09626 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
BEI LDI NG PROJECT I DENTI FICATI ON PERMIT NUMBER
BUILDING APPLICATION & PERMIT
ADDRESS
O _ _ BUILDING - ELECTRICAL-PLUMBING-MEMECHANICAL 09626
R' PLAN CHECK VALIDATION
NAME /^1 QTY. ELECTRIC PERMIT FEE
PHONE /.A4 0
CONTRACTOR'S
Name OUTLETS-SWITCHES-RECEP 10.00(1.00
41-3cU 1�_Uc,No. ,42a.,l LIGHTING FIXTURES 10.00/1.00 F
CONTRACTORS PPLIANCES-RESIDENTIAL 4.00
ADDRESS
PNONE 2 PANELS 10.00
_PNON o DATE K APPLICATION
ARCHITECT'.J� Le,yA�' Clal �i'/-J36 n PANELS (OVER 200 AMP) 20,00 PLAN CHECK FEE P.C.NO.
OR U
ENGINEER
uc.No. SIGNS TRANS. 3.00
ARC EOR ENG SPECIALCIRCUIT 5,00 PERMIT VAU DATION
ZIP EMP.METER OR POLE INS. 20.00
ADDRESS
P
AMOTORS SEE FEE SCH.
^
-y o ( < a__• _ 2 SERVICE CHANGE 20.00 SEP
p 4 1985
wo o LICENSED CONTRACTORS DECLARATION - TEMP.POLE 30.00 /��
a v I hereby affirm that I am licensed under provisions of Chapter 9 ISyYbCo
y n (commencing with Section 7000)of Division 3 of the Business and
¢ BLDG. ELECT. PL H.
F w i Professions Code,and my license is in full force and effect ❑ ❑ ❑
z O - License ClaSSg2 AA,09 ;1g.Lic.Number
oH F w Dph�O-� 9-va A rz 6omracior n / ,
¢ u s 2.9 9-a'X.T BUILDING PERMIT'
¢ ¢o i OWNER=RUILDER DECLARATION INFORMATION
w ; u m I hereby affirm that I am exempt from the Contractor's License MISC.- REFER TO ORD
w O j Law for the following reason.(Sec.7031.5,Businessland Professions pERM1T ISSUANCE 10.00 VALUATION $/FT.
� - Code:Any city or county which requires a permit to construct,alter, I
rt ¢ a o improve,demolish,or repair any structure,prior to its issuance,also ELEC.CONTE. LIC.NO. ELEC.
u requires the applicant for such permit to file a signed statement that TOTAL ERMIT TO
sa w w he is licensed pursuant to the provisions of the Contrmtor s License
Hz >
Law(Chapter 9 lcommencingwith Section 7000)of Division 3 nfllm
- ¢ Business and Professions Code)or that he is excamt thereffonl and DTV. PLUMBING PERMIT FEE
ar r m the basis for the alleged exemption.Any violation of Section 7031.5 STORIES TYPE CONSTR.
d4 z-
; � by any applicant for a permit subjects the applicant to a civil penally ALTER-DRAIN -WATER IEA.) $,00
of not more(Iran five hundred dollars 050R J:
❑ I,as owner of the property,or my employees with wages as BACK FLOW PROTECT. DEVICE 4.00
their sole compensation,will do the work,and the structure is not OCC.GROUP RES.UNITS
intended or offered for sale (Sec. 7044, Business and Po.lcssions 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 thereon,and who does such work FIXTURES-PER TRAP 5.00 SO.FT.FLOOR AREA TOTAL ACREAGE
• himself or through his own employees,provided that such'or
prove-
meaprts are not intended or offered for sale.If,however.the building GAS-EA.SYSTEM-1 INC.4 OUTLETS 6.00
or imovemem is sold within one year of completion,the owner- GAS-EA.SYSTEM-OVER 4 (EA.) 2.00
budder will have the burden of proving that he did not build or fill- BUILDING USE
prove for purpose ofsale.)' INDUSTRIAL WASTE INTER. 3000 E IND CON PB Omar
.
O 1,as owner of the property,mil exclusively contracting with El El 0 0
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 License Law does not apply
to an owner of property who builds or improves thereon,and who LAWN SPRINKLERS-OVER 5(EA.) 1.00
contracts for tach projects with a contractor(s)licensed pursuant to SEWER-SANITARY-STORM EA.200ft/10.00
the Contractors License Law. TRACT NO. PARCEL NO.
Cl I am exempt under Sea ,B.&P.C.tar this WATER HEATER W/VENT 6.00
reason
Owner Date WATER SYSTEM 5.00 ACC.DATE ACC.FILE NO.
WORT:ERS'COMPENSATION DECLARATION WATER TREATING EQUIP. 5.00
1 hereby attirnl that I have a certificate of consent to sell insure,
or a certificate of Workers'Compensation Insurance,or a certified ZONING ENG.SITE NO.
copy Ihcrcof(See 3800,Lub.CJ. /1
Pole No. Q?o,,A,Conlpuny�'2 21 -•-•�-
0 [Jy'Certilie copy is hereby'furnished. FIRE SPRINK ENERGY T 24
z Z ❑ Certified copy is filed with the city inspection division.
O Applicant MISC.- REFER TO ORD. YE:] NE] v ❑ N�
~ to PERMIT ISSUANCE 10.00
� - CIiRI'IEIGLTEOFI CEMPTINSUROhf WORK GES' FLOOD ZONE A.L.U.G.
W need of be completed
INSURANCE PLG.CONTE. LIC.NO. PLG, YE] N� v � N[]
� Z hundred
dollars need not be completed if the permit is for ane TOTAL
hundreJ dollars(5100)or less.)
U O I certify that in the performance of the work for which this per- QTY. MECHANICAL PERMIT FEE FEE SUMMARY
U- 1- mit is issued,I shall not employ any person in any manner so as to
U w become subject to the Wcoker Compensation Laws of California.
a Date Applicant ALTER OR ADD TO MECH. 5.00 BUILDING
} m NOTICE '10 APPLICANT: If,after making this Certificate of Its-
FZ emption,you should become subject to the Workers'Compensation APPLIANCE 5.00 PLAN CHECK
provisions of Ole Labor Code, you must forthwith comply with FEE
U such provisions or this permit shall be deemed revoked. AIR HANDLING UNIT(TO 10MOQF.M.) 4.00
CONSTRUCTION LENDING AGENCY AIR HANDLING UNIT(OVER 109MC.F.M.) 6.00 SEISMIC FEE
I herchy xflinn That Ihere is a construction lending agency for EXHAUST HOOD (WITH DUCT) 5.00 -
(he perlmmunce of the work for which this peanit is issued(Ser. MICROFILM
3097,Civ.C.). `�. HEATING UNIT(TO 100,000 B.T.U.) 8.00 ,oO
lenders Name-_�_G_2��
Lender'sAddre«/ �/£I_ 9 /G"ice^ HEATING UNIT(OVER 100.000 B.T.U.)9.50 ELECTRIC
9V a
I
information
II ui orrect rtI agree
o comply it stately a the above VENTILATION FAN (SINGLE) 4.00 O
information n correct. I s rel to comply with all city and county PLUMBING
ordinances and slam laws relating to building construction, and BOILER-COMPI3 H.P.Or 100,0008.T.U.1 6.00
hereby authorise representatives of this city to enter upon the BOILER-COMP (Over 100,000 BTU)SEE FEE SCH. MECHANICAL
above mentioned property for 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 any way accrue against said City in consequence of the
gmnlm of this permit. MECH.CONT. LIC.NO. MECH.
-a TOTAL TOTAL
ignat re of Appicant/ ontractor Uate .3.SOU r
INSPECTOR COPY