09949 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
BUI LOI NG PROJECT I DENT]FICATION PERMIT NUMBER
awLOINc APPLICATION & PERMIT
oORESP/&1NZ 7 /Q BUILDING-ELECTRICAL-PLUMBING-MECHANICAL 09949
OWNER5 p PLAN CHECK VALIDATION
oN
NAME /� A! R'K. d3a Jr'6/rT QTY. ELECTRIC PERMIT FEE
•
cOsrEFACTORs
AMC UTLETS-SWITCHES-RECEP 10.00/1.00
N
S Llc.No LIGHTING FIXTURES 10.00/1.00
ADDRESS
sss PPLIANCES-RESIDENTIAL 4.00
A.oRE
PHONE PANELS 10.00 DATE OF APPLICATION
ARCHITECT PANELS I OVER 200 AMP) 20.00 PLAN CHECK FEE P.C.NO.
OR
ENGINEER
LIC.No. SIGNS TRANS. 3.00
ARCH.OR ENG. SPECIALCIRCUIT 5.00 PERMIT VALIDATION
ADDRESS
an, TEMP.METER OR POLE INS. 20.00
APPLICANT'$ MOTORS SEE FEE SCH. PAID
ADDRESS
SERVICE CHANGE 20.00
o o LICENSED CONTRACTORS DECLARATION TEMP.POLE 30.00 OCT 2 3 1985
< o w - 1 hereby affirm that I am licensed under provisions of Chapter m ISSUANCE DATE
h <m (commencing with Sectiun 7000)of Division 3 of the Business and BLDG. p{Ef����CT /�ppp)��,((G�,,, C
H w z Professions Code,and my license is in full force and effect. ❑ lrtry 0 LrO Trt 9
z o,A License Class Lie.Number IL'JI IL`Jf
9 z H Date Co ltmctur
<Y s -a BUILDING PERMIT
S, w ¢ OWNER-BUILDER DECLARATION INFORMATION
U REFER TO ORD
X if: LL w I hereby al'l irm That I am ex nm pt from the Contractors License MISC.- VALUATION S/FT.
ro_ Law l'or the following reason, 7031.5,Business and Professions PERMIT ISSUANCE 10.00
Code:Any city or county which requiresa permit to construct,alter.
m2¢ � improve,demolish,or repair any structure,Puerto its issuance,also ELEC.CONTR, LIC,NO, ELEC.
C-LD ac requires the applicant for such permit to I Ile a signed statement that TOTAL E MIT TO
A w es a. he is licensed pursuant to the provisions of the Contractor's License
Fi >
Law(Chapter 9(commencing with Section 7000)of Division 3 ofthe
- a Business and Professions Code)or that he is exempt therefrom and QTV. PLUMBING PERMIT FEE
K ti o the basis for the alleged exemption.Any violation of Section 7031.5 STORIES TYPE CONSTR.
by anyapplicant fora permit subjects the applicant to a civil penalty gLTER-DRAIN&VENT-WATER (EA.) 5.00
of not more than five hundred dollars(8500).1:
❑ 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. 7844, Business and Professions DRAINS-FLOOR,ROOF,AR EA,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 TOTALACREAGE
• himself re through ince his own employees.Provided that such improve
ments are thrimmnded onrfferedemplo employees,
or provided that r.such
building GAS-EA.SYSTEM-1INC.4OUTLETS 6.00
r improvement is sold within one year of completion,the Owner-
builder will have the burden of proving that he did not build or hit- GAS
IND N PB Other
prove for purpose of sale.). INDUSTRIAL WASTE INTER. 30.00
❑ I,as owner of the property,am exclusively contracting with
licensed contractors to construct the project(Sec.7044,Rosiness LAWN SPRINKLERS- 1 INC 5 V.B. 6.00 ASSESSOR PARCEL NO.
and Professions Code:The Contractor's License Law does not apply
to an owner of property who holds or improves thereon,and who LAWN SPRINKLERS-OVER 5(EA.) 1.00
contracts for such projects with a contractor(s)licensed pursuant t. SEWER-SANITARY-STORM EA.200ft/10.00 TRACT NO. PARCEL NO.
the Contractor's License Law.
❑ I am exempt under See.-,B.&P.C.for this WATER HEATER W/VENT 6.00
reason
Owner Date WATER SYSTEM 5.00 ACC.DATE ACC,FILE NO.
WORKERS'COMPENSATION DECLARATION WATER TREATING EQUIP. 5.00
I hereby affirm that I have a certificate of Consent to self-insure.
or a certificate of Workers'Compensation Insurance,ora wrtifild ZONING ENG.SITE N0.
copy thereof(Sec.3800,Lab.C.).
Poh�o. Company
QO rlific Copy is hereby fumlshed. FIRE SPRINK ENERGY T-24
Z Z ❑ C Ri o y is F. th inspection division. MISC.- REFER TO ORD. Y O IN C] Y C] N[]
APPlica t_
PERMIT ISSUANCE 10.00 FLOOD ZONE
CC A.L.u.c.
� > F:R'(I OP FICATE EXEMPTION FROM 1 ORKF.RS'
LD _ COMPENSATION INSURANCE PLG.CONTE. LIC.NO. PLG.
1 O 1 i1 section need not be completed d the permit is for one TOTAL Y N� V N[]
Z hundred dollars(SIDO).11111.)
U O 1 certify that in the performance of the work for which this per- OTY. MECHANICAL PERMIT FEE FEE SUMMARY
LL l- mit is issued.I shall not employ any person in any manner so as to
Ow become subject to the Workers'Compensalion Laws of California. BUILDING
Date ApplicantALTER OR ADD TO MECH. 5.00
} y NOTICE'1'0 APPLICANT: If,after making this Certificate of Ex-
'F ? emptlon,you should become subject to the Workers'Compensation JAPPLIANCE 5.00 PLAN CHECK
provisions of the Labor Code, you must forthwith to with FEE
U such provisions or this permit shall be deemed revoked. AIR HANDLING UNIT(TO 10=C.F.M.) 4.00
CONSTRUCTION LENDING AGENCY AIR HANDLING UNIT(OVER 10p00C.F.M.) 6.00 SEISMIC FEE
1 hereby affirm that ]here is a construction]ending 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.) 6.00
Lender's Name HEATING UNIT(OVER 100,000 B.T.U.)9.50 07 1ELECTRIC
Lender's AJdress
1 certify that I have read this application and stale Ihm the above VENTILATION FAN (SINGLE) 4.00
• Inf.lmafion E correct.I agree to comply with all oily and county BOILER-CONP(3 H.P.or 100,000 B.T.U.) 6.00 PLUMBING
ordinances and orate laws relating m 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 In 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 10.00
gmnlin his permit MECH.CONT. LIG NO. MECH. I
o... L TOTnt�/'✓/, (�_ TOTA �
61 - 1.
Sign Applicant/ on a r )arc
OFFICE COPY