09568 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY X 3224o-�
BUILDING PROJECT IDENTIFICATION PERMIT NUMBER
SLIMING APPLICATION & PERMIT 09568
ADDRESS
BUILDING -ELECTRICAL-PLUMBING-MECHANICAL
O NER'S PLAN CHECK VALIDATION
E• KL, PHONE QTY. ELECTRIC PERMIT FEE ERAcroRs
u „^ UTLETS,SWITCHES-RECEP 10.00/1.00
uc.rvD, LIGHTING FIXTURES 10.00/1.00
f,ONTfl ACTOR'$Q
�-I`R, r i(c
ADDR s JJ �\1188 PPLIANCES-RESIDENTIAL 4.00
PHDNE� U PANELS 10.00 DATE OF APPLICATION
OR
RCHIiECT PANELS (OVER 200 AMP) 20.00 PLAN CHECK FEE P.C.NO.
ENGINEER
LC.NO. SIGNS TRANS. 3.00
ARCH.OR ADDRESS ENG. SPECIALCIRCUIT 5,00 PE 1 ATION
ZIP EMP.METER OR POLE INS. 20.00 NOV - 7 1985
ADDDRESSDRESS
AMOTORS SEE FEE SCH.
SERVICE CHANGE 20.00 Clgsr of Cupertino
w cl e LICENSED CONTRACTORS DECLARATION TEMP,POLE 30.00 x`11
<
Er U I hereby affirm that I am licensed under provisions of Chapter 9 ISSUANCE DATE
lu !commencing ith Section 7000)of Division 3 of the Business and
BLDG. I ELECT. PLG. I MECH.
F i Professions o license is in full fr
Z 0 y- License Class Lie.Number
2 z H Date _ ContractorPrw
Y i J BUILDING PERMIT
¢ ¢i u OWNER-BUILDER DECLARATION INFORMATION
X ; w I hereby affirm that 1 am exempt from the Contractor's License MISC.- REFER TO ORD
w LL 0 ¢ Law for the followingreason.(Sec.7031.5,Businessland Professions VALUATION $/FT.
-0 Code:Anycityorcont PERMIT ISSUANCE 10.00
w> y which requires a permit to construct.aper,
2 s G Improve,demolish,or repair any structure,prior m Its issuance,also ELEC.CONTR. LIC.NO. ELEC.
u w m LL he
the applicant t t such permit to file a signed statement that TOTAL oC�,,,,'T TO -
he is licensed pursuant to the provisions of the Contractor's License
17/]R u"n'1`71s'�-/`J
Hir Law(Chapter 9(commencing with Section 7000)of Division 3 of(he s'w
f 4 o Business and Professions Code)or that he is exempt therefrom and OTY. PLUMBING PERMIT FEE
¢ H $ the basis for the alleged exemption.Any violation of Section 7031.5 STORIES TYPE CONSTR.
u3 by any applicant for a permit subjects the applicant tor,civil penalty ALTER-DRAIN -WATER IEA.) 5.00
of not more than five hundred dollars($500).):
❑ I,as owner of the property,or my employees with wages as BACK FLOW PROTECT. DEVICE 4.00 Dec.GROUP RES.UNITS
their sole compensation,will do the work,and the struclure 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 SO,FT.FLOOR AREA TOTAL ACREAGE himself or through his own employees,provided that such improve.
ments are not intended or offered for sale.If,however,the building GAS-EA.SYSTEM-11NC.4OUTLETS 6.00
or improvement is sold within one year of completion,the owner- GAS-EASYSTEM OVER 4 IEA) 2.00
builder will have the burden of proving that , - .
e did not build or am- BUILDING USE
Prove for purpose of sale.). INDUSTRIAL WASTE INTER3000 E IND CON PS Olur
❑ 1,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 gSSESSORS PARCEL NO.
and Professions Code.The Contractor's License Law docs not apply
to an owner or property who builds or improves(hereon,and who LAWN SPRINKLERS-OVER 5 (EA.) 1.00
contracts for such projects with a contractor(s)licensed pursuant to
the Contractor's License Law. SEWER-SANITARY-STORM EA.200ft/10.00 1 TRACT NO, PARCEL NO.
❑ lam exempt under Sec..,B,&P,C.for this
reason WATER HEATER W/VENT 6.00
Owner Date WATER SYSTEM 5.00 ACC.DATE ACC.FILE N0,
WORKERS'COMPENSATION DECLARATION WATER TREATING EQUIP. 5.00
1 hereby affirm thin I have a certificate of consent to self-insure,
or a cert c e of Wpdrenrsq�lC,0 d�lion�I®nsurance,ors cerfifyyl ZONING ENG.SITE NO.
cop yB edrOL',hlTa s�T�CZ�
Policy o ny
O ❑ Certified copy is hereby furnished. FIRESPRINK ENERGY T-24
Z Z ❑ Certified opyyy��, is� f1�ed with �thir city inspection division.
O Applicant 4l ;A;r_Jb 111 MISC.- REFER TO ORD. v ❑ N❑ v ❑ N❑
it T CERTIFICA,TE``O`FF```EEXf''':```M���PTIOONN���F'''RRO''''MM��'W��,O��`RIIIERS' PERMIT ISSUANCE 10.00 FLOOD ZONE A.L.U.C.
LU > COMPENSA'T'ION INSURANCE PLG,CONTR. LIC.NO. PLG,
a.a (This section need not be completed if the permit is for one TOTAL Y E] N❑ Y❑ N❑
hundred dollars($100)or less.)
U 0 1 certify that in.the performance of the work for which this per. QTY. MECHANICAL PERMIT FEE FEE SUMMARY
IL mit is issued,I shall not employ any person in any manner so as to
Q U become subject to the Workers'Compensation Laws of California.
e Date Applicant BUILDING
EA NOTICE TO APPLICANT: If,after making this Certificate of nix- ALTER OR ADD TO MECH. 5.00
? 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
CONSTRUCTION LENDING AGENCY AIR HANDLING UNIT(OVER 10,000C.EM-) 6.00 SEISMIC FEE
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
Lender's Address HEATING UNIT(OVER 100,000 B.T.U.)9.50 ELECTRIC
1 certify tire,1 have read this application and ,are our the above VENTILATION FAN (SINGLE) 4.00
• information is correct. I agree to comply with all city and county PLUMBING
ordinances and state laws relating to building construction, and BOILER-COMP(3 H,P.Of 100,000 B.T.U.) 8.00
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 liabilities,judgments, costs and expenses which PERMIT ISSUANCE 10.00 CONST.TAX
may any way accrue against said City in consequence of the .
gra in Of s ermll. MECH.CONT. LIC.NO. I MECH.
TOTALle TOTAL
SI areof Appbcan Can actor / /Date C 07F/ 61
OFFICE COPY /2_^ F.,f- ` �_