8257 (3) APPLICANT TO FILL IN INFORMATION WITHIN REDLINES - USE BALL POINT PEN ONLY '
BU I,LDING PROJECT IDENTIFICATION 'r `PERMIT NUMBER
BUILDING APPLICATION & PERMIT
ADDRESS
BUILDING-ELECTRICAL-PLUMBING=MECHANICAL8257
OWNER'$ PLAN CHECK VALIDATION
" E QTY. ELECTRIC PERMIT FEE
(� PHDN W
NAME TO OUTLETS-SWITCHES-RECEP 10.00/1.00
n
.T LIc.No. LIGHTING FIXTURES 10.00/1.00
TRCTOR'S 1APPLIANCES-RESIDENTIAL 4.00
ADDPE5A5
PHONE PANELS 10.00 DATE OF APPLICATION
ARICIPTINECT PANELS (OVER 200 AMP) 20.00 PLAN CHECK FEE P.C.NO.
°R
ENGINEER
LIC.No. SIGNS TRANS. '-- 3.00
ADDRESS ENG. SPECIAL CIRCUIT 5,00 PE _ ATION
APPLICZIP EMP. METER OR POLE INS. 20.00 JUL 8 - 19$5
40DRE SS MOTORS SEE FEE SCH.
ADDRESS
t SERVICE CHANGE 20.00
00 LICENSED CONTRACTORS DECLARATION TEMP.POLE 30.00 City of Cupertino
au -1 hereby aftirm that 1 am licensed under provisions of Chapter 9ISSUANCE DATE
N,z'w (tomnuncing with Section 7000)of Division 3 of the Business and BLDG. ELECT. PLG. MECH
F mo i " I of ss as CnA u n license':' hall far-' fL"t
y z o L ns Clan t Nn nhr ❑ ❑
o z r Dat _�.� m Cr..
I
s BUILDING PERMIT
va
In < ��e.OWNIR-BUILDER DECLARATION e.:..•. - -"-- INFORMATION '
@. Koa " F e MISC.- REFER TO
w 3 u m h mhy nffinn that I fun exempt from the Contractor's License VALUATION SIFT,
'FLLo ¢ Law for the following reason.(Sec.7031.5.Busiocssand Professions PERMIT ISSUANCE 10.00
J Code:Any city ormtmty whichrequiresa permit to construct,anti,
ar Q p improve,demolish,or repair any structure,prior to its issuance,also ELEC.CONTE. LIC.NO. ELEC. -
to d O u requires the applicant for such permit to file a signed statement that TOTAL PERMIT TO
Lc m he is license(]pursuant to the provisions of the Contractor's License
r z a Law(Chapter 9(commencing with Section 7000)of Division 3 ofthe
a Business and Professimu Code)or that he is exempt therefrom and QTY. PLUMBING PERMIT FEE
"ec r o the basis for the alleged exernption.AD,violation of Section 7031.5 STONIESI, TYPE CONSTR.
dam _ by any appfcant 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 F LOW 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(See. 7044, Business and professions DRAINS-FLOOR,ROOF,AREA,COND. 5.00
Code:The Contractor's License Law dos not applyto an owner of
property who builds or improves thereon.and who does such work FIXTURES-PER'TRAP 5.00 SO.FT.FLOORAREA TOTALACREAGE
himself re through his own employees.provided that such int building
meats Bre not through his or offered ee .provior sale. ed thathowevsuhemprovg GAS-EA.SVSTEM-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 int- BUILDING USE
prove for purpose ofsale.). . INDUSTRIAL WASTE INTER. 30.00 R IND CON PB Other
❑ 1,as owner of the property,am exclusively contracting with ❑ ❑ ❑ ❑
licensed contractors m 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,,.,city who builds or improves thereon.and who LAWN SPRINKLERS-OVER 5(EA.) 1.00
contracts for jro
p
such pects with vn
a conaor(s)licensed pursuant to
the Contractor's h project,
License Law. ISEWER-SAN ITARV-STORM EA.200ft/10.00 TRACT NO. PARCEL NO.
❑ I at,exempt under Sec. ,B.&P.C.for this WATER HEATER W/VENT 6.00
reason
Owner Date WATER SYSTEM 5.00
ACG,pATE ACC.FILE NOY M1
WORKS RS'(OMPENSATION DECLARATION WATER TREATING EQUIP. 5.00
I Inerviby Afton that l Iavc t oif cat,ul consent t If-inarm, -
ora cenificar,of Worker]Compensation insurance,or a certified ZONING""'- ENG,SITE NO.
copy thereo
off
f(S�ee 338000,,('L� I,C.). _�Fy y r+/
Policy Nl f li c 1'- 1Q I ICG. it
Q ❑ op) s t n(s `- ^ _ f FIRESPRINK ENERGY T24 Ns
IIIIFv Z 2 Lert`ri c 'y Is ;il d w th th`nly nspe t on dskmn. MISC.� REFER6TO.ORD Y❑ N❑. �y ❑ NO
nPPhcent )1�
w CERI 117 I:OF EXEMPTION FROM WORKERS PERMIT ISSUANCE -.10.00 FLOOD ZONE A.L U.0 •..1:1
F• W COMPIiNSAT'ION INSURANCE PLG.CONTR. LIC.NO. PLG:4 '�❑,`-'N❑ Y❑ N❑t
CL 0( This Section need not be completed if the pe nn it is for one TOTAL
hundred dollars(SI00)or Ices.)
U O 1 certify that in the performance of the work for which this per- QTY. MECHANICAL PERMIT !t FEE :FEE SUMMARY
LL I- mit is issued,1 shall not employ any person in any manner so as to . '
(] w become subject to the Workers'Compensation Laws of California. BUILDING
Q. Date A,phcant ALTER OR ADD TO MECH. 5.00
} m NOTICE TO APPLICANT: If,after making this Certificate of Ex- -
F. ? emption.you should become subject to the Worker]Compensation APPLIANCE 5.00 PLAN CHECK
provisions of the Labor Code, you cost forthwith comply with FEE
C..) such provisions or this permit shall be deemed revoked. AIR HANDLING UNIT(TO 10=CF.M.) 4.00
CONSTRUCTION LENDING AGENCY AIR HANDLING UNIT IOVER 10=C.F.M.) 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.) 6.00
Lender's Name HEATINGUNIT(OVER 100,000 B.T.U.)9.50 ELECTRIC
Lender's Address
1 certify that I have read this application end stat,that the above VENTILATION FAN (SINGLE) 4.00
information is correct. I agree W comply with all city and county PLUMBING
ordinances and state laws relating to building construction, and BOILER-COMP(3 H.P.or 100,000 B.T.U.) 6.00
hereby author] e representatives of this city to enterupon the BOILER-COMP.Over wopoOSTU15EE FEESCH. MECHANICAL
above-mentioned property for inspection purposes.
(We) agree to save, indemnify and keep here,less the City of MISC.- REFER TO ORD.
Cupertino against liabilities,judgments, costs and expenses which PERMIT ISSUANCE 10.00 CONST.TAX
may in any way accrue against said City in consequence of the
grant I f this permit MECH.CONT. LIC.NO. MECH.
q11 1 II OTAL Q� TOTAL
gn APP icant o tr mr 1). _Ur EJ o • ��
INSPECTOR COPY
• I