10050 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
BUILDING PROJECT IDENTIFICATION PERMIT NUMBER
BUILDING APPLICATION & PERMIT O O 0
ADDRESS
BUILDING -ELECTRICAL-PLUMBING-MECHANICAL
OWNER'S` N PLAN CHECK VALIDATION
i
NAME t1 (��+r Aki -` QTY. ELECTRIC PERMIT FEE
J- �C.!-1A ra.'lL PHONE
NAMERACTOR'S
OUTLETS-SWITCHES-RECEP 10.00/1.00
`
`•, LIC.NO. LIGHTING FIXTURES 10.00/1.00 6}
f.O
ADDRESS NTRACTOR'S 3ZI "rNQ , ,_ APPLIANCES-RESIDENTIAL 4.00 DEC 4 1992
-r PHONE ' PANELS 10.00 DA OF APPLICATION
ARCHITECT PANELS (OVER 200 AMP) 20.00 y�'PLA cwg E86ItIV P.C.NO.
OR
ENGINEER
LIC.No. SIGNS TRANS. 3.00
AARCH.OR DDRESS ENG. SPECIAL CIRCUIT 5.00 PERMIT VALIDATION
ZIP TEMP.METER OR POLE INS. 20.00
APPLICANT'S
ADDRESS MOTORS SEE FEE SCH.
A Y' SERVICE CHANGE 20.00
o o LICENSED CONTRACTORS DECLARATION TEMP.POLE 30.00
a u u I hereby affirm that 1 am licensed under provisions of Chapter 9 ISSUANCE DATE
F-
C a (commencing with Section 7000)of Division 3 of the Business and BLDG. ELECT. PLG. MECH.
F o z Professions Co an y I*nse is in full fo ff�.9
. o N - Lice se Class Lic.Number 7
? Z - Date Contracto
N H W
z Y _ BUILDING PERMIT
c tr w 4 OWNER-BUILDER DECLARATION INFORMATION
o a 1- I hereby affirm that 1 am exempt from the Contractor's License MISC.- REFER TO ORD
LL y VALUATION $/FT.
LL o Q Law for the following reason.(Sec.703 1.5,Business and Professions PERMIT ISSUANCE 10.00
N i Code:Any city or county which requires a permit to construct,alter.
G p improve,demolish,or repair any structure,prior to its issuance,also ELEC.CONTR. LIC.NO. ELEC.
U -o tt requires the applicant for such permit to file a signed statement that TOTAL PERMIT TO
` w �°vLL he is licensed pursuant to the provisions of the Contractor's License
Z > Law(Chapter 9(commencing with Section 7000)of Division 3 of the
a Business and Professions Code)or that he is exempt therefrom and QTY. PLUMBING PERMIT FEE
o the basis for the alleged exemption.Any violation of Section 7031.5 STORIES TYPE CONSTR.
:° by any applicant for a permit subjects the applicant to a civil penalty ALTER-DRAIN&VENT-WATER (EA.) 5.00
of not more than five hundred dollars($500).):
❑ 1,as owner of the property,or my employees with wages as BACK FLOW PROTECT. DEVICE 4.00 OCC.GROUP RES.UNITS
their 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-
ments are not intended or offered for sale.If,however,the building GAS-EA.SYSTEM-1 1 NC.4 OUTLETS 6.00
or improvement is sold within one year of completion,the owner- GAS EA.SYSTEM-OVER 4(EA.) 2.00 BUILDING USE
builder will have the burden of proving that he did not build or im-
prove for purpose of sale.). INDUSTRIAL WASTE INTER. 30.00 RES IND CON PB Ocher
❑ 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-OVER 5 (EA.) 1.00
contracts for such projects with a contractor(s)licensed pursuant to
the Contractor's License Law. SEWER-SANITARY-STORM EA.200ft/10.00 TRACT NO. PARCEL NO.
❑ 1 am exempt under Sec. B.&P.C.for this WATER HEATER W/VENT 6.00
reason
Owner Date WATER SYSTEM 5.00
ACC.DATE ACC.FILE NO.
WORKERS'COMPENSATION DECLARATION WATER TREATING EQUIP. 5.00
I hereby affirm that I have a certificate of consent to self-insure,
or a certificate of Workers'Compensation Insurance,Or a certifiedcopy theLab.C.).
ZONING ENG.SITE NO.
Policy N r W- 9tmpany zwa_k rA1Y\P
O ❑ Certified copy is hereby furnished. FIRE SPRINK ENERGY T-24
Z Z Certified copy is.filed with t�e city i ection division. MISC. REFER TO ORD.
O Applicant til 30 VAA.3a� 'R -J- � Y❑ N❑ Y [-] N❑
N CERTIFICATE OF EXEMPTION FROM WORKERS' PERMIT ISSUANCE 10.00 FLOOD ZONE A.L.U.C.
LU > COMPENSATION INSURANCE PLG.CONTR. LIC.NO. PLG.
d O (This section need not be completed if the permit is for one TOTAL Y❑ N❑ Y ❑ N❑
0 Z hundred dollars($100)or less.)
U O 1 certify that in the performance of the work for which this per- QTY. MECHANICAL PERMIT FEE FEE SUMMARY
LL mit is Issued,I shall not employ any person in any manner so as to
U become subject to the Workers'Compensation Laws of California.
a Date Applicant ALTER OR ADD TO MECH. 5.00 BUILDING
} (n NOTICE TO APPLICANT. If,after making this Certificate of Ex-
Z_ emption,you should become subject to the Workers'Compensation APPLIANCE 5.00 PLAN CHECK
provisions of the Labor Code, you must forthwith comply with FEE
V such provisions or this permit shall be deemed revoked. AIR HANDLING UNIT(TO 10,Of)OC.F.M.) 4.00
CONSTRUCTION LENDING AGENCY AIR HANDLING UNIT(OVER 10=C.F.M.) 6.00 SEISMIC FEE
1 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 O
Lender's Name
Lender's Address H EATI NG UN IT(OV ER 100,000 B.T.U.)9.50 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 BOILER-COMP(3 H.P.or 100,000 B.T.U.) 6.00 PLUMBING
ordinances and state laws relating to building construction, and
hereby authorize representatives of this city to enter upon the BOI LER-COMP (Over 100,000 BTU)SEE FEE SCH. MECHANICA �-
above-mentioned property 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 CONST.TAX
may in any way accrue against said City in consequence of the PERMIT ISSUANCE 10.00
granting of this permit. MECH.CONT. LIC.NO. MECH
` .
�^2�yZ TOTAL �oG TOTAL �"`
Signature of Kpp icant/Contractor 14 Date
OFFICE COPY