09985 i
APPLI ANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
_ PERMIT NUMBER
ENAME
G PROJECT IDENTI FICATION BUILDING APPLICATION & PERMIT
ro ok rA-� Xt/ 09985
L/ � BUILDING -ELECTRICAL-PLUMBING-MECHANICAL
` PLAN CHECK VALIDATION
DTV. ELECTRIC PERMIT FEE
CONTPHONENAME
NAME s OUTLETS-SWITCHES-RECEP 10,00/1.00
f3LOODNO0N.4 awl-ptrIel<in)I 4/5193 fo LIGHTING FIXTURES 10.00/1.00
C.N0,
CONTRACTOI PPLIANCES-RESIDENTIAL 4.00
AO REaa
3 � 5. Moat ktS I$'DONE GO� +bF PANELS 1D.6In DATE OF APPLICATION
OR
RcroTecT PANELS (OVER 200 AMP) 20.00 PLAN CHECK FEE P.C.NO.
ENGINEER
LIC,NO. SIGNS TRANS. 3.00
ENG,S S
ADDRE �iN I� IDATIDN
ARCH.OR SPECIAL CIRCUIT 5.00 q-/y
ZIP • EMP.METER OR POLE INS. 20.00
APPLICANT
,ADDRESS MOTORS SEE FEE SCH. OCT 3 O 1985
DD
SERVICE CHANGE 20.00
w w o LICENSED CONTRACTORS DECLARATION TEMP.POLE 30.00 City Of Cupertino
<v I hereby affirm that I am licensed under provisions of Chapter 9 ISSUANCE DATE
r D w (commencing with Section 7000)of Division 3 of the Businessland
w < c BLDG. ELECT PLG. MECH.
r 7 Z Professions Code and my license is in full force aq`�Sfjg�t ❑ ❑ ❑
0 2 w O License Cl_ :yss �.1_d Lic.Number/_ 7_
Datc Contractor uLLm C
a r s BUIL ING PERMIT
LC ao c u OWNER-BUILDER DECLARATION IN RMATI M
e. ; y I hereby affirm that I am exempt from the Contractor's License MISC.- REFER TO ORD
u o ¢ Law for Ile following reason.(Sec.7031.5,Business and ProfessionsVALUAT ON si
0 Code:Anychy circularly which requires a permit to construct,alter,
PERMIT ISSUANCE 10.00
rt ¢ a FO improve,demolish,or repair any structure,prior to its issuance,also ELEC.CONTR. LIC.N0. ELEC.
DLL requires the applicant for such permit to file a signed statement that TOTAL PERMIT O
F
m Ise is licensed pursuant to the provisions of the Contractor's License
Fi > Law(Chapter 9(commencingwilh Section 7000)of Division 3 of the
< Business and Professions Code)or that he is exempt therefrom and OTY. PLUMBING PERMIT FEE
sio
ec r- $ the basis for the alleged exemption.Any violation of Section 7031.5 STORIES TYPE CONSTR.
by any applicant fora permit subjeclsthe applicant tnucivil penalty ALTER-DRAIN (E!1) 5.00
.four more than five hundred dollars($5001.):
❑ I,as owner of the property,or my employees with wages as BACK FLOW PROTECT.DEVICE 4.00
their sole compensation,will do the work,and the structure is not OCC.GROUP RES.UNITS
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 does such work F IXTUR ES-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-1 INC.4 OUTLETS 6.00
or improvement is sold within one year of completion, the owner- GAS-EASYSTEM-OVER 4 (EA) 200 BUILDING USE
builder will have the burden of proving that h . . ,
e did not build or int- E
prove for PurPOW of sale.). INDUSTRIAL WASTE INTER. 30.00 IND CON PB Our.
❑ 1,as owner of the properly,am exclusively contracting with ❑ ❑ ❑ ❑
licensed contractors to construct the 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 for such projects with a nmtractor(s)licensed pursuant In SEWER-SANITARY-STORM EA.200ft/10,00
the Contractor's License Law. ACT N0. PARCEL N0.
C] laammexempt under Sec..,It&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 I WATER TREATING EQUIP. 5.00
I hereby affirm that I have a certificate ofconsent to self-insure,
.or a certificayc of Workers'Compensation Insurance,or a certified ZONING ENG.SITE NO.
copy thereof(.Sec.3800,Lab.C.).
rA,0,
n. Company
ified copy is hereby furnished. FIRE SPRINK ENERGY T-24
Z Z t ied c y is filed with t city ins c n division. MISC.• REFER TO ORD.
Q ant Y❑ N❑ Y ❑ N❑cC IFIC Eof EXEMPTION FROM WORKERS' PERMIT ISSUANCE 10.00 FLOODZONE A.L.U.C.
W COMPENSATION INSURANCE PLG.CONTR. LIC.NO. PLG.
Q. Z( This Section need not be completed iflhe permit is for one TOTAL Y E] N[3N❑ Y ❑ N
hundred dollars($100)or less.)
U O 1 certify that in the performance of the work for which this per- STY. MECHANICAL PERMIT FEE FEE SUMMARY
LL 1- mit is issued,I shall not employ any person in any manner so as to
O W become subject to the Workers'Co mpens lion Laws of California.
Date Applicant BUILDING
S. ALTER OR ADD TO MECH. 5.00
>- 0 NOTICE 'f0 APPLICANT: If,after making this Certificate of Ex-
F Z 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 10=r-F.M.) 4.00
CONSTRUCTION LENDING AGENCY AIR HANDLING UNIT(OVER 10,000C.F.M.) 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 HEATING UNIT 100,000 B.T.U.)9.50
Lender's Address ELECTRIC.
I certify that I have read this application and state that the above VENTILATION FAN (SINGLE) 4,00
information is correct. I agree to comply with all city and county PLUMBING
ordinances and stale laws relating to building construction, and BOILER-COMP(3 H.P.or 100,000 B.T.U.) 6.00
hereby authorize representatives of this city to enter upon the
above-mentioned property for inspection purposes. g01LER-COMP IOver 100,0000701 SEE FEE SCH. MECHANICAL
(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 in any way accme against said City in consequence of the
granting orlhis permit. ECH.CONT. LIC.NO. MECH.
/D�-iq�g TOTAL TOTAL
(Apphcanf/ on[rador Ua0.
OFFICE COPY