2262 APPLICANT TO FILL IN INFORMATION WITHIN REQ1INES — USE BALI. POINT PEN ONLY
PERMIT NUMBER
BUI LDI Nfa PROJECT I DENTI FICA APPLICATION & PE C
v amLUING u C- , U
ADDRESS
OCA [,FE R D ' BUILDING - ELECTRICAL-PLUMBING-MECHANICAL
OWNERPLAN CHECK VALIDATION
NAME 72
,/$�cBI�,�} OTV. ELECTRIC PERMIT FEE
�O/
CONTRACTOR'S
NAME JOUTLETS-SWITCHES-RECEP 5.00/1.00
U 9119- LIC.No ILIGHTING FIXTURES 5.00/1.00
CONTRACTOR
na
ADDRESS
—APPLIANCES-RESIDENTIAL 4.00
- ON
PHONE PANELS 5.00 DATE OF APPLICATION
ARCHITECT - PLAN CHECK FEE P /
OR SIGNS - 6.00
ENGINEER
. . LIC.NO SIGNS TRANS. 3.00
ADDRESS ENO. SPECIAL CIRCUIT 5,00 PERMIT VALIpAT771ONJJ
ZIP TEMP.METER OR POLE INS. 15.00
APPLICANT'S MOTORS SEE FEE SCH. L
ADDRESS '
SERVICE CHANGE 10.00
woo LICENSED CONTRACTORS DECLARATION
R v I hereby affirm that I nm licensed under provisions of Chapter 9 CITYISSUANCE DATE
yz a (Commencin with Section 7000)of Division 3 of the Business and
¢ 9 - BLDG. ELECT. PLG. MECH.
H w z Professions Code,and my license is in full force and effect. ❑ 1:1 1-1 -
z0 0Z w - License Class Lic.Number y -
H Date Contractor SEN 1982
a m s -+ BUILDING PERMIT
¢ ¢ a OWNER-BUILDER DECLARATION
¢ u, u - INFORMATION
w ; ` r 1 hereby affirm that 1 am exempt from the Contractor's License MISC.- �REFER TO ORD
w m VALUATION SIFT.
FLL0 J Law for the ityor followingreason,
c.requirsa permit
roc nil Professions PERMIT IS 6.00 �--- n
w � Code:Any city Or county which structure p prom rotoi construct,alter,also
¢ ¢ a 0 improve,demolish,or repair any structure,prior m its issuance,also ELEC.CONTR. LIC.NO. ELEC. ✓ (/(/Q to 0¢ requires the applicant for such permit to file a signed statement that TOTAL �- PERMIT TO
I,
m u he is licensed pursuant to the provisions of the Contractor's License
'i Law(Chapter 9(commencingwilh Section 7000)of Division 3 of the 4
a - Business and Professions Code)or that he is exempt therefrom and CITY. PLUMBING PERMIT FEE
s' ¢ _ $ the basis for[he alleged exemption.Any violation ofSection 7031.5 STORIES TYPE CONSTR.
aby any applicant for a permit subjects the applicant to a civil penalty ALTER-DRAIN&VENT-WATER (EA.) 4.00 2,
- .of not more than five hundred dollars(SS00)J:
❑ Las owner of the properly,o-my employees with wages us BACK FLOW PROTECT. DEVICE 2.00 OCC.GROUP RES.UNITS
their,sole compensation,will do the work,and the structure is not �j
intended or offered for Sale(Sec. 7044, Business and Professions DRAINS-FLOOR,ROOF,AREA,COND. 4.00
Cade:The Contractor's License Law does not apply to an owner of tl/
property who builds or improves thereon,and who does such work FIXTURES-'PER TR AP 4.00 SO.FT.FLOORAREA TOTALACREAGE
himself or through his own employees,provided that such improve- I
meats are not intended or offered for sale.If,however,the building. GAS-EA.SYSTEM-11NC.40UTLETS 4.00
or improvement is Sold within one year of completion, the owner. GAS:EA.SYSTEM-OVER 4 (EA.) 1,00 BUILDING USE
builder will have the burden of proving that he did not build or im RES IND ��W-1 PB Om.,
prove 1,as ownerose
of the p INDUSTRIAL WASTE INTER. 20.00 ❑ I!O 0 ❑ ❑
❑ Las owner of the properly,am exclusively contracting with
licensed ecn men.rs to construct the project IS,,7044, Business , LAWN SPRINKLERS-1 INC 5 V.B. 5.00 ASSESSORS PARCEL NO.
and Professions Code:The Contractor's License Law does not apply �// -P-1to owner of property who builds r(
improves thereon,and who LAWN SPRINKLERS-OVER 5(EA.) 1.00 •+
contracts
nt
acts for such projects with a coiactoa)licensed pursuant to SEWER-SANITARY-STORM EA. 200ft/8.00
the Contractor's License Law. TRACT NO. PARCEL NO.
❑ I am exempt under Sec. ,B.SPC.for this WATER HEATER W/VENT 4.00
reason
,( Date v_*
caner WATER SYSTEM 4.00 ACC.DATE ACC.FILE NO.
WORK ERS'COMPENSATIONDECLARATION WATER TREATING EQUIP. .4.00 —_
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(See.3800,Lab.C.). �
Policy No. }J]Company _ T
0 ❑ Certified copy is hereby furnished. FIRE SPRINK ENERGY T 24
Z Zp.O ❑ Certified copy is filed with the city inspection division. MISC.- REFER TO ORD. N❑ Y ❑
Applicant
cc T CERTIFICATEOF EXEMPTION FROM WORKERS' PERMIT ISSUANCE 6.00 Ff`0V ZONE �eEC47
LL > COMPENSATION INSURANCE PLG.CONTR. LIC.NO. PLG,
d O (This section need*not be completed if the permit is for one TOTAL Y❑ �—p 'nj.
M Z hundred dollars IS 100)or less.)
U O I certify that in the performance of the work for which this per- OTV. MECHANICAL PERMIT FEE FEE SUMMARY
LL 1- mil is issued, I shall not employ any person in any manner so as to
U become subject to the Workers'Compensation Laws of California.
i Date Applicant _ ALTER OR ADD TO MECH. 4.00 BUILDING .)a
} Us NOTICE TO APPLICANT: If,after making this Certificate of fix- -
? emption,you should become subject to the Workers'Compensation APPLIANCE 4.00 PLAN CHECK
provisions of lite 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.) 3.00
CONSTRUCTION LENDING AGENCY AIR HANDLING UNIT(OVER 10XMC.F.W 5.00 SEISMIC FEE `
I hereby affirm that there is a construction lending agency for EXHAUST HOOD(WITH DUCT) 2.00
the performance of the work for which this permit is issued(Sec. MICROFILM
3097,CN.C). HEATING UNIT.(TO 100,000 B.T.U.) 4.00
Lender's Name
Lender's Address HEATING UNIT(OVER 100,000 B.T.U. 7.50 ELECTRIC CTR I CW
Icertify that l have read this application and state that the above VENTILATION FAN (SINGLE) 3.00
information is correct.I agree to Comply with all city and County BOILER-COMP(3 H.P.OF 100,000 B.T.U.) 4.00 PLUMBING
ordinances and State laws relating to building construction, and
hereby authorize representatives of this city to enter upon the BOILER-COMP (Over 100,000 BTU)SEE FEE SCM. MECHANICAL
above mentioned property for inspection purposes.
'(We) agree to save, indemnify and keep harmless the City at MISC.- REFER TO ORD,
Cupertino against liabilities,judgments, costs and expCONST.TAX
expenses which PERMIT ISSUANCE 3
may in any way accrue against said City in consequence of the .00
granting of this peftnlL MEC..CONT. LIC.NO. MECH.
Z4B�8 OTAL TOTAL
•` Signature of Applicant/Contractor Date
OFFICE COPY