9492 (3) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
BUILDING PROJECT IDENTIFICATION APPLICATION & PERMIT D
PERMIT NUMBER
PHLOING
ADDRESS
ADDRESS
-924411 (A'0 IOV BUILDING -ELECTRICAL-PLUMBING-MECHANICAL 94 92
OWNER'S ``y //^ PLAN CHECK.VALIDATION
NAn/ 'l0 QTY. ELECTRIC PERMIT FEE »r
•- PHONE ar
nAmEACTORS
UTLETS-SWITCHES-RECEP 10.00/1.00
uc.No. LIGHTING FIXTURES 10.00/1.00
CONTRACTOR'S APPLIANCES-RESIDENTIAL 4.00
ADDRESS
PHONE PANELS 10.00 DATE OF APPLICATION
ARCHITECTPANELS (OVER 200 AMP) 20,00 1 PLAN CHECK FEE P.C.NO,
ENGINEER ,
uc.No. SIGNS TRANS. 3.00
ADD ESS ENG, SPECIALCIRCUIT 5.00 PERMIT VALIDATION
ZIP EMP.METER OR POLE INS. 20.00 PAID
ADDRESS r$ MOTORS SEE FEE SCH.
Aoness
SERVICE CHANGE 20.00 AUG 27 1985
w ¢ TEMP.POLE 30.00 IRA
0f(1 C p1I
aoo LICENSED CONTRACTORS DECLARATION sof IS�U A PAU
¢ v v I hereby aflirm that 1 am licensed under provisions of Chapter 9 II ertino
N a h (commn
ecing wH.
it11 Section 7000)of Division 3 of the Ritsiness and BLDG. ELECT. PLG. MEC
H N z Professions Code,and my license is in full force and effect. ❑ ❑ ❑ ❑+
Z
0 m o License Class Lic.Number
o
0 m H J Date Contractor
a x BUILDING PERMIT
¢ ¢ w a OWNER-BUILDER DECLARATION
d O a U INFORMATION
w g LL I- 1 hereby affirm that I an exempt from the Contractor's License MISC.- REFER TO ORD
u0Q Lawlor the reason.lSec:7031.5.Business Professions VALUATIOry $/FT.
I- - PERMIT ISSUANCE 10.00 /
_ m�� Code:Any my or county which requires apermit toconstrucLalter, OOU
Q 4 0 improve,demolish.or repair any structure,prior to Its Issuance,also ELEC.CONTE. LIC.NO. ELEC.
o¢ requires the applicant for such permit to file a signed statement that TOTAL PERMIT TO
X.m" he is licensed pursuant to the provisions of the COnracturs License
H i Law(Chapter 9(commencing with Section 7000)of Division3 oCthe /�
i o Business and Professions Code)or that he is exempt therefrom and /" a Cq
¢ H o the basis for the alleged exemption.Any violation o( DTV. PLUMBING PERMIT FEE G
OF
Section 7031.5 STORIES TYPE CONSTR.
n ; m by any applicant for a permit subjects the applicant to a civil penalty ALTER-DRAIN -WATER IEA.) 5.00
of not more than five hundred dollars(3500).):
Cl I,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 SQ FL FLOOR AREA TOTAL ACREAGE
himself or through his own employees,provided that such improve-
muntsare not intended orofferedfor sale,If.however,the building GAS-EA.SYSTEM-I INC.4 OUTLETS 6.00
or improvement is sold within one year of completion,the owner- GAS EASYSTEM OVER 4 (EA) 200
builder will have the burden of proving that h - . - . .
e did not build or im- BUILDING USE
prove for purpose of sale.). INDUSTRIAL WASTE INTER3000 RES IND CON PB`'Other
❑ I,as owner of the property,am exclusively contracting with . .
El El 1:1 El 1:1licensed 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 contmmods)licensed pursuant to
the Contractor's License Law. SEWER-SANITARY-STORM EA.200ft/10.00 TRACT NO. PARCEL NO.
❑ l am exempt under Sec. ,B.&P.C.for this WATER HEATER W/VENT 6.00
reason
weer < Date WATER SYSTEM 5.00 ACC.DATE ACC.FILE NO.
I PIERS' OM PENSATION DECLARATION WATER TREATING EQUIP. 5.00
I hereby affirm that 1 have a certificate of consent to self-insure,
or a certificate of Workers'Compensation Insurance,or a certified ZONING ENG.SITE NO.
copy thereof(Sec.3800,Lab.C.).
Policy No. P Company
O ❑ Certified copy is hereby furnished. FIRE SPRINK ENERGY T-24
Z Z ❑ Certified copy is fled with the city inspection division.
0 Applicant MISC.- REFER TO ORD. Y ❑ N❑ I Y ❑ N❑
fir y CERTIFICATE OF EXEm PITON PROM WORKERS' PERMIT ISSUANCE - 10.00 FLOOD ZONE A.L.U.C.
LU 1 COMPENSATION INSURANCE PLG.CONTE. LIC NO. PLG.
CL0 1'[his section need not be completed if Bre permit is for One TOTAL Y'[] N❑ Y F] NE]
UO hundred dollars(S 100)or less.)
certify that in the performance of Bre work for which this per- DTV. MECHANICAL PERMIT FEE FEE SUMMARY
LL - mit is issued,I shall not employ any person in any manner so as to
Q W become subject to the Workers Compensation Laws of California.
n. Date Applicant ALTER OR ADO TO MECH. 5.00 BUILDING U/7.J
>_ DO NO'1'ICF: TO APPLICANT: If,after making this Certificate of Ex-
2 anption,you should become subject to the Workers'Compensation APPLIANCE 5.00 PLAN CHECK
provisions of the Labor COda, You must forthwith comply with FEE 11 : 7
V such provisions or this permit shall be deemed revoked. AIR HANDLING UNIT(TO 10=C.F.M1 4.00
CONSTRUCTION LENDING AGENCY AIR HANDLING UNIT(OVER 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.) 8.00
Lender's Name HEATING UNIT(OVER 100,000 B.T.U.)9.50
Lender's Address ELECTRIC
I certify that I have read this application and state that the above VENTILATION FAN (SINGLE) 4.00
• Inform.ce,n n correct. I agree m comply with all city and eouand BOILER-COMP(3 H.P.or 100,000 B.T.U.) 6.00 PLUMBING
imbor n¢s and state lows re t c to building construction, and
hereby authorize representatives of 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 r MISC.- REFER TO ORD.
Cupertino against liabilities,judgments, costs and expenses which PERMIT ISSUANCE 10.00 CONST.TAX
ru
may in any way acce against said City in consequence of the
grants o this permit. MECH.CONT. LOC.NO. MECH.
TOTAL TOTAL a J
29nazure at pp ant/Contra or Date
INSPECTOR COPY