5888 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
BUILDING PROJECT IDENTIFICATION ' PERMITNUMBER
BUILDING APPLICATION & PERMIT
ADDRESS G Q Q Q
BUILDING-ELECTRICAL-PLUMBING-MECHANICAL JuuV
OWNER'S /�- . PLAY C(ILIDATION
NAME - _ QTY. ELECTRIC PERMIT FEE CA`v
PHONE HH .f
CONTRACTOR /< UTLETS-SWITCHES-RECEP 5.00/1.00 AUG 2 G 198"1
<'G , Lie.ND. x��// LIGHTING FIXTURES 5.00/1.00
CONTRACTOR'S APPLIANCES 4.00
AaDREEa/('�/ y � City qt Cupertino
OX PHON )O'-pI PANELS 5.00 DATE OF APPLICATION
ARCHITECT SIGNS 6.00 PLAN CHECK FEE" P.C.NO.
ENGINEER
- LIC.No. SIGNS TRANS. 3.00
ADDRESS era SPECIALCIRCUIT '5.00 P MIT VALIDATION
ZIP FEMP.METER OR POLE INS. 15.00
APPLICANT MOTORS SEE FEE SCH.
ADDRESS
SERVICE CHANGE 10.00 0
o¢ z
Foo LICENSED CONTRACTORS DECLARATION
¢U U I hereby affirm that I am licensed under provisions of Chapter 9 ISSUANCE DATE
wn (commencing with Section 7000)of Division 3 of the Business and
Q - L ELECT. PLG. MECH.
F N z Professions Cod e �gd yyy...license is in full
forceYO License Jas Lic.NumhcrOm Z
1-1 El
FwDate Contractor-
❑
%
a sa f BUILDING PERMIT .
¢¢ OWNER-RUILDER DECLARATION -
a o ur u INFORMATION
w ;u w I hereby uflirm that I am exempt from the Contractor's License MISC.- REFER-WORD V LUATION S/fT.
F LL 0 4 I.aw for the fallowing reason.(Sec.7031.5,Busom.S.nd Professions PERMIT ISSUANCE 6,00 O�
Code:Any city or county which reyuiresa permit to construel,alter,
isimprove,demolish,or repair any structure,Print to its issuance,also ELEC.CONTH. LIC.NO. ELEC.
LL reclaims the applicant for such permit to file a signed statement that TOTAL PERMIT TO
A w m n he is licensed punaanl to the provisions of the Connuctor's License
Hz >
Law(Chapter 9(commencingwith Section 7000)of Division 3 ofthc
i ao Business and Professions Code)or[hat he is exempt therefrom and OTY. PLUMBING PERMIT FEE
IF f m the basis for the alleged exemption.Any violation of Section 7031.5 IES PE CONSTR.
n ; � by any applicant for a permit subjects the applicant It)a civil penalty ALTER-DRAIN -WATER (EA.) q.00
of not more(ban Eve hundred dollars(5500).):
❑ I,as owner of the property,or my employees with wages as BACK FLOW PROTECT.DEVICE 2.00 GROUP 5.t1NlT
their sole compensation,will do the work,and the structure is not
intended or offered for to(Sec. 7044, Business and Professions DRAINS-FLOOR,ROOF,AREA,COND. 4.00
Code:The Contractor's License Law does not apply to an owner of V
property who builds or improves thereon,and who does such work FIXTURES-PER TRAP 4.00 SD.FT.FLOOR ARE TO Ae EAGE
� himself or through his own employees,provided that such improve.
1 menu arc not intended or offered for sale.If,however,the building GAS-EA.SYSTEM-I INC.4 OUTLETS 4.00
or improvement is sold within one year of completion,the owner- GAS-EASYSTEM-OVER 4(EA) 100 BUILDING USE
builder will have the burden of proving Ilial he did not build at im . . .
R IND CON PB Oren
prove for purpose of sale.). INDUSTRIAL WASTE INTER. 20.00
❑ I,as owner of the properly,um exclusively contracting with ❑ ❑ ❑ ❑
licensed conlmeton to Construct the project(Sec.7044,nosiness LAWN SPRINKLERS-1 INC 5 V.B. 5.00 ASSESSORS PARCEL NO.
and Professions Gyle:-The Contractors License Law does not apply
10 an owner of property who builds or improves(hereon,and who LAWN SPRINKLERS-OVER 5(EA.) 1.00
contracts for such projects with a conlracln(s)licensed punuant to
[he Contractor's License Law. SEWER-SANITARY-STORM EA.200ft/8.00 TRACT NO. PARCEL NO.
❑ 1 am exempt under Sec.-,BAP.C.for this
WATER HEATER W/VENT 4.00
reason
Owner Date WATER SYSTEM 4.00 ACC.DATE 7 ACC.FILE NO.
WORK BRS'COMPENSAI'ION DECLARATION WATER TREATING EQUIP. 4.00 .
I hereby affirm that I have a cer[ificam ofconsent to SCITinsure,
or a Certificate of Workers'Compensation Ineorance.or a Certified ZONING ENG.SITE NO.
PoliicylNomT_YV 2CamPany.).NQACe.V
O ❑ Certified copy is hereby furnished, FIRE SPRINK ENERGY T-24
p: ZO ❑ Certified �D�//is hI with the city inspection division. MISC.- REFER TO ORD. ❑ ❑ ❑ ❑ .
Applicant_L.�?, I- V N V N
X W CERTIFICA'I'1:017 EXEMP'HON FROM WORKERS' PERMIT ISSUANCE 6.00 FLOOD ZONE A.L.U.C.
W COMPENSATION INSURANCE PLG.CONTR. LIC.NO. PLO.
Z (This section need not,be completed if[hN
e permit is for one TOTAL Y❑ ❑ Y❑ N
hundred dollars IS 100)or less.)
U O 1 certify that in the performance of the work for which this per- OTV. MECHANICAL PERMIT FEE FEE SUMMARY
W H mit is issued,I shall not employ any person in any manner so as to
Q . .become subject to the Workers Compensation Laws of Calilnmia.
n Date Applicant q,0p BUILDING
ALTER OR ADD TO MECH.
} to NOTICE TO APPLICANT: If,after making this Certificate of Ex-
? emption,you should become subject to the Workers'Cmnpensation APPLIANCE 4.00 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 10=CF.M.) 3.00
CONSTRUCTION LENDING AGENCY AIR HANDLING UNIT(OVER 10=C.F.M.) 5.00 SEISMIC FEE
I hereby affirm that there is a construction mit is
agency far EXHAUST HOOD(WITH DUCT) 2.00
the performance of the work for which this permit is issued(Sec. HEATING UNIT(TO 100,000 B.T.U.) 4.00 MICROFILM
3097,is Na).
Lender's Name
Lender's Address HEATING UNIT(OVER 100,000 B.T.U.)7.50 ELECTRIC
I certify that I have read this application and state ilia[the above VENTILATION FAN (SINGLE) 3.00
information is correct. I agree to comply with all city and county PLUMBING
ordinances and state laws relating 10 building construction,and BOILER-COWIP(3 H.P.Or 100,000 B.T.U.) 4.00
hereby aulhorite representatives of this city to enter upon [hc BOILER-COMP (Over 100,000 BTU)SEE FEE SCH. MECHANICAL
above mentioned property for inspection purpows.
(We) agree to save, indemnify and keep harmless the City of MISC.- REFER TO ORD.
Cupertino against liabilities,judgments, Costs and expenses which CONST.TAX
may in any way accrue against said City in consequence of the PERMIT ISSUANCE 3.00
granting pGthji pernhit. A � /� � MECH.CONT. LIG NO. MECH.
�(IYL1P 4 / TOT"` TOTAL
Signal roof App marl/Contractor Da
OFFICE COPY