15371 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLYG
PERMIT NUMBER
BUILDING PROJECT IDENTIFICATION
BUILDING APPLICATION & PERMIT 15 371
ADDRESS ` 2,.
5'
UILDING - ELECTRICAL-PLUMBING-MECHANICAL
OWNER' / (O�-T PLAN CLMECjC V(Il{QATION
NAM "{ / QTY. ELECTRIC PERMIT FEE r /.l k �J
Co RA s OUTLETS-SWITCHES-RECEP 10.00/1.00 `JUN 15 X992
NAME
uc.rvo. ' 6 LIGHTING FIXTURES 10.00/1.00
ADDRESS
i- PPLIANCES-RESIDENTIAL 4.00 GITY (Ji Wptrl I I1VV
ADOREss w. I .-
C� PHONEZ ;! PANELS 10,00 DATE OF APPLICATION
PLAN lone"FEE P.C.NO.
ATaCHITECT PANELS (OVER 200 AMP) 20.00
OR
ENGINEER
uc.NO. SIGNS TRANS. 3.00
AR, ENG. S.00 PERMIT VALIDATION
ADDRESS
ss SPECIAL CIRCUIT
ZIP EMP.METER OR POLE INS. 20.00
APPLICANTS MOTORS SEE FEE SCH. v
ADDRESS
SERVICE CHANGE 20.00
0 0 LICENSED CONTRACTORS DECLARATION
a va v I hereby affirm that I am licensed under provisions of Chapter 9 ISSUANCE DATE
N<es (commencing with Section 7000)of Division 3 of the Business and BLDG. ELECT. PLG. ECH.
�, h Professions C my li se is in full fo c f l ❑
i F W Licen Clas �GEpp a Number L ❑ ❑
m DamYL_ omracl°r / 2� 42 BUILDING PERMIT
w a
OWNER-BUILDER DECLARATION �G C INFORMATION
w MISC.-
A. 1 hereby affirm that I am exempt from the Contractor's License VALUATION S/FT.
uoa Law forthe following reason.(Sec.7031.5.Business and Professions PERM IT ISSUANCE 10.00
Code:Any city or county which requires a permit to construct.alter,
1 u, Q 2 improve,demolish,or repair any structure,prior to its issuance,also ELEC.CONT R. LIC.NO. ELEC.
0,
requires the applicant for such permit to file a signed statement that TOTAL PERMIT TO
wm he is licensed pursuant to the provisions of the Contractor's License
H i> Law(Chapter 9(commencingw'ith Section 7000)of Division 3 of the
3 z o Business and Profes Code)or that he is exempt therefrom and CITY- PLUMBING PERMIT
ssionFEE
STORIES TYPE CONSTR. '
a H m the basis for the alleged exemption.Any violation of Section 7031.5 -
A. by'any applicant for a permit subjects applicant penalty ALTER-DRAIN&VENT-WATER (EA.) 5.00
of not more than five hundred dollars(S500)J:
❑ I,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,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 F IXTUR ES-PER TRAP 5,00 SQ FT.FLOOR AREA TOTAL ACREAGE
.y himself or through his own employees,provided that such improve- GAS-EA.SVSTEM-l 6.00
dents are not intended or offered for sale.If,however,the building
or improvement is sold within one year of completion,the owner-
r� GAS-EA.SYSTEM-OVER 4 (EA.) 2.00 BUILDING USE
• builder will have the burden of proving that he did not build or im- REB IND CON PB Omer
prove for purpose of sale.). INDUSTRIAL WASTE INTER. 30.00 El ❑ El El 13❑ as owner of the progeny, exclusively'contracting with
licensedd contractors to construct the he 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 forsuch pnvictswith a contracmns)licensed pursuant to SEWER-SANITARY-STORM EA.200ft/10.00TRACTNO. PARCELNO.
the Contractor's License Law.
❑ Iamexemptnmfn Sea .R&P.C.for this WATER HEATER W/VENT 6.00
reason WATER SYSTEM 5.00 ACC.DATE ACC.FILE N0.
Owner Dam
WORKERS'COMPENSATION UECLA RATION WATER TREATING EQUIP. 5.00
1 hereby affirm that I have a certificate of consent to self-insure, ZONING ENG.SITE NO.
or a cenificate of Workers'Compensation Insuran e,ora certified
copy mer qq((ff��SCec��',,.��ggQQ�� }�qy C.1.
Policy No�GjJ�1-J_ILT717�{IY
❑ Cenlfied copy is helFRFRM1-b66yfmvished. FIRE SPRINK ENERGYT 14
Z Z ❑ Certified copy is filed with the city inspection division. MISC.- REFER TO ORD. y ❑ N y ❑ NJ_]
Applicant
H - PERMIT ISSUANCE 10.00 FLOOD ZONE A.L.0 C.
M - CERTIFICATE OF I'XEMPTION FROM WORKERS'
LU > COMPENSATION INSURANCE PLG.CONTR. LIC.NO, PLG. y❑ N❑ Y❑ N❑
d TOTAL
Z hundred
section need n, be completed if the permit is for one
hu1 cert dollars1 n the pe less.) FEE SUM ARY --
U O I certify that h the performance of the work for which this per- OTV. MECHANICAL PERMIT FEE
LL H not is issued,e I shall not employ any person in any manner or as to
O w become subject to the workers'Compensation Laws of California. B
Date LTER OR ADD TO MECH. 5.00
} N NOTICE TO APPLICANT:
if.after making this Certificate of Ex-
F ? empision you should be, Co subject tome forthwith
Compensation APPLIANCE 5.00 ECK, -
provisions io the Labor Code, you most forthwith comply with AIR HANDLING UNIT(TO 10D=MC.F.M.) 4.00 F
ILV
U such provisions or this permit shall be deemed revoked. I
CONSTRUCTION LENDING AGENCY AIR HANDLING UNIT(OVER 10=C.F.M.) 6.00 SEISMIC FEE
I hereby affirm that there is a construction lending agency for EXHAUST HOOD (WITH DUCT) 5.00 MICROFILM
the performance of the work for which this permit is issued(Sec. HEATING UNIT(TO 100,000 B.T.U.) B.
3097.Cw CA
Lender's Name HEATING UNIT(OVER 100,000 B.T.U.)9.50 ELECTRIC
Lender's Address
I certify that I have read this application and state that the above VENTILATION FAN (SINGLE) 4.00 PLUMBING
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
\ ' ordinances and state laws relating to building construction, and
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 T
Cupertino against liabilities,judgments, costs and expenses whichPERMIT ISSUANCE CONST.TAX
may in any way accrue against said City in consequenec of me
ranting of this permit. MECH.CONT. LIG N0. MECH.
TT"1t.� TOTAL
Signature of Applicant/Contractor Dam
OFFICE COPY