9190 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
BUILDING PROJECT I DENTI FICATI ON PERMIT NUMBER
.oil.IG APPLICATION & PERMIT
AUDREss
Z-� ' RAE LN BUILDING - ELECTRICAL-PLUMBING-MECHANICAL 919
OWNER'SPLAN CHAD lkTION
NAME OTV- ELECTRIC PERMIT - . PEE'{' �IJL=
VSS PHONE
NAMERADT UTLETS-SWITCHES-RECEP 10.00/1.00 JUN
y •CLLIC.ND. LIGHTING FIXTURES 10.00/1.00
CONTRACTORS PPLIANCES-RESIDENTIAL 4.00 CRY of Cupertino
ADDRESS
Gr vHONE PANELS 10.00 DATE OF APPLICATION
OR
RCHrtECT PANELS (OVER 200 AMP( 20.00 PLAN CHECK FEE L.NO.
ENGINEER
uc.No. SIGNS TRANS. 3.00
AARCH.OR DDRESS ENG. SPECIAL CIRCUIT 5,00 PERMIT VALIDATION
ZIP rrEMP.METER OR POLE INS. 20.00
A
ADDRESS
MOTORS SEE FEE SCH.
DDR ESS UUUU
SERVICE CHANGE 20.00
ve o O LICENSED CONTRACTORS DECLARATION TEMP.POLE 30.00
a v v I hereby affirm that I am licensed under provisions of Chapter 9 ISSUANCE DATE
Nw (commencing with Section 7000)of Division 3 of the Business and
¢ A BLDG. ELECT. M C
H H i Professions Code,a my license is in full(once'n ( t ❑ El
o x - License Cl a s c.Number
-
Date H w Date on tractor
`amf r °'•t %'BUILDING P RMIT,j.i-,:'J
¢ ec w OWNER-BUILDER DECLARATION ,>b --�,
'x ;a. N I hereby affirm that 1 am exempt from the Contractor's License
MISC.- REFER TO ORD :i.INPORMATION-,
w VALUATION S/FT.
LLoj Law for to
Professions PERMIT ISSUANCE 10.00
Code:Any city or county which requires a permit to construct,alter,
Y ELEC.CONTR. LIC.NO.
y ¢ ¢ G improve,demolish,or repair any structure,prior to its issuance,also ELEC.
O LL requires the applicant for such permit to file a signed statement that TOTAL PER T TD
X
$ he is licensed pursuant to the provisions of the Contractor's License
z i Law(Chapter 9(commencing with Section 7000)of Division 3 of the -
E Business and Professions Code)or that he is exempt therefrom and OT.Y. PLUMBING PERMITFEE;.,•
¢ I- $ the basis for the alleged exemption.Any violation of Section]031.5 - - - STORIES TYPE CONSTR.
i by any applicant for a permit subjects the applicant to a civil penalty ALTER-DRAIN -WATER (EA.) 5.00
of not more than five hundred dollars($500).1:
❑ 1,as owner of the property,or my employees with wages as BACK FLOW PROTECT. DEVICE 4.00 OCC.GROUP RES.UNITS
sole compensation,will do 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 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 improve-
trentsare not intended or offered for sale.If,however,the building GAS-EA.SYSTEM-11NC.40UTLETS 6.00
or improvement is sold within one year of completion, the owner- GAS-EA.SYSTEM-OVER 4(EA.) 2.00
builder will have the burden of proving that he did not build or im- BUILDING USE
prove for purpose of sale.). RE IND CON PB CO.,
O I,as owner of the property,am exclusively contracting with INDUSTRIAL WASTE INTER. 30.00 0 ❑
0 El
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 contractors)licensed pursuant(o SEWER-SANITARY-STORM EA.200ft/10.00
the Contractor's License Law. TRACT NO. PARCEL NO.
❑ Ium exempt under Sec.-,BAP.C.for this WATER HEATER W/VENT 6.00
reason
Owner Date WATER SYSTEM 5.00
ACC.DATE ACF FILE NO.
WORK ERS'COMPENSATION DECLARATION WATER TREATING EQUIP. 5.00
1 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 thereon Sec.3800,LAC.).
Policy No. Company
O ❑ Certified copy Is hereby furnished.
24
Z Z t ified cop ed with the 't ction division. FIRE SPR INK ENERGY T N
F-- O Applicant MISC.- REFER TO ORD. v❑ N� v N�
L0 PERMIT ISSUANCE 10.00
Lu - CERTIFICATE EX ION FROM WORKERS' FLOOD ZONE A.L.u.c.
Lu >6. O COMPENSATION INSURANCE PLG.CONTR. LIC.NO. i`OT.AL Y IN C] Y N0
Z (This Section need not be completed if the permit is for one
hundred dollars($100)or less.) _
U O 1 certify that in the performance of the work for which this per, OTV MECHANICAL PERMIT FEE.- „�FEB8UMMARY;
LL k- mit is issued, I shall not employ any person in any manner ao as to
O w become subject to the Workers'Compensation Laws of California.
Date Applicant BUILDING
>_ 0NOTICE TO APPLICANT: If,after making this Certificate of Ex-
emption,you should become subject to the Workeri Compensation APPLIANCE 5.00 A PLAN CHECK
provisions of the Labor Code, you must forthwith comply with FEE
U such provisions or this permit shall be deemed revoked. AIR HANDLING UNIT(TO 10,000C.F.M.) 4.00
CONSTRUCTION LENDING AGENCY AIR HANDLING UNIT(OVER 10=CEM.) 6.00 SEISMIC FEE
I hereby affirm 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.C.), HEATING UNIT(TO 100,000 B.T.U.) 8.00
Lender's Name HEATING UNIT(OVER 100,000 B.T.U.19.50
Lenders Address ELECTRIC
I certify that I have read this application and state that the above LJ VENTILATION FAN (SINGLE) 4.00
information is correct. I agree to comply with all city and countyPLUMBING 01
ordinances and state laws relating to building construction, and BOILER-CORIP 13 H.P.or 100,000 B.T.U.) 6.00
s hereby authorize representatives of this city to enter upon the
above.mentioned property for inspection purposes. BOILER-COMP(Over 100,000 BTU(SEE FEE SCM. MECHANICAL
(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 10.001/0.' CONST.TAX
may in any way accrue against said City in consequence of the
granting of this permit. MECH.CONT, LIC.NO. MECH.
TOY` /' TOTAL
Sign ure pylic ntractor Date e
OFFICE COPY