9262 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
T BUI LDING PROJECT IDENTIFICATION PERMIT NUMBER
r D.Ess APPLICATION & PERMIT 9262
._ooness t �•� \ BUILDING—ELECTRICAL—PLUMBING—MECHANICAL
'OWNER'S l••/' _�/_!� PLAN CHECK VALIDATION
• Me V QTY. ELECTRIC PERMIT FEE -
trio
' re L P
orvrRAcrDRs
NAME OUTLETS-SWITCHES-RECEP 10.00/1.00
UC.No. LIGHTING FIXTURES 10.00/1.00
C.ONTRACTOmsAPPLIANCES-RESIDENTIAL 4.00- `
ADDRESS
PHONE PANELS 10.00 DATE OF APPLICATION
RCHrtECT PANELS (OVER 200 AMP) 20.00 PLAN CHECK FEE P.C.NO.
O
OR
ENGINEER
uc.No. SIGNS TRANS. 3.00
ARCH.OR ENG. PERMIT VALE DATE N
PAI
ADDRESS SPECIAL CIRCUIT 5.00 DQ9
ZIP EMP. METER OR POLE INS. 20.00 f
APPLICANTS MOTORS SEE FEE SCH.
ADDRESS J U L 12 1985
SERVICE CHANGE 2
woo -LICENSED CONTRACTORS DECLARATION TEMP.POLE 30.00 cI1 of Cupertino
¢ U 1 hereby affirm that I am licensed under provisions of Chapter 9 ISS NCE DA
y a w (commencing with Section 7000)of Division 3 of the Business and BLDG. ELE T. MECH.
r O z Professions Code,and my license is in full force and effect. ❑ ❑
z 0 L License Class Lie.Number _
9 L H wt
Date Contractor
P: u s �
BUILDING PERMIT
¢ ¢
to ¢ OWNER-BUILDER DECLARATION INFORMATION
u
w3 e- H 1 hereby affirm that I am exempt from the Contractor's License MISC.— REFER TO ORD
u0 ¢ Law mrlhe fnllowingreason.(Sec.7031.5,Business and Professions VALUATION
ce Code:Any molish county pair any structure permittots issuance,
also
PERMIT ISSUANCE
E
¢ ai p improve,demolish,Dr repair any structure,prior l0 its issuance,also ELEC.CONTR. LIC.NO. ELEC.
O¢ require S the applicant for Such permit to file a signed statement that TOTAL ' PERMIT TO
whe is licensed pursuant to the provisions of the Contractor's License
Hii Law(Chapter 9(commencingwith Section 7000)of Division 3 ofthe
¢ Business and Professions Code)or that he is exempt therefrom and DTV. PLUMBING PERMIT FEE
ai the basis for the alleged exemption.Any violation of Section 7031.5 T IES TYPE NSTR.
a3 � by any applicant for a permit subjects the applicant toacivilpenalty ALTER-DRAIN -WATER (EA.) 5.00
of not more than five hundred dollars(5500).):
❑ 1,as owner of the property,or my employees with wages as BACK F LOW PROTECT.DEV ICE 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 Contractors 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 S FT.FLOOR AREA TOTALACREAGE
meats are not hrough
ownemred for sale.
If,
however,the
improve-
ments
mprove GAS-EA.SVSTEM-11NC.40UTLETS 6,00
mems are not intended or offered for sale.If,ed that s the mprovbuilding-
or improvement is Sold within one year of completion,the owner
-
.-�qg EASYSTEM OVER 4 (EA.) 2.00
build will have the burden of proving Ihal he did not buil)or im- BUILDING USE
It v for purpose of sale.). INDUSTRIAL WASTE INTER30.00 RES IND CON PB Other
1 .as owner of the property,am exclusively contracting with ❑ Cl ❑ ❑ ❑
lie ed contractors to construct the project(Sec.7044,Business LAWN SPRINKLERS-1 INC 5 V.B. 6.00 ASSESSORS PARCEL NO,
a rofessions Code:The Contractor's License Law does not apply
t in,owner of property who builds or improves thereon,and who LAWN SPRINKLERS-OVER 5(EA.) 1.00
c atmos for such projects with a contramoos)licensed pursuant to SEWER-SANITARY-STORM EA.200ft/10.00
Ih niractor's License Law. TRACT NO. PARCEL NO.
ri
m exempt under Sec.—,BAP.C.for this WATER HEATER W/VENT 6.00
on
er Date WATER SYSTEM 5.00
ACC.DATE ACC FILE NO.
WORKI:RS'COMPHNSATION )f:CLA RATION WATER TREATING EQUIP. 5.00
hereby affirm that I have a certificate ofconsent to self-insure. ZONING or a certificate of Workers' ZG Compensation Insurance,or a certified ENG.SITE NO.
copy thereof(Sec.3800,Lab.C.).
Policy No. Conhpany
O ❑ Certified copy is hereby furnished, FIRE SPRINK ENERGY T-24
Z Z ❑ Certified copy is filed with the city inspection division. MISC.- REFERTOORD.
O Applicant _ Y ❑ N❑ Y ❑ N❑
� y C17RTIFICATG OF EXEMPTION PROM WORKERS' PERMIT ISSUANCE FLOOD ZOrvE A.L.U.C.
W > COMPFNSATION INSURANC17 PLG.CONTR. ❑c.NO. PLG. /
(L 0 (Phis section need not be completed if the permit is for one TOTAL V❑ N❑ Y ❑ N❑
D Z hundred dollars IS 100)or less.)
U O I certify that in the performance of the work for which this per. DTV. MECHANICAL PERMIT FEE FEE SUMMARY
1L• I— mit is issued,I shall not employ any person in any manner so as to
U become subject to the Workers'Conspensat inn Laws of California.
i Date Applicant ALTER OR ADD TO MECH. 5.00 BUILDING
} rn NOTICE TO 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=C-F.M.) 4.00
CONSTRUCTION LENDING AGENCY AIRHANDLING UNIT(OVER 10,01DOC.EM.) 6.00 SEISMIC FEE
I hereby affirm that there is a construction houling agency for EXHAUST HOOD(WITH DUCT) 5.00
(hepeCbrC MICROFILM
3097, )nce of the work for which this permit is issued(Sec. 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 cerlily tient I have read this application andslate Ihm fim 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(3H.P.Of100,000B.T.U.) 6.00
hereby authorUe representatives of this city to enter upon the BOILER-COMP IOver lO0,000 BTU)SEE FEE SCH. MECHANICAL
above-mentioned property for inspection purposes.
(We) 'gree to Save, indemnify and keep Isannless the City o1' MISC.- REFER TO ORD.
Cupert against liabilities, 'u amen costs and expenses which' CONST.TAX
may ny way acc i t sa' By in conseruence of the PERMIT ISSUANCE 10.00
gra t f this pe ..F—�•0 Ey MECH,CONT. LIC.NO. MECH,
h ! L d OT"` TOTAL
re App Contractor Date
OFFICE COPY