09634 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
BU LDI NG PROJECT I DENTI FI CATION PERMIT NUMBER
BUILDING APPLICATION & PERMIT
ADDRESS .h BUILDING - ELECTRICAL-PLUMBING-MECHANICAL 09634 96Jq
OWNERS
PLAN CHECK VALIDATION
NAME• QTY. ELECTRIC PERMIT FEE ry n PHONE _
JAIV
NAIERAcroas UTLETS-SWITCHES-RECEP 10.00/1.00
n /' uc.No. a- LIGHTING FIXTURES 10.00/1.00
CONTRACTOR OR's
ADDRESS PPLIANCES-RESIDENTIAL 4.00
CONTRA
-3 7,9L4
f, PHON r �^ �J 'OS PANELS 10.00 DATE OF APPLICATION
ARCHITECT �• _ _ ` r ( J�- PANELS (OVER 200 AMP) 20.00 PLAN CHECK FEE P.C.NO.
ENGINEER
LIC.NO SIGNS TRANS. 3.00 � n
ADDRESS ENG. SPECIAL CIRCUIT 5.00 PERn�1(P��TION
IIP EMP.METER OR POLE INS. 20.00 r„„�,
ADDRESS A MOTORS SEE FEE SCH.
J 1A ADDRESS �y SERVICE CHANGE 20.00 SEP 0 41985
(`
0 0 o LICENSED CONTRACTORS DECLARATION TEMP.POLE 30.00 City Of Cupertino
a 1-
. I hereby affirm that I am licensed under provisions of Chapter 9 ISSUANCE DATE
v, < N (commencing with Section 7000)of Division 3 of the Business and BLDG. ELECT. PLG. MEC .
r m z Professions Code,and my license is in full force and effect ❑ ❑ ❑
License Cli sse,24•-3q-ad ic.Number
-
3
z r D Date -- ''•Contractor
¢ Y f 33 - '�-d-8 BUILDINGPERMIT
¢ o ar ar U OWNER-BUILDER DECLARATION INFORMATION
wB: ¢ H I hereby affirm that I am exempt from the Contractor's License IMISC.- REFER TO ORD
uoj Law for the following reason.(Sec.7031.5,Business and Professions PERMIT ISSUANCE 10.00 VALUATION , $/FT.
Lo Code:Any city or county which requires a perm it to construct,alteq
Q Q Q improve,demolish,or repair any structure,prior to its issuance,also ELEC.CONTR. LIC.NO. ELEC.
o C requires the applicant for such permit to file a signed statement that TOTAL PER IT TO
E
m H he is licensed pursuant to the provisions of the Contractor's License
z a
Law(Chapter 9(commencing with Section 7000)of Division 3 of the
E D Business and Professions Code)or that he is esenrpt therefrom and QTY. PLUMBING PERMIT FEE /
the basis for tire alleged exemption.Any violation of Section 7031.5 STORMS TYPE-CONSTR.
d3 °-a by try applicant for a permit subjects the•applicunl to a civil penalty ALTER-DRAIN -WATER IEA.) 5.00
of not more than five hundred dollars($5001):
❑ I,as owner of the property,or my employees with wages as BACK FLOW PROTECT. DEVICE 4.00 OCG GROUP RES.UNITS
their sole compensation,will do the work,and the structul'c is not
intended or offered fur sole(Sec 7044, Business and Prolcssions DRAINS-FLOOR,ROOF,ARE'A;COND. 5.00
Code:The Contractor's.License Law docs not apply to un ownor of
property who builds or improves thereon,and veil!Roos such work FIXTURES-PER TRAP 5.00 SO.FT.FLOOR AREA TOTAL ACREAGE
himself or Olrough his own employees,provided that such improve
mcnts are not intended or offered for sale.ll',however the building GAS-EA.SYSTEM-11 INC.4 OUTLETS 6.00
or improvement is sold within one year of comPlclion,the owner- GAS-EA.SYSTEM-OVER 4 (EA.) 2.00
builder will hove the burden oft,..rving that he did mol build or in,. BUILDING USE
prove for purpose of sale.). INDUSTRIAL WASTE INTER. 30.00 E IND CON PB Other
O I,as owner of(lie property,am exclusively contracting will, ❑ ❑ ❑ ❑
licensed contractors to construct the project (Sec.7044,Business LAWN SPRINKLERS- 1 INC 5 V.B. 6.00 ASSESSORS PARCEL NO.
and Professions Code,'Fire Contractor's Licelsc Law docs 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 SEWER SANITARY-STORM EA.200ftl10.00
the Contractor's License Law. TRACT NO. PARCEL NO.
Peas.,❑ tl am exempt under Sec. .li.&I'.C.for this WATER HEATER W/VENT 6.00 n
Owner Date WATER SYSTEM 5.00 A' ACC.DATE ACC.FILE NO.
WORKERS'COMPENSAIION DECLARATION WATER TREATING EQUIP. 5.00 f
1 hereby affirm that 1 have a ecrHhcale Of consent to self-insure. ZONING ENG.SITE NO.
or a certificate Of Workers'Compensation Insurance,or a certified
copy thereof(Sce.3800,Lab.C.).
Policy No. Company
O ❑ Certified copy is hereby furnished. FIRE SPRINK ENERGY T-24'
z Z ❑ Certified copy is filed with the city inspection division. MISC.- REFER TO ORD.
0 Applicant Y❑ IN Y ❑ N❑
ft. y CE RTI FICA'1'1:01:1:xIiMP'IION FROM WORKERS' PERMIT ISSUANCE 10.00 FL000 ZONE A.L.U.C.
LUD COMPENSATION INSURANCE PLG.CONTE. LIC.NO. PLG. V❑ N❑ Y❑ N❑
CLZ( This section need not be completed if the permit is for one TOTAL
U O hundred dollars(S 100)or Icss.)
I certify that In the performance of the work for which this per, QTY. MECHANICAL PERMIT FEE FEE SUMMARY
LL U mit is issued.I shall not employ any person in any manner so as to
become subject to the Workers'Compensation Laws of California.
a Date Applicant ALTER OR ADD TO MECH. 5.00 BUILDING
} rn NOTICE'1'0 APPLICANT: If,after making this Certificate of Ex-
♦- ? emption,you should become subject to the Workers'Compensation APPLIANCE 5.00 PLAN CHECK
provisions of the Labor Code, you must lorthwilh comply with FEE
U such provisions or this permit shall be deemed revoked. AIR HANDLING UNIT(TO 10PMC.F.M.) 4.00
CONSTRUCTION LENDING AGENCY AIRHANDLING 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 Ole work for which this permit is issued(Sec. MICROFILM
3097,Civ.C.). HEATING UNIT(T0100,000 B.T.U.) 8.00 net
Lenders Name
Lender's AddreHEATI NG UN IT(OVER 100,000 B.T.U.)9.50 ELECTRIC
ss
I certify that l have read this application and Stam Olaf the above VENTILATION FAN (SINGLE) 4.00
n
ordinances n correct I agree to comply with all city and county PLUMBING
ordinances and state laws relating to building construction, and BOILER-COMP(3 H.P.or 100,0008.T.U.) 6.00
hereby aulhorrm representatives of this city In enter upon Mho BOILER-COMP (Over 100.000 BTU)SEE FEE SCH. MECHANICAL
above mentioned properly for inspection purposes.
(Wc) agree to save, indenrody and keep harmines the City of MISC.- REFER TO ORD.
Cupertino against liabilities,judgments, coils and expcnws which PERMIT ISSUANCE 10.00 CONST.TAX
may in any way accrue against said City in consequence of the n r
granting of this permit. MECH.CONT. LIC.NO. MECH.
TOTAL TOTAL
Signature of Applicant/Contractor ])at, .3.J'Ov
INSPECTOR COPY