9415 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
BU I LDING PROJECT I DENTIFI ATION PERMIT NUMBER
BUILDING APPLICATION & PERMIT 9415
ADDRESS jW
O BVeBUILDING-ELECTRICAL-PLUMBING -MECHANICAL
OWNER 5 PLAN CHECK VALIDATION
NAMV,
�/�[y� OTY. ELECTRIC PERMIT FEE
• _fZ_/ PHONU�0_//LJ0
C rU,NTRACTOR'S
NAME /�/ UTLETS-SWITCHES-RECEP 10.00/1.00
_51 f IW2� LIC N41IAq LIGHTING FIXTURES 10.00/1.00
CONTRACTORS
R's SAMy AAiq 7/C�/ APPLIANCES-RESIDENTIAL 4.00
o�J
CON
E 0n/9 DrvE q� PANELS 10.00 DATE OF APPLICATION
RRCHITECT PANELS (OVER 200 AMP) 20.00 PLAN CHECK FEE P.C.NO.
OR
ENGINEER
LIc.No, SIGNS TRANS. 3.00 PAID
ADDRESS ENG. SPECIAL CIRCUIT - 5.00 P I DATION
ZIP EMP. METER OR POLE INS. 20.00 AUG 2 0 1995
ADDRESS Ts %' MOTORS SEE FEE SCH.
y n SERVICE CHANGE 20.00 City of Cupertino
1 i
w w o LICENSI!DCONTRACTORS/DECLARATION y TEMP.POLE 30.00
a i w I hereby affirm that I am licensed under provisions of Chapter 9 ISSUANCE GATE
H (commencing with Section 7000)of Division 3 of the Business and
¢ hD ELECT. PLG. MECH.
r N Z Professions Code,agyj my license is in-fulluh tome and e f• ❑ ❑ ❑
Z O m - License Clus S, Lic.Number
o r Dale Cmvructnr -
a BUILDING PERMIT
¢ ¢ w a OWNER-y UILUL'R DECLARATION
o A u e INFORMATION
X ; u H I hereby affirm that 1 a .exempt from Om Contractors License MISC.- REFER TO ORD
w VALUATION q/FT.
w• LL o J Law for the following reason.(Sec.7031.5,Business and Professions PERMIT ISSUANCE 10.00
� y Code:Any city or county which requiresa permit to construct,alter,
¢ ¢ a O improve,demolish,or repair any structure,prior to its issuance•also ELEC.CONTR. LIC.NO. ELEC.
¢ requires the applicam for such permit In lite a signed statement that TOTAL
Ar111720).
com a he is licensed pursuant to the provisions ol'the Contractor's License ERMIT O
Uzi
Law(Chapter 9(commencingwith Section 7000)of Division3 ofthe
a Business and Professions Code)or that he is exempt therefrom and QTY. PLUMBING PERMIT FEE
Eio
¢ r• o the basis for the alleged exemption.Any violation of Section 703 L5 STORIES TYPE CONSTR.
a ;m by any applicant for permit subjects the applicant moa civil penally
ofnot more than five hundred dollaRS(S500).): ALTER-DRAIN&VENT-WATER (EA.) 5.00
❑ 1,as owner of the property,or my employees with wages as BACK FLOW PROTECT. DEVICE 4.00
their sole compensation,will do the work,and the structure is not OCC.GROUP RES.UNITS
intended or oil..it for sale (See. 7044, Business and Professions DRAINS-FLOOR,ROOF,ARE EA,COND. 5.00
Code:The Contractor's License Law does not apply to an owner of
properly who builds or improve%thereon,and who does such work FIXTURES-PER TRAP 5.00 6Q FT.FLOOR AREA TOTAL ACREAGE
• himself re through his own cored fors,provided that such imprcwr
or nts improvement not
sold or within Tone year
I completion,
the building GAS-EA.SVSTEM-11NC.40UTLETS 6.00
or ider will le v is sold within one ycgr of completion.the owner- GAS-EA.SYSTEM-OVER 4 (EA.) 2.00
builder will leave the burden of proving that he did not buil)or int- BUILDING USE
prove for purpose of sale.). INDUSTRIAL WASTE INTER. 3000 RES IND PB Other
❑ I,as owner of the properly,ant exclusively contracting with . ❑ ❑ ❑ ❑
licensed contractors to construct the project)Sec. 7044, Business LAWN SPRINKLERS- 1 INC 5 V.B. 6.00 ASSESSo 5 ARCEL NO.
and Professions Code:The Contractor's License Law docs Imt apply
to an owner of property who builds or improves thereon.and who LAWN SPRINKLERS-OVER 5 IEA.) 1.00
contracts for such projects with a conlmelons)licensed pursuant to SEWER-SAN V-STORM EA.200ft/10.00
CrDl.n
aefo�s Liecnsc Law. TRACT NO. PARCEL NO.
in exempt under Sec.-.B.&P.C.far this WATER HEATER W/VENT 6.00
Dale WATER SYSTEM 5.00 ACC.DATE ACG FILE NO.
WORK ERS'COMPENSA'PION DECLARATION WATER TREATING EQUIP. 5.00
I hcrch uI irm flim I have a certificate ofconsent to sell-insure,
u a cerci t n Workers'Cam, dli.,I Insurance,of a eer'ifie ZONING ENG.SITEN0.
copy Cher Lab.C.l.
Z 2 ;Policy reMEN
�C( eby'( nfIRESPRINK ENERGY T2<
pRp Cefled I t c �It suer division. MISC.- REFER TO ORD.Q pphCanY❑ N❑ V ❑ N❑OF F EMI'TION PROM WORKERS• PERMIT ISSUANCE 10.00 FLOOD ZONE A.L.0c.
W - �"'� SATION INSURANCE PLG.CONTR. LIC.NO. PLG, s v❑ N❑ v ❑ ❑
CL Z (This section need not be completed if the permit is for one TOTAL N
hundred doll...(SI00)or less.)
U O 1 certify that in the performance of the work for which this per- OTY MECHANICAL PERMIT FEE FEE SUMMARY
IL 1- nn it is issued.I shall not employ any person in any manner so as to
O W become subject to the Workers'Compensation Laws of California.
Date-Applicant BUILDING
} tdn NOTICE. TO APPLICANI` If,after making this Certificate of Ex- ALTER OR ADD TO MECH. 5.00
F" Z cmptioa,you should become subject or the Workers'Compensation APPLIANCE 5.00 PLAN CHECK
provisions mIthe labor Code, you must forthwith Conmply with FEE
U (such provisions or this permit shall be deemed revoked. AIR HANDLING UNIT(TO 10SMC.F.M.) 4.00
CONST RUCTION LENDING AGENCY AIR HANDLING UNITIOVER IO,OODO.F.M.) 6.00 SEISMIC FEE
1 hereby affirm Thal 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.). H EATING UN IT ITO 100,000 B.T.U.) 8.00
Lender's Name HEATING UNIT(OVER 100,000 B.T.U.)Lender's Address ELECTRIC
I certify that I have read this application and Stmt that Ili above V ENTI LATION FAN (SINGLE) 4.00
info.malion is correct. I agree to comply with all city and county PLUMBING
ordinances and state laws relating to building Construction. and BOILER-COMP I3 H.P.or 100,000 B.T.U.) 6.00
hereby authorize representatives of this city to enter upon Ore BOILER-COMP(Over 100,000 BTUI SEE FEE SCH. MECHANICAL
above-mentioned property for inspection purposes.
(we) agree to save, indemnify and keep harmless the City of MISC.- REFER TO ORD.
Cupertino again 1 liab'lit ies, figments, costs anJ expenses which CONST.TAX
may in any y ue a r t at in c.mo&the PERMIT ISSUANCE 10.00
gramm f sp• L MECH.CONT. LIC.NO. MECH.
Signatorof AppTOTAL TOTAL
licant/.ontractor m
INSPECTOR COPY
I