10265 PPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
/ 'BUI LDI NG PROJE ENTI FICA*N PERMITNUMBER
n ARIL APPLICATION & PERMIT
vAODM 9 9 BUILDING -ELECTRICAL-PLUMBING-MECHANICAL 10265
OWNER'S
NAME PLAN CHECK VALIDATION
• OTY. ELECTRIC PERMIT FEE
PHONE
co c aR's UTLETS-SWITCHES-RECEP 10,00/1,00
u .C.N LIGHTING FIXTURES 10.00/1.00
noN ORs �. APPLIANCES-RESIDENTIAL 4.00
PRO N PANELS 10.00 DATE OF APPLICATION
ARCHITECT PANELS (OVER 200 AMP) 20,00 PLAN CHECK FEE P.C.NO.
ENGINEER
LIC.NO, SIGNS TRANS. 3.00
ARCH,OR ENG. PE�I�uJfyIpATION
ADDRESS SPECIAL CIRCUIT 5.00
ZIP ITEMP. METER OR POLE INS. 20.00
no NT MOTORS SEE FEE SCH. MAR 2 8 1986
SERVICE CHANGE 20.00 JU
w o o LICENSED CONTRALTO SDECLARATION TEMP.POLE 30.00 City �f Cupertino
_
IS
u uI hereby uffirm that I am licensed under provisions of Chapter
< w 9 ISSUANCE DATE
h (commencing with Section 7000)of Division 3 Of I Business and
FOi Professions Code 'testa is in full forces BLDG. ELECT. PLO. MEC .
Zo i n G License Class Lk.Number
r w H J Dufc Contractor
r f BUILDING PERMIT
a a w OWNEWBUILDER UECLARA INFORMATION
is ; uA.y 1 hereby affirm that I am exempt from the Contractor's License MISC.- REFER TO ORD
Fay J Low for the following reason.(Sec.7031.5,Business and Professions PERMIT ISSUANCE 10.00 VALUATION $/FT,
Code:Any city orcounty whichrequiresapermittoconstruct„Oter, -
¢ K ¢ p improve,demolish,ser repairany structure,prior to its issuance,also ELEC.CONTR. LIC,NO. ELEC.
4 W m LL requires the applicant for such permit t0 file`a signed statement that TOTAL PE MIT T
he is licensed pursuant to the provisions of the Contractor's License
ri > Law(Chapter 9(commencing with Section 7000)ofUivision 3 ofthe
4 c Business and Professions Code)Or that Ise is exempt therefrom and CITY. PLUMBING PERMIT FEE
IS 1-c� the basis for the alleged exemption.Any violation of Section 7031.5 STORIES TYPE CONSTR.
by any applicant for a permit subjects the applicant to a civil penalty ALTER-DRAIN IEA.) 5.00
of not more titan five hundred dollars(5500).):
❑ 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. 7044, Business and Professions DRAINS-FLOOR,ROOF,AR EA,COND. 5.00
Code:The Contractor's License Law does not apply to an owner of
properly who builds or improves thereon,and who does such work FIXTURES-PER TRAP 5.00 SO.FT.FLOOR AREA TOTAL ACREAGE
himself or through his own employees,provided that such improve-
mentsarenot intended oroffered 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-EA.SYSTEM-OVER 4 IEA.) 2.00
builder will have the burden of proving that he did not build or ins- BUILDING USE
prove for purpose of sale.). INDUSTRIAL WASTE INTER. 30.00 IND CON PB Omar
❑ I,as owner of the property,am exclusively contracting with
licensed contractors to construct the project(Sec. 7044,BusinessLAWN SPRINKLERS- 1 INC 5 V.B. 6.00 ASSEssOR S PARCEL NO.
and Professions Code:The Contractor's License Law dues not apply
to an owner of property who builds or improves Ofereon.:md who LAWN SPRINKLERS-OVER 5 (EA.) 1.00
contracts for such projects with a wntracto(s)licensed pursuant Io
file Contractor's License Law. SEWER-SANITARY-STORM EA.200ft/10.00 TRACT NO, PARCEL NO.
❑ I am exempt under Sec. ,B.&P.C.for this WATER HEATER W/VENT 6.00
reason
Owner Dale WATER SYSTEM 5.00 ACC.OATE ACC.FILE NO.
WORKERS'COMPENSATION DECLARATION WATER TREATING EQUIP. 5.00
1 hereby affirm that I have a certificate of consent to self-insure,
or a certificate of Workers'Compensation In ranee,ora UrtifaHt ZONING ENG.SITE NO.
copy there 0,�f).
Policy No, rFP'nY '
O ❑ er d. d copy is . by fur 'ql�d. FIRE SPRINK ENERGY T-24
Z Z Certified co is led IS the inspection division.
F O A ant MISC.- REFER TO ORD, v N� v ❑ N�
O: y CERTIFICA -OFB MPT'ION RO WO PERMIT ISSUANCE 10.00 FLOOD ZONE A.L.U.C.
LU - CO PENSATION INSURANCE PLO.CONTE. LIC.NO, PLG.
CL Z( This section need not be completed if the permit is for one TOTAL Y F] N[:JY C] N
hundred dollars IS 100)Or less.)
U O I certify that in the performance of the work for which this per. OTY MECHANICAL PERMIT FEE FEE SUMMARY
U. F- mit is issued,I shall not employ any person in any nsanner so as to
O L) become subject to the Workers'Compensation Laws of California.
CL Date.Applicant ALTER OR ADD TO MECH. 5.00 BUILDING
} SO NOTICE TO 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 must forthwith comply with FEE
U such provisions or this permit shall be deemed revoked. AIR HANDLING UNIT(TO 10A00C.F.M.) 4.00
CONSTRUCTION LENDING AGENCY AIR HANDLING UNIT(OVER IO,000C.FM.16.00 S ISMIC FEE
I hereby affirm that there is a construction lending agency for EXHAUST HOOD IW ITH DUCT) 5.0
the performance of the work for which this permit is issued(Sec. ICROFILM
3097,Civ.C.). HEATING UNIT(TO 100,000 B.T.U.) 8.0
Lender's Name
Lender's Address HEATI NG UNIT(OVER 100,000 B.T.U.0.5 F.6ECTRIC
I certify that I have read(his application and state that the above VENTILATION FAN (SINGLE) 4.00
• information n correct I agree to comply with all city ucti county BOILER-COMP13 H.P.or 100,000 B.T,U.I 6.00 PLUMBING
ordinances and emit laws relating t0 building construction,upon
the
hereby authorize representatives for ins inspection
this city es enter upon the BOILER-COMP (Ova,100,000 BTU)SEE FEE SCH. MECHANICAL
above-mentioned property for inspection purposes.
(We) agree to s Inde I and keep harmless the City of MISC.- REFER TO ORD.
Cupertino aguins tall liti jt gments, costs and expenses which PERMIT ISSUANCE 10.00 NST.TAX
may in any w' ru a^ avt said City in conscyuenee of the
gra of fit mil. t ME .CONT. LIC.NO, MECH.
TOTAL TOTAL
Si to pp Ic nt/Contractor Da
OFFICE COPY '