09948 APPLICANT TO FILL IN INFOR .TION WITHIN RED LINES - USE BAJIL POINT PEN ONLY
BU I LDING PROJECT I DENTIFICATIW PERMIT NUMBER
RDILDING �p� APPLICATION & PER 09948
AO/L4,ODRESS
BUILDING - ELECTRICAL-PLUMBING-MECHANICAL
• O rvER's PLAN CHECK VALIDATION
NAME `4 4'/1�/C, OTY- ELECTRIC PERMIT FEE
CONTRACTOR
-� PHONE .
s
NpM ,,, UTLETS-SWITCHES-RECEP 10.00/1.00
, cz/m
uc.rvo. LIGHTING FIXTURES 10.00/1.00
CONTRACTOWs PPLIANCES-RESIDENTIAL 4.00
ADDRESS
ONE PANELS 10.00 DATE OF APPLICATION
ARCXITECT PANELS
(OVER 200 AMP) 20.00 PLAN CHECK FEE P.C.NO.
OR
ENGINEER
LIC.No. SIGNS TRANS. 3.00
ADDRESS END' SPECIALCIRCUIT 5,00 FERMI _ N
ZIP EMP.METER OR POLE INS. 20.00 q
APPLICANTS MOTORS SEE FEE SCH. OCT 2 3 1985
ADDRESS
SERVICE CHANGE 20.00
w o o LICENSED CONTRACTORS DECLARATION TEMP.POLE 30.00 City of Cupertino
a U u I hereby affirm that I am licensed under provisions of Chapter 9 ISSUANCE DATE
y<o6i (commencing with Section 7000)of Division 3 of the Business and BLDG. ELECT. PLG4ME z Professions Code,and my license is in full force and effect. ❑O vi - License Class Lic.Number 1 13o o4r Dale ContractoryBUILDING PER
saw u OWNER-BUILDER D17CLARATION
0 o MISC.- REFER TO ORD INFORMATION
wLL N I hereby allinn that I am exempt from the Contractor's License
LLoa Law for the following reason.(Sec.7031.5.Businessand Professions PERMIT ISSUANCE 10.00 VALUATION :6/FT.
� - to Code:Any city orcounly which requires a permit to construct,alter,
Q2 ¢o improve,demolish,or repair any structure.prior to its issuance,also ELEC.CONTR. LIC.NO. EL C.
¢ requires the applicant for such permit to file a signed statement that TOTAL MIT T
w $ he is licensed pursuant to the provisions of the Contractors License
F as i Law(Chapter 9(Commencing with Section 7000)of Division 3 ofihc
a Business and Professions Code)or that he is exempt therefrom and QTY. PLUMBING PERMIT FEE
ec F Oo the basis for the alleged exemption.Any violation of$ection 7031.5 STORIES TYPE CONSTR.
a ;m by any applicant for a permit subjects the applicant toa civil penalty
of not more than five hundred do11ars(85000.): ALTER-DRAIN&VENT-WATER (EA.) 5.00
❑ 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. 1044, 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 FIXTURES-PER TRAP 5.00 SD.FT.FLOOR AREA TOTAL ACREAGE
rentSf re through his own employees,provided that such int building
mmselfc throuhh isot or employees,lfiened lot prove. ided
thathowevSihe building GAS-EA.SYSTEM-11NC.40UTLETS 6.00
or improvement is sold within one year of completion,the owner- GAS-EA.SYSTEM-OVER 4(EA.) 2.00 BUILDING USE
builder will have the burden of proving that he did or build or int- RES IND O PB Omer
prove for purpose of sale.). INDUSTRIAL WASTE INTER. 30.00
CJ 1,as owner of lire property,ton exclusively contracting with ED El ❑ ❑
licensed contractors to construct the project(Sec. 7044,Business LAWN SPRINKLERS- 1 INC 5 V.B. 6.00 ASSESSOR RCEL NO.
and Professions Code:The Contractor's License Law does Apt apply
to an owner of properly who builds or improves thereon.and who LAWN SPRINKLERS-OVER 5(EA.) 1.00
contracts fur such projects with a contractor(s)licensed pursuant to SEWER-SANITARY-STORM EA.200ft/10.00
the Contractor's License Law. TRACT NO. PARCEL NO.
❑ I am exempt under Sec.-,BAP.C.for this WATER HEATER W/VENT 6.00
reason
Owner Dale WATER SYSTEM 5.00 ACO,DATE ACC.FILE NO.
WORK ERS'COM PF,NSA'I'ION DECLARATION WATER TREATING EQUIP, 5.00
1 hereby.]firm that I have a certificate of consent to lf-insure. ZONING ENG.SITE NO.
or a Certificate of Workers'Compensation Insurance,or a certified
copy thereof(Sec.3800,Lab C.).
Policy No. Cmnpany
0 ❑ Certified copy is limeby famished. FIRE SPRINK ENERGY T 24
Z Z ❑ Certif 'opy is -1 1 1 cit ins error]error] division.
O Applicant_ _ Le MISC.- REFER TO ORD. Y N❑ Y ❑ N❑
CC CERI'11'ICA'IIEOFEXF.MPTI0 F OMWORKERS' PERMIT ISSUANCE 10.00 FLOOD ZONE A.L.U.C.
LU > COMPENSATION INSURANCE PLG.CONTR. LIC.NO, PLG.
CL 0 (This section need out be Completed if the permit is for one TOTAL Y❑ N❑ Y ❑ N❑
0 Z hundred dollars IS 100)or less)
U O 1 certify that in the performance of the work for which this per- QTY. MECHANICAL PERMIT FEE FEE SUMMARY
U_ I- mit is issued. I shall not employ any person in any manner so as to
U hec... e.object to the Worker]'CmR,cRs.tion Laws of Califon.i..
U a Date Applicant ALTER OR ADD TO MECH. 5.00 BUILDING
} W NOTICE 1'0 APPLICANT: If,after making this Certificate of Ex-
Z emption,you should become subject to the Workers'Compensation APPLIANCE 5.00 PLAN CHECK
provisions of the Labor Code, you most 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=CF.M) 6.00 SEISMIC FEE
I hereby affirm that there is a construction lending agency for tire00 EXHAUST HOOD (WITH DUCT( 5.00
the performance of .c work for which this permit is issued(Sec. HEATING UNIT(TO 100MICROFILM
,0B.T.U.) 8.00
3og7,civic).
Lender's N.n'c HEATING UN IT(OVER 100,000 B.T.U.)9.50 ELECTRIC
Lender's Address
I certify that 1 have read this application and state that(fie above VENTILATION FAN (SINGLE) 4.00
Anlaws
is correct. 1 agree to comply with all city and county PLUMBING
ordinances and state relating to building construction, and BOILER-COMPO H.P.or 100,000 B.T.U.) 6.00
hereby authorize representatives of this city to enter upon the BOILER-COMP (Over 100,000BTU)SEE FEE SCH. MECHANICAL
above-mentioned property for inspection purposes.
(WC) agree to save, indemnify and keep harmless the City of MISC.- REFER TO ORD.
Cupertino against liabilities,judgments, costs and expensca which PERMIT ISSUANCE 10.00 CONST.TAX
may in any way accrue against said City in consequence of the
gra of[hisper MECH.CONT. LIC.NO. MECH. _
C- TOTAj TOTAL l
Signature of Applica ontractoi;f Date '
OFFICE COPY