9257 (3) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
BU LOI NG PROJECT I DENTI FI CATION PERMIT NUMBER
BUILDING APPLICATION & PERMIT g25�
�'- ADDRESS
C EBUILDING-ELECTRICAL-PLUMBING-MECHANICAL
L OWNER'S PLAN CHECK VALIDATION
NAME �J� �r ��O'
QTY. ELECTRIC PERMIT FEE
A. cZ,vo T PHONED -2 4
CONTRACTOR SA UTLETS-SWITCHES-RECEP 11L00/1.00 0"0
NAME
sec.No. 'jsj Q LIGHTING FIXTURES 1p.00/1.00
CONTRACTORS PPLIANCES-RESIDENTIAL 4.00 W
ADDRESS
! PHONE
on PANELS 10.00 DATE OF APPLICATION'
A CHITEc PANELS (OVER 200 AMP) 20.00 PLAN CHECK FEE P.C.NO.
ENGINEER
LIC.NO. SIGNS TRANS. 3.00
/ ARCH.OR ENG. PERMIT VALIDATION
! ADDRESS SPECIAL CIRCUIT 5.00
ZIP TEMP. METER OR POLE INS. 20.00 .t
APPLICANTS MOTORS 11 SEE FEE SCH. -
ADDRESS
SERVICE CHANGE 20.00 p
09 LICENSED CONTRACTORS DECLARATION I TEMP.POLE 30.00
W. I II Toth.... that I Con licensed Under provisions of Chapter 9 ISSUANCE DATE
< u (commencing With Section 7000)of Division 3 of fl a Business and BLDG- ELECT. PLG. MECH.
H m i Professions Code,and my license is full force and effecQ ❑
z O w - Licen �"
se Cluas _{ Lie Number
9 z 5 O/ Dulc- FIT y Contractor
a ce 'I O NE BUILDING PERMIT
¢ w ¢ OWNER-Ii UILUlili DECLA 1 .
A o A o MISC.- REFER TO ORD INFORMATION
w 3 LL h I hereby ul firm that 1 am exempt from the Contractor's License VALUATION S/FT.
F a. o J Law fill the following reason.(Sea 7031.5.BmRmr,saad Professions PERMIT ISSUANCE 10-n0. fjp
Code Any city or County which requires a permit to construct,alter, _
ac ¢ ¢ p improve,demulish,or repair any structure,prior to its issuance,also ELEC.CONTH. LIC.NO. ELEC. �Lw
o u, requires the applicant for such permit to file a signed statement that TOTAL V PERppM��ITggTO
a w m w he is licensed pursuant to thee provisions of the Contractor's License
z a Law(Cha ter 9(commencin•with Section 7000)of Division 3 of the G
Business and Professions Code)cur that he is exempt therefrom and OTY. PLUMBING PERMIT FEE
IS I m the basis for the alleged a eruption.Any violation of Section 7031.5 STORIES TYPE CONSTR.
F_ by any applicant far a'pemtit subjects the applicant toacivil penalty ALTER-DRAIN&VENT-WATER IEA.I 5,00
of not more than five•hundred dollars(S50R.):
D 1,as owner of the property,or my employees with wages as BACK F LOW PROTECT.DEV ICE 4.00 OCC.GROUP RES.UNITS
their sole compensation,will do the work,and the structure is not
intended or carded for sale(Sec. 7044, Business and Profusions DRAINS-FLOOR,ROOF,AR EA,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 6? SO.FT.FLOOR AREA TOTAL ACREAGE
himself re through his own employer,provided that such
improve.
hients mself a through
inteugh his or employees.ffered for provided
thathowever.the building' _ GAS-EA.SVSTEM-11NC.4OUTLETS 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-
pro,for purposeofNile.). INDUSTRIAL WASTE INTER. 30.00 RES IND CON PR Other
❑ I,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 docs not apply
to an owner of Property who builds or improves thereon,and who LAWN SPRINKLERS-OVER 5(EA.) 1.00
,contracts forSuch projects with a contructons)licensed pursuant to
the Contractor's License Law. SEWER-SANITARY-STORM EA.200ft/10.00 TRACT NO. PARCEL NO.
❑ lant esempl under Sec. ,B.&P.C.for Cols .WATER HEATER W/VENT 6.00
reason
Owner Date WATER SYSTEM 5.00 ACC.DATE ACC.FILE NO.
WORK ERS'COMPENSATION VECLARATION WATER TREATING EQUIP. 5.00
1 hereby affirm that I have a certificate Of consent to sel Giasure. - ZONING
or a cerlifieme of Workers'Campenwtion Insurance or a certified ENG.SITE N0.
copy thereof(Sec.3800,Lab.C.). OH' O G,15s,(hLT b'
policy No. CompanyOf t ,I
O ❑ Certified copy is hereby furnished. J FIRE SPRINK ENERGY T 24
Z Z ❑ Certified copy is filed with the city inspection division. MISC.- REFER TO ORD.
O Applicant Y ❑ N❑ Y ❑ N❑
rn CERt'IrFICA'I'Ii OF EXEMPTION PROM WORKERS' PERMIT ISSUANCE 1-0 n0 (/Y� FLOOD ZONE A.L.U.C.
LL > COMPENSATION INSURANCE PLG.CONTR. LIC.NO. PLG.O (This section need not be completed if the Permit is for one TOTAL aZ Y❑ N❑ Y❑ N❑
Z hundred dollar'IS 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 1- mit is issued-I shall not employ any person in any manner so as to
U become subject to lire Wbrken'Compensation Laws of California.
Q n Date Applicant ALTER OR ADD TO MECH. 5.00 r� BUILDING '
>_ N NOTICE 70 APPLICANT': If,after making this Certificate of Ex-
F Z emption,you should become subject to the Workers'Compensation APPLIANC 5.00 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 1OPMCF.M.) 4.00
CONS"rRUCI'ION LENDING AGENCY AIR HANDLING UNIT(OVER IQOWC.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 fSec. MICROFILM
3097,Civ.C.). HEATING UNIT(TO 100,000 B.T.U.) 8.00
Lender's Name
Lender's Address HEATING UNIT(OV ER 100,000 B.T.U.)9.50 ELECTRIC. .� 0`0
I certify mat I have read this appGcalrm and state that
the aboveVENTILATION FAN (SINGLE) 4,00
infornmtion is correct. I agree to comply with all city and county PLUMBING
ordinances and state laws relating m building construction, and BOILEfl-COMP(3 H.P.or 100,000 B.T.U.) 6.00 �OZ
hereby authorire representatives of this city to enter upon lire BOILER-COMP IOver 100,000 BTU)SEE FEE Sc". MECHANICAL
above mentioned property Inr 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 PERMIT ISSUANCE 10.00 CONST.TAX
may in an accrue against said C, Y in consequence of the
gmntin, thienniL MECH.CONT. LIC.NO. MECH. .
TOTAL ( 11 TOTAL d0
ignu ser o p n a Tru mato D' c /J I
INSPECTOR COPY
• I