09616 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
BUILDING PROJECT 1DENTIFICATION PERMIT NUMBER
So APPLICATION & PERMIT
A',RE c 09616
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BUILDING - ELECTRICAL-PLUMBING-MECHANICAL
OWNER'5 PLAN CHECK VALIDATION
NAME qq QTY. ELECTRIC PERMIT FEE
V vwoNE
NOMERac*oas UTLETS-SWITCHES-RECEP 10.00/1.00
(7 11 117, Uc.No. ,r LIGHTING FIXTURES 10.00/1.00
CONTRASDDRESS DR�s
APPLIANCES-RESIDENTIAL 4.00
PHONE PANELS 10.00 DATE OF APPLICATION
ARCHITECT �lA,i i ��33� PANELS (OVER 200 AMP) 20,00 PLAN CHECK FEE P.C.NO.
OR T
ENGINEER
Llc.NO. SIGNS TRANS. 3.00
nooniW ENG. SPECIAL CIRCUIT 6.00 PERMIT VALIDATION
Zip TEMP.METER OR POLE INS. 20.00 PAID
APPLICANTS rs
AMOTORS SEE FEE SCH.
SERVICE CHANGE 20.00 SEP 0 4 1985
woD LICENSED CONTRACTORSDECLARATION TEMP.POLE 30.00
¢ u I hereby affirm (flat I am licensed und�provisions of Chapter 9 155(1 D
yQ H (commencing with Section 7000)of Division 3 of the Business and BLDG. ELECT. PLG:
H D A Professions Code,and my license Is in full force and effect.
z D y - License Cfic,% , Lie Numhcr, �-y a�Fye ❑ El ❑
L
-.a.-r_.drntraclor .a.Z %- .
r
i Y E t 5-3- BUILDING PERMIT
¢ ¢ ¢ OwNf R-UUILDIiR DCCLA RATION
o a MISC.- REFER TO ORD INFORMATION
w g LL 1 hereby utlirni that 1 um exempt troll the Contractor's License
a, VALUATION $/FT.
� a_ 0Q Law forthe followingmason.(Sec.7031.5.BusinessarniPd.sums PERMIT ISSUANCE 10.00
Code:Any city or county which r,uiresa Dernih to const rue 1,alter,
ur , Q 2 inlpoev.[demolish,or repair any structure,prior to it.issuance,also ELEC.CONTR. LIC.NO. ELEC.
D u requires the applicoml for such permit to file a signed statement that TOTAL PERMIT TO
A w m m he is licensed pursuant to the provisions 01 till Contractors License
� z >
Law(Chapter 9(cummoncingwith Section 7000)o1 Division 3 ofthc
¢ Business and Professions Code)or that he is exempt therefrom andQTY. PLUMBING PERMIT FEE -
¢ r o the basis for the alleged exemption.Any violation of-Section 7031.5 STORt S -TYPE CONSTR.
a ;_' by any applicant for a permit subjects the applicant to a civil penalty ALTER-DRAIN -WATER (EA.) 5.00
of not mon:than five hundred doll urs($5000.):
❑ I,as owner of the property,or my employees with wages., BACK FLOW PROTECT. DEVICE 4.00 OCC.GROUP RES.UNITS
their sole compensation,will do the work,and the structure is not
intended or offered for sale (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 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 imProve-
ments are not intended or offered for sale.IL however,the building GAS-EA.SYSTEM-11NC.40UTLETS 6.00
or improvemenl is sold within one year of completion,the owner- GAS EASYSTEM-OVER 4(EA ) 200
builder will have the burden of proving that h - . . .
e did not build or im- BUILDING USE
prove for purpose of sale.). INDUSTRIAL WASTE INTER. 30.00 ES IND CON PR Omer.
❑ I,as owner of the property,am exclusively contracting with M ❑ ❑ ❑ ❑
licensed contractors to construct the project(Sec. 7044,Business LAWN SPRINKLERS-1 INC 5 V.B. 6.00 ASSESSORSPARC ELNO.
and Professions Code: The Contractor's License 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 contractods)licensed pursuant to SEWER-SANITARY-STORM EA.2001[/10.00
the Contractors License Law. TRACT NO. PARCEL NO.
❑ l um exempt under Sec.-,B&P.C.for this WATER HEATER W/VENT 6.00
reason
Owner Date WATER SYSTEM 5.00
ACC.GATE ACC.FILE NO.
WORK ERS'COMPENSATION DECLARATION WATER TREATING EQUIP. 5.00
1 hereby affirm that I have a cenifiene of consent to self-insure. ZONING
or a cenificate of Workers'Compensation Insurance,or a certified ENG.SITE NO.
copy thereof(Sec.3800,Lab C.) -
Policy n.t'2cz npmny �r
Q Cer0lied copy is hereby lura ish-d, v FIRE SPRINK ENERGY T$4
z Z C-rtified copy is tiled with the'city inspection division.
O Applicant' MISC.- REFER TO ORD. Y ❑ N❑ Y ❑ N❑
CC y CER'I'IPICAI"1i 01'EXEMPTION FROM WORKERS' PERMIT ISSUANCE 10.00 FLOOD ZONE A.L.U.C.
W > COMPBNSWION INSURANCE PLG.CONTR. LIC.NO. PLG.
Z (This section need not he completed if the permit is 1'or one TOTAL Y❑ NO Y ❑ NEIhundred dullurs($1001 or Icss.)
U O 1 certify that in the performance of Ihn work for which this Per- QTY. MECHANICAL PERMIT FEE FEE SUMMARY
U_ U nail is issued,I shall not employ I,r rernrn In any Inanner se as to
become u1n.t to the Workers'Con,Pensution Lows of C.Iifonlia.
LU Dat` Applicant ALTER OR ADD TO MECH. 5.00 BUILDING
} to Nona '1'0 APPLICAN I': If,after nuking Ibis Certificate of Lx-
F.. z cmption,you should beerona subject m the Work,,,Co ipensau0n APPLIANCE 5.00 PLAN CHECK
provisions of the Labor Code, you must forlhwfth comply with FEE
U such provisions or this permit shall be dermad revoked. AIR HANDLING UNIT(TO 10=CF.M.) 4.00
CONSTRUCTION LENDINC AGIiNC1AIR HANDLING UNIT(OVER 10=C.EM.) 6.00 SEISMIC FEE
I hereby affirm, that there is a construction lending agency for EXHAUST HOOD (WITH DUCT) 5.00
Hill, performance of the work for which this permit is issued(Sec. ,n MICROFILM
3097,Civ.C.). HEATING UNIT(TO 100,000 B.T.U.) 8.00
Lender's Name HEATING UNIT(OVER 100,000 B.T.U.)9.50
Lenders Address _ ELECTRIC
I certify that I tlar�fiad?h eppliatl and stat-that the above v VENTILATION FAN (SINGLE) 4.00 a v.nl
• information is correct. I agree to comply with all city and county PLUMBING
ordinances and state laws relating m building consvuction, and BOILER-CDMP(3 H.P.or 100,000 B.T.U.) 6.00
hereby authorize representatives of this city to ever upon the BOILER-COMP (Over 100,000BTU)SEE FEESCH. 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 CONST.TAX
may in any way accrue against mid City in consequence of the PERMIT ISSUANCE 10.00 anal
granting of this permit. MECH.CONT. LIC.NO. MECH.
TOTAL . TOTAL
ignmge of Applicant Contractor Date '3100 .
INSPECTOR COPY