8988 (2) A`4PLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
• BUPLDING PROJECT I DENTI FICAT - PERMIT NUMBER
BUILDING
APPLICATION & PERMIT'
POORESS �OSoo lj/D6� UILDING-ELECTRICAL-PLUMBING-MECHANICAL 8988
OWNER'5 J K. PLAN CHECK VALIDATION
NAME rn. b1(�-,-IPHONE QTY. ELECTRIC PERMIT FEE 1 "L
CONTRACTOR S
NAIVEUTLETS-SWITCHES-RECEP 10.00/1.00 �..
- f'j r/ LIC.ND. I7 Y[,3 7 9 LIGHTING FIXTURES 10.0011.00 744
fDNrRAcros
A �
PPLIANCES-RESIDENTIAL 4.00D77 �- "VL/// //,,ll T O.E /-/000
PANELS 10.00 DATE OF APPLICATION
ARCHITECT ANELS (OVER 200 AMP) 20.00 PLAN CHECK FEE P.C.NO.
OR X40.0
ENGINEER
LIc.No, ISIGNS TRANS. 3.00 PAI
moo eRENcSPECIAL CIRCUIT 5,00 PERMIT VALIDATION
ZIP TEMP.METER OR POLE INS. 20.00 MAR 31 1987
APPLICANT MOTORS SEE FEE SCH. ,Q
SERVICECHANGE 20.00 City of Cupertino
0 o O LICENSFD CONTRACTORS DECLARATION TEMP.POLE 30.00
u v I hereby affirm that 1 am licensed under provisions of Chapter 9 / - 30 _/Q / _3-6-PISSUANCE DATE
N <y (commencing with Section 7000)of Division 3 of the Business and y BLDG. ELE T. PLG. MECH.
E.N z Professions Code,a my license is in full(once and n feet. O/x� O LS ,O ❑ ❑ ❑
a o m - License Clss hie Number
o T H w Date �,����7 Conimnor_>�� .era .
a y 2 � Et- / / 56 k✓A- .•.E'er 0A0 B ILDING PERMIT
at u OWNER-BUILDER DECLARATION INFORMATION
w3 LL y 1 hereby affirm that 1 am exempt from the Contractor's License MISC.- REFER TO ORD VALUATION E/PT.
H04 Law for the following mason.(SCE.703 1.5,Business and Professions PERMIT ISSUANCE 10.001000
Code:Any city or county which requires permit to construct.alter,
2 S ¢ p improve,demolish,or repair any structure,prior to its issuance,also ELEC.CONTR. LIC.NO. ELEC.
0 LL requires the applicant for such permit to file a signed statement that Tw 7 I�' TOTAL ERMIT O
ww he is licensed pursuant to the provisions of the Contractor's License M1AJ T
Law(Chapter 9(commencingwilh Section 70000.1'Division3 of the
a Business and Professions Code)or that he is exempt therefrom and OTY. PLUMBING PERMIT FEE
¢ o the basis for the alleged exemption.Any violation of Section 7031.5 SfORIn TYPE CONSTR.
by any applicant for a permit subjects the applicant loo civil penalty ALTER-DRAIN -WATEfl (EA.) S.QQ
of not more than five hundred dollars(55000.):
❑ 1,as owner of the property,or my employees with wages as BACK FLOW PROTECT. DEVICE 4.00 Oce.GROUP RES.UNITS
their sole compensation,will do the work,and the structure is not
intended or offered for sale (Sea 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
Tritearc through his own employees,Provided that such ibuildi e-
mmselfonotinthhis or employeeffered for sa e.molded thathowever,the building GAS-EA.SVSTEM-11NC.40UTLETS 6.00
u improvement is sold within one year of completion,the owner-
build" GAS-EA.SYSTEM-OVER 4 (EA.) 2.00 BIL,DIN USE
will have the burden orproving that he did not build or im RES IND C PB Omar
prove for purpose of sale.). INDUSTR IAL WASTE INTER. 30.00
❑ I,as owner or the property.am exclusively Contracting with ❑ ❑ ❑ ❑
licensed contractors to construct the project ISec.7044,Business LAWN SPRINKLERS- 1 INC 5 V.B. 6.00 ASSESSO SP RCEL NO.
and Professions Code The Contractor's License Law does not apply
to an owner of property who builds or improves(hereon.and who LAWN SPRINKLERS-OVER 5(EA.) 1.00
contracts for such projects with u eentructons)licensed pursuant to
the Contractor's License Law. SEWER-SANITARY-STORM EA.200ft/10.00 TRACT NO. PARCEL NO.
❑ I am exempt under Sec. .B.&P.C.for this WATER HEATER W/VENT 6.00
reason
Owner Date WATER SYSTEM 5.00
ACC.DATE ACL.FILE NO.
WORKERS'COMPFNSAT1ON DECLARATION WATER TREATING EQUIP. 5.00
I hereby alfirn that l have a certificate of consent toulf-insure, ZONING ENG.SITE NO.
or a certificate of Workers'Compensation Insurance.or a Certified
copy thereof(Sec.3800,Lab.C.I
Policy No.ioL Ul Cmnpany
O ❑ Certified copy is hereby furnished FIRE SPRINK ENERGY T 24
Z z Q Certificp o y s filed with theity inspection division.
O Applicant CI��'t-a✓n €'L£C' MISC.- REFER TO ORD. Y ❑ N❑ Y ❑ N❑
CCN CE-RTIFICATIi Op EXEMPTION FROM WORKERS' PERMIT ISSUANCE 10.00 1 FLOOD ZONE A.L.U.C.
> COMPENSATION INSURANCE PLG.CONTE. LIC.NO. PLG,
CIL O (This Section need not be completed if the permit is for one TOTAL Y❑ N❑ Y ❑ N❑
0 Z hundred dollars IS 100)or less)
U O 1 certify that in the performance of the work for which this per- OTY. MECHANICAL PERMIT FEE FEE SUMMARY
LL F mit is issued,1 shall not employ any person in any manner SO as to
U become subject to the Workers'Compensation Laws of California.
ii Date ApplicantALTER OR ADD TO MECH. 5.00 BUILDING
} to NOTICE TO APPLICANT: If,after making do,Certificate of Ex.
F Z emption,you should become subject RI the Workers'Conpeasat ion APPLIANCE 5.00 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
CONST RUCTION LENDING AGENCY AIR HANDLING UNIT(OVER 10MC.F.M.) 6.00 SEISMIC FEE
I hereby affirm that there is a construction lending agency for EXHAUST HOOD(WITH DUCT) 5.00
the 3097,Civ.0 MICROFILM
ince of the work for which this permit is issued(Sec. HEATING UNIT(TO 100,000 B.T.U.) 8.00
Lender's Name
Lender's Address
HEATING UNIT(OVER 100,000 B.T.U.)9.50 ELECTRIC
I certify that h have read thn.pplication and state that the aboveVENTILATION 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(3 H.P.or100,000B.T.U.) 6.00
hereby authorize representatives ol' this city to enter upon the BOILER-COMP (Over 100,000BTU)SEE FEESCH. MECHANICAL
above-mentioned property for inspection purposes.
(We) agree to save, indemnify and keep harmless the City of MISC.- REFER TO ORD.
Curer ino against liabilities,judgments, costs' and expenses which CONST.TAX
may . ny way accrue against said Cit - con ace of the PERMIT ISSUANCE 10.00
g .__In
this permit. MECH.CONT. LIC.N0,
MECH.
OT"` TOTAL
Sign re of Applicant/Contractor Uate
OFFICE COPY