09562 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY r< -a0(0
BUILDING PROJECT IDENTIFICATION , PERMITNUMBERR
BUILDING APPLICATION & PERMIT 09562
NER
ADDRESS
Tl8 8, BUILDING-ELECTRICAL-PLUMBING-MECHANICAL
OW 's181 PLAN CHECK VALIDATION
NAME
y� { n C 1,.�. OTV. ELECTRIC PERMIT FEE
L•LL• Las Solar PHONE-G 5- 409
r CONTRACTORS
NAME
rvgME UTLETS-SWITCHES-RECEP 10.00/1.00
Atlas Heating LIC.No. 24321 LIGHTING FIXTURES 10.00/1100
CONTRACTOR'S DRESS rDR•s/� �{. APPLIANCES-RESIDENTIAL 4.00
155 Commercial St PHONE 739-0516 PANELS 10.00 DATE OF APPLICATION
ARRCHITECT PANELS (OVER 200 AMP) 20,00 PLAN CHECK FEE P.C.NO.
ENGINEER
ARC OR LIC.No, SIGNS TRANS. 3.00
ADDRESS ENG. SPECIAL CIRCUIT 5,00 PER .y�y�y710N
ZIP EMP.METER OR POLE INS. 20.00APPLICAN
J' ABY
ADDRESSTS MOTORS SEE FEE SCH. .NOV - 7 1985
SERVICE CHANGE 20.00
w o o LICENSED CONTRACTORS DECLARATION TEMP.POLE 30.00 City of Cupertino
M u t I hereby affirm that I am licensed under provisions of Chapter 9 ISSUANCE DATE
w < a (commencing with Section 7000)of Division 3 of the Business and BLDG. ELECT. PLG. MECH.
D i Professions Code�anslsRly license is in full force orld b[[6
Z 0 m W LiceoI&t., a� VVS..,_hie,Number YV LA ❑ ❑ ❑
H w H J Uatc LV 99Y 000 Contractor
a I j � = BUILDING PERMIT
¢ ¢ w a OWNER-BUILDER DECLARATION INFORMATION
MISC.-
w g n vHi I hereby afOnn that 1 am exempt from the Contractor's License REFER TO ORD VALUATION $/FT.
u o 4 Law for the following reason.(Sec.7031.5,Business and Professions 10.00
-w PERMIT ISSUANCE
se ra Code:Any city or county which structure permit to
¢ (C ¢O improve,demolish,or repair structure,prior to its issuance,also ELEC.CONTR. LIC.NO. ELEC.
i w m¢ requires the applicant for such permit to file a signed statement that TOTAL PERMIT TO
he is d pursuant to the provisions of the )ofDivisContractor's License
the
i i 4 Law(Chapterand
roco moos C Cutlet
or Secthat
is exempt theref o and
f z o Business and Professions Codas)or that he is exempt therefrom and DTV. PLUMBING PERMIT FEE
¢ H$ the basis for the alleged exemption.Any violation of Sectionu L5 STORIES TYPE DDNBTfl,by any applicant for permit subjects the applicant to a civil penalty
of not more than five hundred dollars($500).): ALTER-DRAIN& VENT-WATER (EA.) 5.00
❑ I,as owner of the property,or my employees with wages as BACK FLOW PROTECT. DEVICE 4.00
their sole compenWl ton,will do tilt work,and the Structure is not OCC.GROUP RES.UNITS
intended or offered for sale(Sec. 7044, Business and Professions DRAINS-FLOOR,ROOF,AREA,COND. 5.00
Code:The Contractor's License Law does not apply to an owner of
property who builds or improves(hereon,and who does such work FIXTURES-PER TRAP r 5.00 g0,FT.FLOOR AREA TOTAL ACREAGE
himself or through his own employees,provided that such improve-
mentsarenotintendedoroffered for sale.If,however,the building GAS-EA.SYSTEM-I INC.4 OUTLETS 6.00
or improvement is sold within one year of completion,the owner- GAS EASYSTEM OVER 4 IEA) 2.00
builder will have the burden of proving that h - . - .
e did not build or im- BUILDING USE
prove for purpose of sale.). INDUSTRIAL WASTE INTER. 30,00 E IND CON PB Other
❑ I,as owner of(lm property,unl exclusively contracting with 1:1 Cl 1:1 ❑
licensed contractors to construct the project(Sec. 7044,Business LAWN SPRINKLERS-1 INC 5 V.B. 6.00 ASSESSORS PARCEL NO.
and Professions Code:The Contractor's License Law does not apply
to an owner of property who builds or improves thereon,and who LAWN SPRINKLERS-OVER 5(EA.) 1.00 "
contracts for such Projects with a contractor(s)licensed pursuant to
the Contractor's License Law. I SEWER-SAN ITARY•STORM EA.200ft/10.00 TRACT NO. PARCEL NO.
❑ l am exempt under Sec. ,B.&BC.for this
reason WATER HEATER W/VENT 6.00
Owner Date WATER SYSTEM 5.00
ACC.DATE ACC.FILE NO.
WORK F.RS'COMPP.NSATION DECLARATION WATER TREATING EQUIP. 5.00
I hereby affirm that P have a certificate of consent to self-insure,
or a certificate of Workers'Compensation Insurance,or a certified ZONING ENG.SITE NO,
copy there ISe 0
roller No. � 6 1 l 1 Bd Pae £i
0 ❑ Certified copy is hereby furnished.
Z Z ❑ Certified copy is riled with the city inspection division. FIRE$PR INK ENERGY T-Z4
O Applicant-Ilil {eaU_Dg misc.- REFER TO ORD. y [3 NYo No
= N CERTIFICATE OF EXEMPTION PROM WORKERS' PERMIT ISSUANCE 10.00 FLOOD ZONE A.L.U.C.
LU COMI1I;NSA'1'ION INSURANCE PLG.CONTR. LIC.NO. PLG.
CLZ (This xclion need not he completed if the permit is for one TOTAL V N� Y N�
U O hundred dollars IS 100)Ua Wsr.)
I certify that in the performance of the work for which this per- OT,r MECHANICAL PERMIT FEE FEE SUMMARY
LL F mil is issued,I shall not employ any person in any manner so as to
O W become subject to the Workers'Compensation Laws of California.
Datt Applicant BUILDING
>_ N NO'I'ICIS'TO APPLICANT': If,after..laking this Certificate of Ex ALTER OR ADD TO MECH. 5.00
Z Caption,you should bec6me subject to the Workers'Compensation APPLIANCE 5.00 PLAN CHECK
provisions of the Labor Code, you must forthwith comply with FEE
V such provisions or this permit shall be deemed revoked. AIR HANDLING UNIT(TO 10,000C.F.M.) 4.00
CONS'1'RI1CI'ION L17NDING AGENCY AIR HANDLING UNIT(OVER 10=C.F.M.) 6.00 SEISMIC FEE
I,hereby affirm Dat 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 8 00
Lender's Name HEATING UN IT IOVER 100,000 B.T.U.)8,50
s, Lender's Address ELECTRIC
I certify that l have read this application and state that the above VENTILATION FAN (SINGLE) 4.00
ordinances nc statelIssrccticomply with all city and county BOILER•COMP 13 H.P.or 100,000 B.T.U.16.00 PLUMBING
ordinances and slate laws ativesns ID building construction, the
hereby authorize representatives ins inspection
this city to enter upon the 801 LER-COMP loin,100,000 BTU)SEE FEE$CH. MECHANICAL
above-mentioned property for inspection purposes.
(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 ],Q O CONST.TAX
may in any way accrue against said City in consequence of the
g tin6 of th' p it. MECWCONi i 4 f}/ MECH. .00
�_�,,� � VV��II'' ll ay TOTAL TOTAL
SI reo�p ca'IF tmcto�I pate`y Atla8 Heatin 24321 a
OFFICE COPY