09635 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
BUILDING PROJECT IDENTIFICATION
PERMIT NUMBER
D
ADRESSILDIN APPLICATION & PERMIT o09635X n '^�J BUILDING-ELECTRICAL-PLUMBING -MECHANICAL
OWNER'S PLAN CHECK VALIDATION
NAME QTY. ELECTRIC PERMIT FEE
• O PRONE O
NAMERAcroRs UTLETS-SWITCHES-RECEP 10.00/1.00
uc.No.
4, LIGHTING FIXTURES 10.00/1.00
CONTRASDDRESS ons
APPLIANCES-RESIDENTIAL 4.00
�' pHON ye/-.� �.. PAN ELS 10,00 DATE OF APPLICATION
ARCHITEC / PLAN CHECK FEE ill P.C.NO.i
oR 9H-6'r PANELS (OVER 200 AMP) 20.00 M
ENGINEER P A'
LIc.NO, SIGNS TRANS. 3.00 „
meows;ENG, SPECIAL CIRCUIT S.QQ PERMIT VALIDATION
ZIP EMP.METER OR POLE INS. 20.00 SEP 0 4 1985
APPLI MOTORS SEE FEE SCH.
ADDRESS
SERVICE CHANGE 20.00 City of Cupertino
w o o LICENSED CONTRACTORS DECLARATION TEMP.POLE 30.00 .c
a U u I hereby affirm that I am licensed under provisions of Chapter 9 ISSUANCE DATE
maw (commencing with Section 7000)of Division 3 of the Business and BLDG-_ ELECT. PLG. MEC
H w z Professions Code,and my license is in full force and effect. ❑ ❑ ❑
z i m o Lice CIasq^�20_,-'"4 LIc.Number
9 w wLa Da"tr a`/" oT- Contractor
yf -3 9-3-JS BUILDING PERMIT
a a a OWNER-BUILDER DECLARATION III
A o a caINFORMATION
w LL r- I hereby affro that I am exempt from the Contractors License MISC.- REFER TO ORD
VALUATION $/FT.
H u o j Law for the fallowing reason(Sea 7031.5,Business and Professions PERMIT ISSUANCE 10.00
Code:Any city or county which requiresa permit m construct,alter,
IS o improve,demolish,or repair any structure,prior to its issuance,also ELEC.CONTR. LIC.N0. ELEC.
O , requires;the applicant for such permit to file a signed statement that TOTAL PER
T TO
d w$w he is licensed pursuant to the provisions of the Contractor's License
Fy >
Law(Chapter 9(commencing with Section 7000)of Division 3 ofthe
- a Business and Professions Code)or that Ire is exempt therefrom and QTY. PLUMBING PERMIT FEE
r c the basis for tire alleged exemption.Any violation of Section 7031.5 STORIES TYPE CONSTR.
w. by any applicant for a permit subjects the applicant to a civil penalty ALTER-DRAIN -WATER (EA.) 5.00
of not more than five hundred doll...(8500).):
U I,as owner of the property,or my employers with wages as BACK F LOW PROTECT. DEV ICE 4.00 OCD.GROUP RES.UNITS
their sole compensation,will do the work,and the structure is not
intended or offered for to (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 t ercon,and who docs such work FIXTURES-PER TRAP 5.00 So,FT.FLOOR AREA TOTALACREAGE
himself or through his own employees.provided that such in.piece-
mentsarenotintendedoroffered for 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-EA.SYSTEM-OVER 4 (EA.) 2.00
builder will have the burden of proving that he did not build or",I BUILDING USE
prove for purpose or sale.). INDUSTRIAL WASTE INTER. 30.00 E IND CON PB One,
❑ h as owner of the property,am exclusively cont ruching with ❑ ❑ El ❑
licensed contractors to construct the project(Sec.7044,Business LAWN SPRINKLERS- 1 INC 5 V.B. 6.00 ASSESSORS PARCEL NO.
and Professions Cor The Contractor's License Law does not 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 contractots)licensed pursuant to SEWER-SAN V-STORM EA.200ft/10.00
the Contractors License Law. TRACT NO. PARCEL NO.
❑ I am exempt under Sec.-,B&P,C.for this WATER HEATER W/VENT 6.00
reason
Owner Duce WATER SYSTEM 5.00 ACC.OATE ACC.FILENO.
W'ORKERS'COMPENSATION DECLARATION WATER TREATING EQUIP. 5.00
1 hereby affirm that 1 have a certificate ofconsaB ID elfmmsure, ZONING ENG.SITE NO.
or a certificate of Workers Compensation Insurance,or a certified
copy thereof(See.3800,Lab.C.). ,
folicy No./w+.+s.2o hereby
Q 0 Certified Copy is hereby furnished.wi , the
FIRE SPRINK ENERGY T44
Z 0 Certified copy is filed with tlm city inspcniun Division. MISC.- REFER TO ORD.
Q APPlic:un YE] N YE] NE]
jr y ,CERTIFICATE 01'EXEMPTION FROM WORKERS' PERMIT ISSUANCE 10.00 FLOOD ZONE A.L.U.C.
W > COMPENSATION INSURANCE PLG.CONTE. LIC.NO. PLG. N� V NNF]13. 0 This section need not be completed if the permit is for.one TOTAL y
hundred dollars(S 1001 or loss.)
U 0 I certify that in the performance of the work for which this per QTY. MECHANICAL PERMIT FEE FEE SUMMARY
LL U Tint is issued, I shall not employ any person in any ntamterso us to
become subject to the Workers'Compensation Laws of California.
a
Date Applicant BUILDING
>- DO NOTICE TO APPLICANT: If,after making this Certificate of Ex- ALTER OR ADD TO MECH. 5.00
F 2 emption,you should become subject to the Workers'Compensation APPLIANCE 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 10=r-F.M.) 4.00
CONSTRUCTION LENDING AGENCY AIR HANDLING UNIT(OVER 110,000C.FM.) 6.00 SEISMIC FEE
I hereby affirm that there is IT construction lending agency for EXHAUST HOOD (WITH DUCT) 5.00 T,n
the performance of the work it,,which this pcnnit is issued ISec. MICROFILM
3097,Civ.C.l. HEATING UNIT(TO 100,000 B.T.U.) 8.00 q n
Lender's Name ( / HEATING UNIT 100,000 B.T.U.)9.50
Lender's Add��ress ss q q ELECTRIC
( certify tlraPt-have reddthts PffM for and state that the above • VENTILATION FAN (SINGLE) 4.00
• information is 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 100,000 B.T.U.) 6.00
hereby uuthorwe representatives of this city to enter upon the BOILER-COMP(Over 100,000 BTU(SEE FEE SCH. MECHANICAL
above-mentioned property for inspcetion purposes.
(We) agree to save, indemnify and keep harmless the City of MISC.- REFER TO ORD.
Cupertino against liabilities,judgments, costs and expenses which CONST.TAX
may in any way acerre against mid City in consequence of the PERMIT ISSUANCE 10.00 /0•00
granting of this permit. MECH.CONT. LIC.NO. MECH.
TOTAL TOTAL
'Sitgnittk2 of APPlicult Co Tractor ):dc
3i. 60
INSPECTOR COPY