09564 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY' K-LLIS S.
BUI LD1 NG PROJECT I DENTI FICATION PERMIT NUMBER
aODFESS APPLICATION & PERMIT 09564
AOORE55
BUILDING -'ELECTRICAL-PLUMBING-MECHANICAL
CHECK VALIDATION
OTY. ELECTRIC PERMIT FEE
PHONE -
'.O NAME AcroRs QOUTLETS•SWITCHES-RECEP 10.00/1.00
(\ Lie NO. LIGHTING FIXTURES 10.00/1.00
ADDRESS OHS/a SUALAS'H to .. PPLIANCES-RESIDENTIAL 4,00
1 - �L, yyN, PHONe� PANELS 10.00 DATE OF APPLICATION
ARCHITECT PLAN CHECK FEE P.C.NO.
OR PANELS (OVER 200 AMP) 20.00
ENGINEER
LIC No, SIGNS TRANS. 3.00 Pao
ARCH.OR ENG. PERMI N
ADDRESS " SPECIAL CIRCUIT 5.00
ZIP EMP.METER OR POLE INS. 20.00 NOV
ADDRESSra _ ' MOTORS SEE FEE SCH. rr 1900
SERVICE CHANGE 20.00 CI� Of Cil vJ
w o o LICENSED CONTRACTORS DECLARATION TEMP.POLE 30.00 Cupertino
< u v I hereby al'1'irm thatI um licensed undtr provisions of Chapter 9 ISSUANCE DATE
y w Icnmmenemg with Section 7000101'Division (the Busine anA
F 7 2 Professions Co license is in full f0 c ppp�,,I��'(�spp BL❑OG: ELECT. PL❑G. MECH.
G 0 a W License Class Lic.Number-bJ b -
Umey1 .. _Contractor
E O w OWNER-BUIu)IiR UECLARn'flpN - ,BUILDING PERMIT
IAxu ;LL y I hereby affirm that I am exempt from the Contractor's License MISC.- REFER TO ORD INFORMATION
r LL o J Law for the following reason.(Sec.7031.5,Businessand Professions PERMIT ISSUANCE - VALUATION /FT.
LA Code:Any city or county which requiresa permit toconstrmt,alter, 10.00
2 ¢ > o improve,demolish,or repair any structure,prior to its issuance,also ELEC.CONTR... LIC.NO. ELEC.
A wG¢ requires the applicant for such permit to file a signed statement that TOTAL
m" he is licensed pursuant to the provisions of the Contractor's License RM IT-TO
Fri
Law(Chapter 9(commencing with Section 7000)offusision 3 of the
Q ' Business and Professions Code)or that he is exempt therefrom and QTY. PLUMBING PERMIT FEE-
Fm , the basis fill tire alleged exemption.Any violation of Sectio.7031.$ STORIES - TYPE CONSTR.
u ; by any applicant for a permit subjects tire applicant to a civil penalty ALTER-DRAIN -WATER IEA.) 5.00
of not more than five hundred dollars(5500).1:
❑ I,as owner of the property,or my employees with wages as BACKFLOW PROTECT. DEVICE 4.00
.their sole compensation,will do the work,and the Structure is not OCC.GROUP RES.UNITS
'+ intended or offered far 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 S0.FT,FLOOR AREA TOTAL ACREAGE
himself re through his own employees.Provided that such improve-
mentsaovnot emenlnendodwithinoffered
oneyearoILhowever,ionthebuilner. GAS-EA.SV$TEM-11NC.40UTLETS 6.00
or improvement is held within one year bathe did rot Ihe owner. GAS-EA.SYSTEM-OVER 4 IEA.) 2.00
builder will have the burden of proving that he did not build or iln- BUILDING USE
prove for purpose of sale.). - INDUSTRIAL WASTE INTER. 30.00 IND CON Pa Omer
❑ 1,as Owner of the property,am exclusively contracting with ❑ ❑ ❑
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-OV ER 5(EA.) 1.00
contracts for such projects with a contractods)licensed pursuant to SEWER-SANITARY-STORM EA.200ft/10.00
the Contractor's License Law. TRACT NO. PARCEL N0.
Cl I am exempt under Sec..,Ij for this
mason WATER HEATER W/VENT 6.00
Owner - Date WATER SYSTEM - 5.00 ACG DATE ACC.FILE NO.
WORK ERS'COMPENSATION D17CLARATION WATER TREATING EQUIP. 5.00
I hereby affirm that I hove a certi-i"Te titconsaot to self-insure, - 20NING
ora cel f "1 oFW ork' C sution Insurun1ey�',,)x y ce hlicA ENG.SITE NO.
Poilryempuny s Py'�M'f0'
CI ❑ Certified copy is hereby fumished. FIRE SPRINK ENERGY T 24
❑•Cert ificdAcopy�is filed�w' h the cjty inspeetlon division. MISC.- REFER TO ORD. Y
A hese! 1la'Ll�c"'L� N V N
CCN CERTIFICATE OF:EXEMPTION FROM- RKERS' PERMIT ISSUANCE 10.00 FLOOD ZONE A.L.U.C.
LU C0M111:NSATION INSURANCE, PLG.CONTE. LIC.NO. PLG.
d 0 IF]its section'need nut be completed if the permit is rot one TOTAL ' ,Y❑ N Y N[J
Z hundred dollars(SI00)nrle.J
U O I certify that in the performance of the work for which this per- OTY. MECHANICAL PERMIT t/FEE FEE SUMMARY
LIE H not is issued, I shall not employ any person in any manner so as to K/
00 become subject to the Workers'Compensation Laws of California. 04
( n, Dale AppEcanl - ALTER OR ADD TO ME ,00 BUILDING '
} W NO'T'ICE'1'0 A1113LICAN'1': If,after making this Certificate of Ex-
?
camphor.you should become subject to the Workers'Compensation APPLIANCE -� .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 1 Xm C.F. .) 4.00
CONSTRUCTION L17NDING AGENCY - AIR HANDLING UNIT(OVER IOAODC.F.M.) 6.00 SEISMIC FEE
- -� I herebyaffirm that there is a construction lending y EXHAUST HOOD (WITH DUCT) 5.00 -
g agent for
the performance of the work for which this permit is issued ISec. MICROFILM
3097, .am HEATING UNIT(TO 100,000 B.T.U.) 8.00
Lender's Addle H EATI N G UN IT(OVER 100,000 B.T.U.)9.50
Leader's Address 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 'l PLUMBING
ordinances and state laws relating to building conslinetion.'and BOILER-COMP(3 H.P.or 100,000 B.T.U.) 6.00 GOD
hereby authorize representatives of this city to enter upon tire Yn,10
me BOILER-COMP m0,000 BTU)SEE FEE SCH. MECHANICAL
above- entioned properly for inspection purposes.
(We) agreeto save,,indemnify and keep harmless the.City of MISC.- REFER TO ORD.
Cupertino against liabilities,judgnicars, costs and expenses which CONST.TAX
may in any way accrue against said City in consequence of the 'PERMIT,ISSU ANCE 10.00
gr n ng tis MECH.CONT. LIC.NO. MECH.
- . 0 b bS TGT 9,/ TOTAL
Sig lure of Applicant/Contr ctor Date (f
OFFICE COPY s
.