The URL can be used to link to this page

8902 (2)APPLICANT TO FILL IN INFORMATION WITHIN RED LINES -USE BALL POINT PEN ONLY a57--) 'BUI L^DI NG PROJECT 1 DENTI FICATION APPLICATION & PERMIT BUILDING - ELECTRICAL- PLUMBING - MECHANICAL , PERMIT NUMBER 8902 HULOING /or AooRESs 1996 ®i[7E ` OWNER'S NAM ✓ OTV. ELECTRIC PERMIT FEE CVALIDATION PLAN CHECITI C PHONE DATE OF APPLICATION CONTRACTORS CP T e71/C-GO-.�Cuc. Na. /;7/rj OUTLETS-SWITCHES-RECEP 10.00/1.00 LIGHTING FIXTURES 10.00/1.00 0o ^ess/ioR�'s/ qa mai �,/J/JKIC„SNt � PHONE f-/ 'OSS APPLIANCES- RESIDENTIAL - 4.00 PANELS 10.00 OORRCHITECT ENGINEER LIC. NO, PANELS (OVER 200 AMP) 20,00 PLAN CHECK FEE P.C. NO. SIGNS TRANS. 3,00 nooAEss ENG. SPECIAL CIRCUIT 5.00 - TVALIDATION TEMP. METER OR POLE INS. 20.00 ZIP PR T4 198SI it'd of Cupertino APPLICANTS 9.:5"1/3- LICENSED CONTRACTORS LARATION :C MOTORS SEE FEE SCH. SERVICE CHANGE 20.00 TEMP. POLE 30.00 I hereby affirm that I am licensed undo provisions of Chapter 9 (commencing with Section 7000) of Division 3 of the Business and Professions Code and my license is In full farce and effe 1. License C ass Lic. Number ISSUANCE DLITZ BLDG. ❑ ELECT. ❑ Date _Contractor BUILDING INFORMTION OWNER -BUILDER DECLARATION 1 hereby affirm that I am exempt from the Contractor's License Law for the following reason. (Sec 7031.5, Basinessand Professions Code: Any city or county which requires a permit to construct, alter, improve, dem ish, or repair any structure, prior to its issuance, also requires the a lease for such permit to file a Signed statement that he is licensed p mart to the provisions of the Contractor's Licen MISC. - REFER TO ORD PERMIT ISSUANCE 10.00 VALUATION S/FT. ELE ONTR. LIC. NO. ELEC. TOTAL PERMIT TO Law (Chapter 9(co encing with Section 7000)ofDivision Sof e Business and Professi Code) or that he is exempt [bereft and CITY. PLUMBING PERMIT FEE STORIE TVP CONSTR. the basis for the alleged a mption. Any violation of Secti 031.5 by any applicant for a perm subjects the applicant too it penalty of not more than five barium ollars (5500).): ALTER -DRAIN -WATER (EA.) 5.00 ❑ I, as owner of [lie proper or my emplo s with wages as their sole compensation, will Jo r work, an a structure is not BACK FLOW PROTECT. DEVICE 4.00 OCC. GROUP REA UNITS DRAINS -FLOOR, ROOF, AREA,COND. 5.00 intended or offered for sale (Sec. 44, It mess and Professions Code: The Contractor's License Law or apply to an owner of property who builds or improves the and who docs such work himself or through his own emplo s, to 'ded that such improve- mems, are not intended or offer for sale,I however, the building FIXTURES - PER TRAP 5.00 d SQ FT. FLOOR AREA TDTALACREAGE Ob GAS-EA.SYSTEM-11NC.40UTLETS 6,00 01 or improvement is sold wit)' one year of co lerion, the owner builder, will have the bur of proving that he of build .,am- prove for purpose of s' ❑ 1, as owner a property, am exclusively contracting with GAS - EA. SYSTEM - OVER 4 (EA.) 2.00 BUILDING USE RES IND CON PB Other INDUSTRIAL WASTE INTER. 30,00 licensed conte Io construct the project (Sec. 7044, Business and Professi. ode: The Contractor's License Law does not apply to an owner of property who builds or improves thereon, and who LAWN SPRINKLERS- 1 INC 5 V.B. 6.00 LAWN SPRINKLERS - OVER 5 (EA.) 1.00 ASSESSORS PARCEL NO. contracts for such projects with a contractogs) licensed pursuant toSEWER-SAN the Contracroi s License Law. ITARV-STORM EA. 200ft/10.00 TRACT N0, PARCEL N0. ❑ I ani exempt under Sec.-, L&P.C. for this reason WATER HEATER W/VENT 6.00 (o.� Owner Date WATER SYSTEM 5.00 - ACC. DATE ACC. FILE NO. WATER TREATING EQUIP. 5.00 WORK ERS'COMPENSATION DECLARATION I hereby affirm that I have a certificate of consent to selhinsure, or a certificate of Workers' Compensation Insurance, or a certified copy thereof(Sec. 3800, Lab.C.). / Policy No,1!2$_q0_AC.mpany' e/ilYf�/7Ht� ZiZi/2.Q ZONING ENG. SITE NO. ❑ Certified copy is hereby furnished. 'W Certified cry is fi��w-i'th th ny ins ection division. Applicant sPE t LLa� FIRE SPRINK V ❑ N❑ ENERGY T-24 Y [] N[3 MISC. - REFER TO ORD. CER'fIFICA11: OF EXEMPTION FROM WORKERS' PERMIT ISSUANCE 10.00 11D- FLOOD ZONE A.L.U.C. , PLGA CONTR. LIC. NO. G�'�/�S✓(g/� / % s3 PLG. TOTAL C04ENSATION INSURANCE (This section need not be completed if the permit is for one Y ❑ N� Y ❑ N� hundred dollars (S 100) or less.) i t that in me performance of the work for whi '- mit is .I 1 not employ any Pers. runners. as t0 MECHANICAL PERMIT FEE FEE SUMMARY BUILDING _ become subject to true' CO orlon L'ews of California. Date APPIIca 'TO 'ficatc ALTER OR ADD TO MECH. 5.00 NOTICE. APPLI : If, aRcr making this u of I>x- emption, you s become subject to the Workers' Compensation provisions of the Labor Code, you must forthwith comply with such provisions or this permit shall be deemed revoked. APPLIANCE 5.00 AIR HANDLING UNIT (TO 10,000CF.M.) 4.00 PLAN CHECK FEE AIRHANDLING UNIT(OVER 10=C.EM.) 6.00 SEISMIC FEE CONSTRUCTION LENDING AGENCY I hereby a that there is aconstruction ency for EXHAUST HOOD (WITH DUCT) 5.00 the performance o rk for whi ermit is issued (Sec. 3097, Civ.C.). MICROFILM HEATING UNIT (TO 100,000 B.T.U.) 8.00 Lender's Nam• ' � Lender's Address HEATING UNIT (OVER 100,000 B.T.U.) 9.50 ELECTRIC VENTILATION FAN (SINGLE) 4.00 1 certify that I have read this application and state that the above information is correct. I agree to comply with all city and county unlinunres End state taws re luring to building construction, and PLUMBING BOILER- COMP(3 H.P. Or 100,000 B.T.U.) 6.00 hereby authorize representatives of this city to enter upon the above-mentioned property for inspection purposes. BOILER -COMP (Over 100,0008TU1 SEE FEE BCH. MECHANICAL (We) agree to save, indemnify and keep harmless the City .f Cupertino against liabilities, judgments, uses End expenses which may in any way accrue against Said i In consequence of the gapting� O/f lhJ�yTeemifr.MECH. UpGLCtJ y MISC. - REFER TO ORD. CONST. TAX PERMIT ISSUANCE 10.00 CONT. LIC. NO. MECH. TOTAL TOTAL Signature o(Appllcant/Contmemr Dare OFFICE COPY