8535 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BAL'•L POINT PEN ONLY
BUI LDI NO PROJECT I DE14TI FICATIONPERMIT NUMBER
BUILDING - APPLICATION & PERMIT
ADDRESS �Q ^ -�/ 1� I I DING-ELECTRICAL-PLUMBING-MECHANICAL 8535
OWrvER's - // (a`f(�•J _ , PLAN CHECK VALI DATION
NAME oh
� / 7 ELECTRIC PERMIT FEE
PRONE 11,
CONTRACTOR'Sr'
NAME If PUTLETS-SWITCHES-RECEP 10.00/1,00
)ho LIC.ND. LIGHTING FIXTURES . 10.00/1.00
ADDRESS TORS QQ APPLIANCES-RESIDENTIAL - 4.00
PHONE - p _ PANELS 10.00 DATE OF APPLICATION
aRCm cT - - PLAN CHECK FEE P.C.NO.
OR - - PANELS (OVER'200 AMP) 20.00 -
ENGINEER ,
' LIC.No. SIGNS TRANS. - - 3.00' '
AARCH,OR DDRESS ENG. - SPECIAL CIRCUIT - 5,00 'PERMIT VALIDATION
PAID
-
ZIP TEMP.METER OR POLE INS. 20.00 -
A - _ MOTORS SEE FEE SCH. -
ADDDRESSDRESS SERVICE CHANGE 20.00 'JUN 5 1985,
roo. LICENSED CONTRACTORS DECLARATION TEMP.POLE `"' 30.00
a u("j I hereby affirm that I am licensed under provisions of Chapter 9 ,City 0MR00%,
H a w (commencing with Section 7000)of Division- of h�B iness,aod BLDG. ELECT, vLG.- EC .
r N z Professions s an license is in full for e t / ❑ ❑ •a
Z o m - License Class Lic.Non-be -
o - o Date "Contractor
y f BUILDING PERMIT If
co i u NF - UILDER DECLA ATION - INFORMATION
E:
g m I hereby affirm tt am exempt from the Contractor's License MISC.- REFER TO ORD
u O Q Law for the following reason.(Sec.7031.5,Business and Professions VALUATION $/FT.
� - Code'.Any city or county which requires a permit to construct,alter, PERMIT ISSUANCE 10.00
Q Q ¢,� improve,demolish,or repair any structure,prior to its issuance,also ELEO.CONTR. - LIC.NO, ELEC. '
wo LL requires the applicant for such permit to file a signed statement that TOTAL PERMIT TO
$m he is licensed pursuant to the provisions of the Contractor's License
Fz > Law(Chapter 9(commencing with Section 7000)ofDivision 3 cribs
Q Business and Professions Code)or that he is exempt therefrom and QTY. PLUMBING PERMIT FEE
$ the basis for the alleged exemption.Any violation of Section 7031.5 5 OR ES TYPE CONSTR.
i ; _ by any applicant for a permit subjects the applicant to a civil penalty 'ALTER-DRAIN&VENT-WATER (EA.) 5.00
of not more than five hundred dollars(S500).):
❑ 1,as owner of the property,or my employees with wages as BACK FLOW PROTECT.DEVICE 4.00 OCD.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 does such work FIXTURES-PER TRAP 5,00 SO.FT,FLOOR AREA TOTAL ACREAGE
himself or through his own employees,provided that such improve-.•, GAS-EA.SVSTEM-I 6.00 1.mems are not intended or offered for sale.If,however,the budding'
or improv - .ement is sold within one year of completion,the owner- GAS EASYSTEM-OVER 4(EA.) 2.00
builder will have the burden of proving that he did not build or im- BUILDING USE
prove for purpose of sale.). INDUSTRIAL WASTE INTER: 30.00 RES IND CON RB oma, '
❑ I,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(EA.) 1.00
contracts for such projects with a contractor(s)licensed pursuant to - SEWER-SANITARY-STORM EA.200ft/10.00
She Contractor's License Law. -TRACT NO. PARCEL NO.
- ❑ lam exempt under Sec. ,B.&P.C:for this WATER HEATER W/VENT - - 6.00
reason
5M I
Owner Date WATER SYSTEM 5.00
•ACC.DATE ACC.FILE NO, .
WORKERS'COMPENSATION DECLARATION WATER TREATING EQUIP. 5.00 .µ
1 hereby affirm that I have a certificate of consent to selhima re' ZONING ENG.SITE NO.
or a certificate of Workers'Compensetio /1,an ,ora ertified
copy Che
r t
Policy NqL
O ❑ Cefed opyi�hye -
rh6RIbed. .vvzo
FIRE$PRINK ENERGY T-24
Z 2 ertified c y Is Iled with:the city inspection division. - - .
SIVA MISC.- REFER TO ORD.
O ppli ant - Y ❑ N❑� Y ❑ N❑
~ rn , PERMIT ISSUANCE - 10.00 PLDOD ZONE A.L.U.C.
C:-- CERTIFICATE OF EXEMPTION FROM WORKERS' -
LU > I COMPENSATION INSURANCE' PLG.CONTR. - LIC.NO,. PLG.
IL O (This section need not,be completed If the'permit is for one TOTAL Y.❑ •,N❑ Y ❑ No
7.z. hundred dollars IS 100)or less.)
U O ' I certify that in the performance of the work for which this per- OTY. MECHANICAL PERMIT FEE FEE SUMMARY
ly H mit is issued,I shall not employ any person in arty manner so as to
U become subject to the Workers'Compensation Laws of California. ,
SO Date Applicant ALTER OR ADD TOMECH.',: 5.00 BUILDING
} W NOTICE TO APPLICANT: If,after making this Certificate of Ex-
L.. 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
U such provisions or this permit shall be deemed revoked. AIR HANDLING UNIT(TO 10MC.F.M.) 4.00 -
CONSTRUCTIONLENDINGAGENCY AIR HANDLING UNIT(OVER 10A00C.F.M.) 6.00 SEISMICFEE•-
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. MICROFILM'
3097,Civ.C.). + HEATING UNIT(TO 100,000 B.T.U.) 8.00
Lender's Name - HEATING UNIT(OVER 100,000 B.T.U.) IELECTRIC
Lenders Address _
I certify than have read this application and state that the above VENTILATION FAN (SINGLE) . 4.00
information is correct. 1 agree to comply with all city and county PLUMBING r
ordinances and state laws relating to building construction, and BOILER-COMP 13 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. MECHANICAL
above-mentioned property for inspection purposes.
(We) agree to save, indemnify and keep harmless the City of MISC.- _ " REFER TO ORD.
Cupertino against liab'ities,judgments, costs and expenses which CONST.TAX
may . �nY way ace against said City in consequence of the 'PERMIT ISSUANCE .10.00
grant g of this per - q ECH.CONT. LIC.N0. MECH.' /
TOTAL TOTAL
*gnalitre of Applicant/Contractor Date
' OFFICE COPY - -