09546APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
BU LOI NG PROJECT IDENTIFICATION
APPLICATION &PERMIT
BUILDING - ELECTRICAL- PLUMBING - MECHANICAL
PERMIT NUMBER
09546ADORES$
BUILDING
R'S
NAME S
PRONE /- /
OTY. ELECTRIC PERMIT FEE
PLAN CHECK VALIDATION
NDMERACTo
OUTLETS -SWITCHES -RECEP 10.00/1.00
No. Q
LIGHTING FIXTURES 10.00/1.00
CONTRACTORS
ADDRESS
APPLIANCES -RESIDENTIAL 4.00
PANELS 10.00
PRONE -
DATE OF APPLICATION
AOR ECT
PANELS (OVER 200 AMPI 20,00
PLAN CHECK FEE P.C. NO.
ENGINEER
LIC. NO.
SIGNS TRANS. 3.00 '
ARCH. OR ENG,
ADDRESS
SPECIAL CIRCUIT 5.00
PE(�11T'ALIDATION
PAD
p
TEMP. METER OR POLE INS. 20.00
ZIP
AUG 2 3 1985
APPLICANT
A
ADDRESS
MOTORS SEE FEE SCH.
SERVICE CHANGE 20.00
vSS J
City of Cupertin?
ISSUANCE DAT
BLDG. ELECT. L MECH.
1
LICENSED CONTRACTORS DECLARATION
1 hereby affirm that Iain licensed under powisimts of Chapter 9
(commenting with Section 7000) of Division 3 of the Business and
Professions Code and my license is in full force and effect
License Class Lc. Number 1 S
TEMP. POLE 30.00
'
Date - Contractor
f RMIT
INFORMATION
OWNF-R-BUILDER DECLARATIONBUILDING
1 heathy affirm that I am exempt from the Contractor's LicenseMISC.
Use for the following reason. (Sec 7031.5, Business and Professions
Code: Any city or county which requires a permit to construct, alter,
- REFER TO ORD
PERMIT ISSUANCE 10.00
VALUATION
SIFT.
ELEC. CONTR. LIC. NO. ELEC.
TOTAL
improve, demolish, or repair any structure, prior to its issuance, also
requires the applicant for such permit to file signed statement that
he is licensed pursuant to like provisions Of the Contractor's License
PER
IT TO
Law (Chapter 9 ( commencing with Section 7000) of Division 3 of the
Business and Professions Code) or that he is exempt therefrom and
OTY. PLUMBING PERMIT FEE
the basis for the alleged exemption. Any violation of Section 7031.5
by any applicant lora permit subjects the applicant toa civil penalty
of not more than five hundred dollars (350().):
I
I
TYP ONSTR.
ALTER -DRAIN -WATER (EA.) 5.00
❑ 1, as owner of the property, or my employees With wages as
their sole compensation, will do the work, and the structure is not
BACK FLOW PROTECT. DEVICE 4.00
OCC. GROUP
RES. UNITS
DRAINS -FLOOR, ROOF, AR EA, 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
'
FIXTURES - PER TRAP 5.00 1�rJCIC
GAS - EA.SYSTEM - I INC.4 OUTLETS 6.00 Co
property who builds or improves thereon, and who does such work
himself or through his own employees, provided that such ImprovC-
mentaare not intended oroffered forsala. If. however, the building
FT. FLOOR AREA
TOTALACREAGE
or improvement is sold within one year of completion' the owner-
builder will have the burden of proving that he did not build or im-
GAS - EA. SYSTEM -OVER 4 (EA.) 2.00
BUILDING USE
prove for purpose ofsaleJ'
❑ I, as owner of the property, am exclusively contracting with
IND CON PS Other
❑ ❑ ❑ ❑
. .
INDUSTRIAL WASTE INTER3000
licensed contractors to construct the Project(See. 7044, Business
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- 1 INC 5 V.8. 6.00
ASSESSORS PARCEL NO. i
LAWN SPRINKLERS - OVER 5 (EA.) 1.00
contracts for such projects with a contractors) licensed pursuant to
the Conlractnr s License Law.
SEWER -SANITARY -STORM EA. 2001t110.00 Vt/
TRACT NO.
PARCEL NO.
Cl I ant exempt under SBC. ,B.&P.C. for this
reason
WATER HEATER W/VENT 6.00
Owner Date
WATER SYSTEM 5.00
ACC. DATE
ACC FILE NO.
WORK 17 RS'COMPFNSATION DECLARATION
WATER TREATING EQUIP. 5.00
'
I hereby affirm that I have a certificate ofconsent to self -insure.
or a Certificate of Workers' Compensation Insurance, or a certified
ZONING
ENG. SITE NO.
copy thur .f(SCc. 3800, Lah.C.).
Policy No. Company
FIRESPRINK
y❑ N❑
ENERGYT24
Y❑ N❑
❑ Certified copy ishcreby furnished
p Certified cnpZ is filed with the coq inspection Division.
AlpGcant r �p�}1C nr Ste'
CER TIFICA7'1: 01' EXEMPTION FROM WORKERS'
MISC.- REFER TO ORD.
PERMIT ISSUANCE 10.00 00
FLOOD ZONE
A.L.U.C.
COMPENSA'1ION INSURANCE
section need not he completed if the permit is for one
Y ❑ N ❑
Y ❑ N ❑
PLG.CONTR. LIC. NO.
PLG. CO(This
TOTAL CO
hundred dollars 1$ 100) or less.)
I certify that in the perl'oonance of the work for which this per-
mit is issued I shall not employ any person in any manner so as to
QTY. MECHANICAL PERMIT FEE
FEE SUMMARY
BUILDING
become subject to the Workers' Compensation Laws of California.
Date ApplicarR
ALTER OR ADD TO MECH. 5.00
NOTICE '10 APPLICAN9': If, after making this Ccrtificalc of I x-
APPLIANCE 5.00
PLAN CHECK
FEE
emption, you should become subject tD the Workers' Compensation
provisions of the Labor Code, you must forthwith comply with
such provisions or this permit shall be deemed revoked.
AIR HANDLING UNIT (TO 10MC.F.M.) 4.00
AIR HANDLING UNIT(OVER 10=C.EM.) 6.00
SEISMIC FEE
CONSTRUCTION LENDING AGENCY
I hereby affirm that there is a construction lending agency for
tiro performance of the work for which this permit is issued (SeC.
3097, Civ.C.).
EXHAUST HOOD (WITH DUCT) 5.00
MICROFILM
HEATING UNIT (TO 100,000 B.T.U.) 8.00
Lender Name
Lender's Address
H EATING UNIT (OV ER 100,000 B.T.U.19.50
ELECTRIC
VENTILATION FAN (SINGLE) 4.00
I Certify that I have read this application and state that the above
information is correct. I agree to comply withall city and county
uburnces and state laws relating to building construction, anJ
PLUMBING
U 0
BOILER-COMP(3 H.P. or 100,000 B.T.U.) 6.00
BOILER-COMP (Over 100,000 BTU( SEE FEE SCH.
MECHANICAL
hereby authorize representatives of this city to enter upon the
above-mentioned property for inspection purposes.
(Wal agree: to save, indemnify and keep ha..uncis 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
grant got spermit
PERMIT ISSUANCE 10.00
CONST. TAX
MECH. CONT. LICNO.
MECH.
(�/4 / /
TOTAL
TOTAL
Slgff.td,C rM 114 Il I 1 J'CIOr
INSPECTOR COPY