09557 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
BUILDING PROJECT I DENTI FICATION PERMITNUMBER
7c Bu,LOING APPLICATION & PERMIT
GOORE55
Z z BUILDING - ELECTRICAL-PLUMBING -MECHANICAL 09557
OWNER'S PLAN CHECK VALIDATION
NAME QTY. ELECTRIC PERMIT FEE
PHONE
CONT ACTOR'S
NAME OUTLETS-SWITCHES-RECEP 10.00/1.00
Uc.No.-�rC/may f' LIGHTING FIXTURES 10.00/1,00
AoonFEE^'�o^RsPPLIANCES-RESIDENTIAL 4.00
rjJ b V (A)PRONE -S",?r-1 PANELS 10.00 DATE OF APPLICATION
ORRCR,TECT PANELS (OVER 200 AMP) 20.00 PLAN CHECK FEE P.C.NO.
ENGINEER
UC.NO, SIGNS TRANS. 3.00
ADDRRESSs Erva SPECIAL CIRCUIT 5,00 PERMla fi&10N
ZIP EMP. METER OR POLE INS. 20.00 ��rreF yy
ADDRESS TS MOTORS SEE FEE SCH.
AUG�I {2 19y85
SERVICE CHANGE 20.00
0 0 o LICENSED CONTRACTORS DECLARATION TEMP.POLE 30.00 City OI Cupertino
a v I hereby affirm that I am licensed under provisions of Chapter 9 ISSUANCE DATE
y a w (commencing with Section 7000)of Division 3 of the Business and BLDG. ELECT. PLG. H.
r w a Professions Cod my license is in full fort effect�i ❑ ❑ ❑
0 0 m C License C's^ Lia Number /�.1
r m J Date Contrumo _ -
w J OWNER-BUILDER Dli ARATI BUILDING PERMIT
MISC.- REFER TO ORD INFORMATION
X ;a. r 1 hereby affirm that I am exempt from the Contractor's License VALUATION $/FT.
.. o J Law for the following reason.(Sec.7031.$;Business.ad Professions
r - PERMIT ISSUANCE 10.00
Corte:Any city or County which requires a permit m construct,alter,
E
Q ¢ M Improve,demolish,or repair any structure,prior to Its issuance,also ELED.CONTR. LIC.NO. ELIC.
A. w m u requires the applicant for such permit to file a signed statement that TOTAL OEM T O
he is licensed pursuant to the provisions of the Contractor's License
rz > Law(Chapter 9(commencing with Section 7000)of Division 3 Ofthe
4 o Business and Professions Code)or that he is exempt therefrom and QTY. PLUMBING PERMIT FEE
H $
the basis for the alleged exemption.Subje.Any violation of Section malty STORIES TYPE CONSTR.
by any applicant fora permit dolfatsthe$500).licant fee civil penalty ALTER-DRAIN -WATER (EAJ 5.00
of not more than five hundred Prep dollars(my em:
❑ Las owner at the property,or my employees with wages as BACK F LOW PROTECT.DEVICE 4.00 OCC.GROUP RES.UNITS
their sole compensation,will Jo the work,and the structure is not
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 int proves thereon,and who docs such work FIXTURES,PER TRAP 5.00 SO.FT.FLOOR AREA TOTAL ACREAGE
himself or through his own employees,provided that such improve.
ments are not intended or offered for sale.If,however,the building GAS-EA.SYSTEM-I1NC.40UTLETS 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 im- BUILDING USE
prove for purpose of sale.). S IND CON PB Other
❑ 1,as owner of the property,an,exclusively contracting with INDUSTRIAL WASTE INTER. 30.00 ❑ ❑ ❑ ❑
licensed contractors to construct the project(Sec.7044,Business LAWN SPRINKLERS- 1.INC 5 V.B. 6.00 SSESSORS 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 eontractN{S)licensed pursuant to
the Contractor's License Law. SEWER-SANITARY-STORM EA.200tt/10,00 TRACT NO. PARCEL NO.
❑ I am exempt under Sec. ,B.&P.C.for this WATERHEATERW/VENT 8,00
reason
Owner Date WATER SYSTEM - 5.00 ACC.OATE ACC.FILE NO,
WORKERS'COMPENSA'I'ION DECLARATION WATER TREATING EQUIP. 5.00
1 hereby affirm that I have a certificate of consent to self-usum' ZONING ENG.SITE N0.
Or a certificate of Workers'Compensation Insurance.or a certified
copy thereof(See.3800,Lah.C.).
Policy No. Company
O ❑ Certified copy is hereby furnished. FIRE SPRINK ENERGY T-24
Z Z s�Certifte - epy is Jed he city inspection division.
F" O� A pliant Misc.- REFER TO ORD. Y❑ N❑ Y ❑ ' N❑
LU ti' .RTIFICA rXF.MPTION FROM WORKERS' PERMIT ISSUANCE 10.00 FLOOD ZONE A.L.U.C.
W COMPENSAIION INSURANCE. PLG.CONTR. LIC.NO. PLG,
Cl- O CI his section need not he comlileted if file permit is for one TOTAL Y❑ N❑ Y❑ N❑
::) Z hlmdfed d00urs(S HAD or less.)
U O 1 certify that in the performance of the work for which this per OTV. MECHANICAL PERMIT FEE FEE SUMMARY
LL t- mit is issued,I shall not employ any person in any manner so as to
0 L) become subject to the Workers'Compensation Laws of California.
y Dmc Applicant ALTER OR ADD TO MECH. 5.00 BUILDING
} w NOTICE TO APPLICANT: IL after making this Certificate of Iix
Z emption,you should became subject to the Workers'Cempeas911nn APPLIANCE
5.00 PLAN CHECK
provisions of the Labor Code, you must forthwith comply with
U such provisions or this permit shall be deemed revoked. AIR HANDLING UNIT(TO 10)000C.F.M.) 4.00 FEE
CONSTRUCT ION LENDING AGENCY AIR HANDLING UNIT(OVER 10PWC.@M.) 6.00 SEISMIC FEE
I homily affirm that there is n construction lending agency for EXHAUST HOOD(WITH DUCT) 5.00
the performance of the work for which this permit is issued(See. MICROFILM
3097,Civ.C.). HEATING UNIT(TO 100,000 B.T.U.) 8.00
Lender's Name
NHEATING UNIT(OVER 100,000 B.T.U.)9.50
Lender's Names ELECTRIC
I 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,Gr 100,000B,T.U.) 6.00
hereby authorize representatives ec this city to enter upon the BOILER-COMP (Over 100,000 BTU)SEE FEE SCH. MECHANICAL
hereby authorize
properly 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 CONST.TAX
-T7771-
may in any way accrAgaintsot, City in consequence of thegranlin s permit MECH.CONT. LIC,NO, MECH.
� g TOTAL TOTAL
Si are ofA is Da[
OFFICE COPY