09547APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
BUILDING PROJECT IDENTIFICATION
APPLICATION & PERMIT
BUILDING -ELECTRICAL -PLUMBING -MECHANICAL
PERMIT NUMBER
BUILDING
ADDRESS
^.
_09547
.(L %
PHOrvE
OTY. ELECTRIC PERMIT FEE
PLAN CHECK VALIDATION
NAMEn
UTLETS-SWITCHES-RECEP 10.00/1.00
IC..NO. (
LIGHTING FIXTURES 10.00/1.00
CONTRACTOR
ADDRESS
ADDRESS
PPLIANCES- RESIDENTIAL 4.00
TPA0N
DATE OF APPLICATION
PANELS 10.00
Op ED
ENGINEER
Lie NO,
PANELS (OVER 200 AMP) 20.00
PLAN CHECK FEE P.C. NO.
SIGNS TRANS. 3.00
ADDHHEss ENG.
SPECIAL CIRCUIT 5.00
PER AI&TIDN
EMP. METER OR POLE INS. 20.00
ZIP
r�
AUG 2 3 1985
ADDRESS
ADDRESS
MOTORS SEE FEE SCH.
SERVICE CHANGE 20.00
1J
City Of Cupertino
ISSUANCE DATE.
LICENSED CONTRACTORS DECLARATION
I hereby affirm that 1 am licensed under provisions of Chapter 9
(commencing will, Section 7000) of Division 3 of the Business and
Professions Code and my license is in full force and effect
License Class Lie" Number 0 Y V A% (7 1
TEMP. POLE 30.00
BLDG. ELECT.
❑ 1:1❑
PLG
MECH.
Date Contractor
BUILDING RIERMIT
INFORMATION
OWNER -BUILDER DECLARATION
1 hereby affirm that I am exempt from the Contractor's License
Law for the following reason. (Sec. 7031.5, Businessand Professions
Code: Any city or county which requires a permit to construcq alter,
MISC.- REFER TO ORD
PERMIT ISSUANCE 10.00
VALUATION
S/FT.
ELEC. CONTR. LIC. NO.
ELEC.
TOTAL
improve, demolish, or repair any Structure, prior to its issuance, also
requires the applicant for Site), permit to file a signed statement that
he is licensed pursuant to the provisions of the Contractor's License
T TO
GTY- PLUMBING PERMIT FEE
Law (Chapter 9 (commencing with Scot ion 7000) of Division 3 of the
Business and Professions Code) or that he is exempt therefrom and
the basis for the alleged exemption. Any violation of Section 7031.5
by any applicant for a permit subjects the applicant to a civil penalty
of not more than five hundred dollars (SSOO.):
1
STORES
T PCONSTR.
ALTER -DRAIN & VENT -WATER (EA.) 5.00
❑ 1, as owner of the propmy, or Iby employees with wages as
their sole compensation, will do the work, and the structure is nal
BACK FLOW PROTECT. DEVICE 4.00
OCC. GROUP
RES. UNITS
DRAINS -FLOOR, ROOF, AREA, COND. 5.00
intended or offered for Sale (Sec. 7044, Business and Professions
Code: The Contractor's License Law does not apply to an owner of
properly wltu builds or improves thereon, and who does such work
himself' or through his own employees, provided that such improve.
meats are not intended or offered for sale. IL however. the building
l�
F IXTUR ES - PER TRAP 5.00„ K+
GAS-EA.SYSTEM-11NC.40UTLETS 6.00 �[)
50. FL FLOOR AREA
TOTAL ACREAGE
or improvement is sold within one year of completion, the owner-
builder will have the burden of proving that h e did not build or int-
- . -.
GAS EASYSTEM OVER 4 (EA) 2,00
BUILDING USE
Prose for purpose of sale.).
❑ 1, as owner of the property, am exclusively contracting with
R IND CON PB Orher
INDUSTRIAL WASTE INTER. 30.00
SPRINKLERS - 1 INC 5 V.B. 6.00
LAWN SPRINKLERS - OVER 5 (EA.) 1.00
licensed contractors to construct the project (Sec. 7044, BusinessLAWN
and Professions Code: The Contractor's License Law docs not apply
to an owner of property who builds or improves thereon, unit who
ASSESSORS PARCEL NO.
contracts for such projects with a contraetoos) licensed pursuant to
the Contractor's License Law.
SEWER -SANITARY -STORM EA. 200ft/10.00
TRACT NO.
PARCEL NO.
❑ Iron exempt under Sec. ,BAP.C. for this
a9Un
WATER HEATER W/VENT 6.00 W
owner Date
.i WATER SYSTEM 5.00 00
ACC.DATE
ACC. FILE NO.
WATER TREATING EQUIP. 5.00 -CO
WORKF-RS'COMPENSAT10N D17CLARATION
I hereby affirm that 1 have a ccudicate of consent m s,H4in,uur,
or a Certificate of Workers' Compensation Insurance, or a certified
ZONING
ENG. SITE NO.
copy thereof (See. 3800, Lab.C.).
Policy No. Company
❑ Certified copy is hereby fuil'ohed'
Certified pY is fled wish the city inspection division.
Bean[ %n'j
FIRE SPRINK
Y NEI
ENERGY T-24
Y N�
MISC.- REFER TO OR D.
CERTIFICATP, OI' EXEMPTION FROM WORKERS'
PERMIT ISSUANCE 10.00
FLOOD ZONE
O
A. L. U.C.
COMPENSATION INSURANCE
section need not be Completed if the permit is for one
PLG. CONTR- LIC. No. -
PTOTLG,AL n G�
y N ❑
Y ❑ NEI(This
hundred dollars IS 100) or less.)
I certify that in the perllmnance of the work for which this per.
mil is issued, I shall not employ any person in any utanner so as to
CITY. MECHANICAL PERMIT FEE
FEE SUMMARY
become subject to the Workers' Compensation Laws of California.
ALTER OR ADD TO MECH. 5.00
Date Applicant
NOTICE TO APPLICANT: If, atter making this Certificate of Ex-
BUILDING
APPLIANCE 5.00
AIR HANDLING UNIT (TO 10=C.F.M.) 4.00
PLAN CHECK
emption, you should become subject to the Workers'Compensation
provisions of the Labor Code, you must forthwith comply withFEE
such provisions or this permit Shall be deemed revoked
AIR HANDLING UNIT(OVER 10MIOF.M.) 6.00
SEISMIC FEE
cONSTRUC'f ION LENDING AGENCY
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
3097, Civ.CJ.
MICROFILM
HEATING UNIT (TO 100,000 B.T.U.) 8.00
Lender's Name
Lender's Address
HEATING UNIT (OVER 100,000 B.T.U.) 9.50
ELECTRIC
VENTILATION FAN (SINGLE) 4.00
I certify that 1 have read this application and state that the above
information is correct. I agree to Comply with all city and county
ordinances and slate laws relating In building Construction, and
PLUMBING
00
BOILER-COMP(3 H.P. or 100,000 B.T.U.) 6.00
hereby authorizerepresentatives of this city to enter upon the
above-mentioned property for inspection purposes.
BDI LER-COMP lover 100,000 BTU) SEE FEE SCH.
MECHANICAL
(We) agree m save, indemnify and keep harmless the City of
MISC. - REFER TO ORD.
Cupertino against liabilities, judgments, costs and expenses which
may in any way accrue against said City in consequence of the
PERMIT ISSUANCE - 10.00
CONST. TAX
gmnltmit�
MECH. CONT, LIG NO.
MECH.
/
TOTAL
TOTAL
Sl Date
Mcrc p t/Co racto
INSPECTOR COPY