS 100)or less.)
U O 1 certify that In the performance of the work for which this Per- DTV. MECHANICAL PERMIT FEE FEE SUMMARY
LL H mit is issued I shall not employ any person in any manner so as to
O W become subject to the Workers Compem tion Laws of Calitmmw.
Ia. Datc Applicant ALTER OR ADD TO MECH. 5.00 BUILDING
} m NOTICE TO APPLICANT: If,after making this Certificate of Ex-
F Z emption,you should become subject to the Workars'Compensation APPLIANCE 5.00 PLAN CHECK
U
provisions
of he Labor Code, you must forthwith comply with
such
ons
p tPermit shall be deemed revoked. I AIR HANDLING UNIT(TO 10X0C.F.NL) 4.00 FEE
CONSTRUCTION LENDING AGENCY AIR HANDLING UNIT(OVER 10=11F.M.) 6.00 SEISMIC FEE
I hereby affirm that there is o construction lending agency for EXHAUST HOOD (WITH DUCT) 5.00
tlm performance of the work for which this permit is issued(Sec.
3097,Civ.C.). HEATING UNIT(TO 100,000 B.T.U.) 8.00 MICROFILM
Lendds e
amNHEATI NG UNIT 100,000 B.T.U.)9.50
Lender's Names, ELECTRIC
I certify that I have read this application and ,are that the above VENTILATION FAN (SINGLE) 4.00
• information is correct. I agree to comply with all city and county PLUMBING G 00
ordinances and state laws relating to building construction. and BOILER-CONE(3 H.P.or 100,000 B.T.U.) 6.00
hereby authorize representatives of this city to enter upon the BOILER-COMP (Over 100,000 BTU)SEE FEE SCH.
alcovenrentioned property for inspection purposes. MECHANICAL
(We) agree to save, indemnify and keep harmless the City of MISC.- REFER TO ORD.
Cupertino against liabilities,judgments, costs and exlsenses which PERMIT ISSUANCE 10.00 CONST.TAX
may in any way accrue against said City in consequence of the
grand f this pcnni6 MECH.CONT. LIC.NO. MECH.
It ) TOTALI, TOTAL
Signatu AImans/Contractor JV E�
' OFFICE COPY
I