09661 APPLICANT TO FILL IN I `f`OK'MATION WITHIN RED LINES,- USE BALL POINT PEN ONLY
BUI LDI NG PROJECT I DENT[FICATION. PERMIT NUMBER
BUILDING ' APPLICATION & PERMIT
�f ADDflsss _ 09661
�
r ' Is r= - BUILDING -ELECTRICAL-PLUMBING-MECHANICAL
OW NE WS, PLAN CHECK VALIDATION
QTY. _ ELECTRIC PERMIT FEE
I� ONE •:2..
flncroR's
NAMEUTLETS-SWITCHES'-RECEP 10,00/1.00
- 'uc.No. LIGHTING FIXTURES 10.00/1.00
ADDRESS Rs PPLIANCES-RESIDENTIAL 4.00
PHONE PANELS 10.00 DATE OF APPLICATION
ARCHITECT PANELS (OVER 200 AMP) 20.00 PLAN CHECK FEE V.C.NO.
ENGINEER, '
. I.C.c.NO. SIGNS TRANS., 3.00
AARCH OR DDRESS ENG. - SPECIALCIRCUIT ,'5.06 ' PERMIT VALIDATION
ZIP TEMP.METER OR POLE INS. 20.00 PAID
APPUCANT'S - - MOTORS- ' SEE FEE SCH: p
ADDRESS ' ep fJ \f r{ A 5F �ppAs
' SERVICE CHANGE 20.00 VA�f' �lCl1INNppYgYq
°¢iZ F
TEMP.POLE 30.00 {
Foo LICENSED CONTRACTORS DECLARATION city, O{CaI�� i4R
a i w 1 hereby affirm that I am licensed under provisions of Chapter 9 N `l, 1 ISS ARC TE
1 n - (commencing with Section 7000)of Division 3 of the Business and BLOC. ELEC PLG. MECH.
r N i Professions Code,and my license is in full force and effect ❑
Z o m - License Class Lic.Number 1 -D
o r Date CmDattor ,Q
a m ✓ BUILDING PERMIT
¢ ¢ ma OWNER-BUILDER DECLARATION
A -
C a U INFORMATION
X g; LL N 1 hereby affirm that 1 am exempt firm the Contractor's.License MISC. R ER TO ORD z. VALUATION - $/FT.
F ¢ o j
APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
BU LD1 NG PROJECT IDENTIFICATION PERMIT NUMBER
BUILDING - APPLICATION & PERMIT ^
ADDRESS CHANICAL f` b
1 r BUILDING-ELECTRICAL-•PLUMBING-ME
61
wN 'E PLAN CHECK VALIDATION
v NAME QTY. ELECTRIC PERMIT FEE
•/(� HorvE
sAmsERAcroRs UTLETS-SWITCHES-RECEP 70.00/1.00
LIC NO. LIGHTING FIXTURES 10.00/1.00
CCONTRACTORS
ADDRESS PPLIANCES-RESIDENTIAL 4.00
PHONE PANELS 10.00 DATE OF APPLICATION
RRCHIrEcr PANELS (OVER 200 AMP) 20.00 PLAN CHECK FEE P.C.NO.
OR
ENGINEER
uc.No. SIGNS TRANS. 3.00 ..
ARCH,
DRESS ENG SPECIAL SPECIAL CIRCUIT 5.00 PERMIT VALIDATION
ZIP EMP.METER OR POLE INS. 20.00 PAID
ADDRESS
• AMOTORS SEE FEE SCH.
oREss
SERVICE CHANGE 20.00 J/) SEP 0 1985
ww o LICENSED CONTRACTORS DECLARATION TEMP.POLE 30.00
a o U 1 hereby uffinn that I an licensed under provisions of Chapter 9 I
y n (commencing with Section 7000)of Division 3 of the Business and
H m i Professions Code,and my license is in full for"and effect. BLD E C MECH.
z o„s- License Class Lic.Number ❑ . -1,
o w D Date Contractor
r.
a ¢ OWNER-BUILDER UECLARA'f10N BUILDING PERMIT
X o d INFORMATION
X
; u r hereby uffinn that 1 ren exempt from 0m Contractor s License MISC.- REFER TO ORD
F LL o J Law for the following reason.(Sea 7031.5,Buxinessand Profsson
eis PERMIT ISSUANCE 10.00 VALUATION S/FT.
Code',Any city or county which requires a permit to Construct.alley,
¢ ¢ Q p improve,demolish,or repair any structure;prior to its iomanCe,also ELEC.CONTR. LIB.NO. ELEC.
a
IT requires the applicant for such permit to tile a signed slet.Rmnl thud TOTAL PER T TO
Le .'y he is licenced pursuant to the provisions of the Contractor's License
FZI Law(Chapter 9(commencing wilh'Section 7000)of0ivision 3 of the
¢o Business and Professions de)or that he is exempt therefrom and QTY. PLUMBING PERMIT FEE /
E i
¢ F $ the basis for the alcgctl xemplion.Any violulion of Section 7031.5 STORIES E CONSTR.
u g by any applicant for a permit subjects the applicant to a civil penally
of not more than five hundred dollars(S500Lp ALTER-DRAIN& VENT-WATER (EA.) 5.00
❑ I,as owner of the property,or an,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 FIXTURES-PER TRAP 5.00 SO.FT.FLOOR AREA TOTAL ACREAGE
• himself or through his own employees.provided that such imprsne-
ments are not intended or offered for sal,If,however,the building GAS-EA.SYSTEM-1 INC.4 OUTLETS 6.00
or improvement is sold within one year of completion, - . - . .00 the owner- GAS EASYSTEM OVER 4(EA ) 2
builder will have the burden of proving Mat he did not build or ire- BUILDING USE
e for purpose ofsale.). INDUSTRIAL WASTE INTER. 30.00 RES IND CON Pe Omer
I,as owner of the property,am exclusively contracting with ❑ El 13tic .d Contractors to construct the project(Sec 7044,Business LAWN SPRINKLERS-1 INC 5 V.B. 6.00 ASSESSORS PARCEL NO.
on 1 Professions Code'The Contractor's License Law docs not apply
to un owner of property who builds or improves thereon,and who LAWN SPRINKLERS-OVER 5(EA.) 1.00
contracts for such projects with a contractor(s)licensed pursuant to
the f`Nmnar's Lice nse Law. SEWER-SANITARY-STORM EA.200tt/10.00 TRACT NO. PARCEL NO.
�❑ lam exempt liniENP�AITION
c. ,B.&I'.C.for this WATER HEATER W/VENT 6.00
A
wn`r I)al' WATER SYSTEM 5.00 ACC.DATE ACC.FILE N0.
WORKI7RS' DIiCLARATION` 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,Or a certified ZONING ENG.SITE NO.
copy thereof(Sec.3800.Lab.CJ.
Policy No. Company
0 ❑ Certified copy is hereby furnished.
Z Z ❑ Certified copy is fled with the city inspection division. FIRE SPRINK ENERGY T 24
O Applicant • MISC.- REFER TO ORD. Y❑ IN C] Y ❑ N❑
w CERTIPICA'('EOP EXEMPTION FRONT WORKIiRS. PERMIT ISSUANCE / 10.00 FLOOD ZONE A.L.U.C.
LU > COMM'NSATION INSURANCE. PLG.CONTR. LIC.NO. PLG.
i � Z (This section need not be completed if the permit is for one TOTAL Y❑ NE) Y ❑ NE]
hundred dollars(S 100)or less.)
U O 1 certify That in the performance of the work lilt which this per. QTY. MECHANICAL PERMIT 'FEE FEE SUMMARY
LL F mit is issued,I shall not employ any person in any trainer so as to
Qw, heC011la subject to the Workers Compensation Laws of CILAOTiia.
Dcte Applicant BUILDING
} N NO'T'ICE TO APPLICANT: II',after making this Certificale of fix- ALTER OR ADD TO MECH. 5.00
(_ 2 entption,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 of this permit shall be deemed revoked. AIR HANDLING UNIT(TO 10=C.F.M.) -4.00
CONSTRUCTION LENDING AGENCY AIR HANDLING UNIT(OVER 10=C.F.M.) 6.00 SEISMIC FEE
I hereby ](firm 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.CA HEATING UNIT(TO 100,000 B.T.U.) 8.00
Lender's Name HEATING UNIT(OVER 100,000 B.T.U.)9.50
Lender's Address ELECTRIC
1 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 state laws relating to building construction, and BOILER-COMP(3H.P.or100,000B.T.U.) 6.00
Hereby authorize representatives of this city to enter upon the
above-mentioned property for inspection purposesBOILER-COMP(Over 100,0008TU)SEE FEE SCR. MECHANICAL
(We) agree to save, indemnify and keep Iwrnrless 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 accrue against said City in consequence of the
granlingof this I Limit. MECH.CONT. LIC.NO. MECH.
TOTAL TOTAL
SignaMre ofApplican Con tactor Da c `
INSPECTOR COPY
1