09617 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
BUILDING PROJECT 1DENTIFICATION PERMIT NUMBER
APPLICATION & PERMIT
BUILDING ^ w
ADDRESS A _ _ _ U (u,�
BUILDING - ELECTRICAL-PLUMBING-MECHANICAL
i.. . J
17
OWNER'S PLAN CHECK VALIDATION
NAME OTY. ELECTRIC PERMIT FEE
lLC:-P� , PHONE /I' - ✓O .
NAM>ERACToas OUTLETS-SWITCHES-RECEP 10.00/1.00
'qg 6 uc.NO.Zn .C' LIGHTING FIXTURES 10.00/1.00
ADDRESsrons APPLIANCES-RESIDENTIAL 4.00
yL PHONE _ PANELS 10.00 DATE OF APPLICATION
ARCHITECT PLAN CHECK FEE P.G NO.
OR It Bd A, PANELS (OVER 200 AMP) 20.00
ENGINEER
uc.No. / SIGNS TRANS. 3.00
ARCH OADDRESR END
SPECIAL CIRCUIT 5.00 PERMIT VALIDATION
ZIP EMP.METER OR POLE INS. 20.00 PAID
ARMOTORS SEE FEE SCH.
ADDDDRESSESS c�
SERVICE CHANGE 20.00 SEP Q 4 1985
i J(7d
0 0 o LICENSED CONI'RACTORS DECLARATION TEMP.POLE 30.00
a v u I hereby affirm that 1 am licensed under provisions of Chapter 9 - City OfB6,
"u (commencing with Section 7000)of Division 3 of the Business and
�n 0 m BLDG. ELECT. M C
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H z Professions Code,and my license is in full force and effect.
e o y - Licenm Class ..Lic.Numher411 E El
QZF � DatL'f-A4-N9�.a�r..;y'ontrantor - Z _
a x 9-3-'F'r BUILDING PERMIT
¢ ¢ w OWNISR-BUILDER DECLARATION INFORMATION
w ;LL w I hereby affirm that 1 am exempt from the Contractor's License MISC.- REFER TO ORD
u o J Law for the following reason.(Sec.]031.5,Business and Professions 77777
ALUATION $/FT.
H - PERMIT ISSUANCE 10.00
Ps Code'.Any city or county which requires a permit to construct,alter,
re ¢ ¢ 2 improve,demolish,or repair any structure,prior to its issuance,also ELEC.CONTR. LIC.NO, ELEC.
- o or requires the applicant for such permit to filo a signed statement that TOTAL
n is
ea he is licensed pursuant to the provisions of the Contractor's License P RMIT TO
H z i
Law(Chapter 9(commencing with Section 7000)of Division 3 ofthe
a Business and Professions Code)or that he is exempt therefrom and OTV. PLUMBING PERMIT FEE i
T i
T o F o the basis for the alleged exemption Any violation of Section 703 LS ST IES -TyPtTONSTR,
u by any applicant for a permit subjects tine applicant ton civil penalty t
.feet more Fan five hundred donar,($5000.). ALTER-DRAIN& VENT-WATER (EA.) 5.00 I
❑ 1,as owner of the propery,or my employeeswith wages as BACK FLOW PROTECT. DEVICE 4.00 oee.caouPl REB.UNITS
sole compensation,will do[tic work,and the structure is not
unhurried or offered for sale (Sec. 7044, Business and Professions DRAINS-FLOOR,ROOF,AREA,CONE). 5.00
Code:The Contractor's License Law does not apply to an owner of
property who builds or improves thereon,and who docs such work FIXTURES-PER TRAP 5.00 SOFT ELOORAREA TOTALACREAGE
himself or through his own employees,provided that such Improve-
ments are not intended oPoffered for sale.If,however,the building GAS-EA.SYSTEM-11NC.4OUTLETS 6.00
or improvement is sold within one year of completion,the owner-
builder will have the burden of proving that he did uld huild on ire- GAS-EA.SYSTEM-OVER 4 (EA.) 2.00 BUILDING USE
prove for purpose of sale.). INDUSTRIAL WASTE INTER. 30.00 IND CON PB Other
CI 1,as owner of the property,am exclusively contracting with ❑ ❑ C1
licensed contractors to construct the project(Sec. 7044,Business LAWN SPRINKLERS- 1 INC 5 V.B. 6.00 1 ASSESSORS PARCEL NO..
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 contractors)licensed pursuant to SEWER-SANITARY-STORM EA.200ft/10.00
the Contortion's License Law. TRACT NO PARCEL NO.
❑ I am exempt under Sec.-,L&P.C.1'or this WATER HEATER W/VENT 6.00
reason
Owner 3 Dots WATER SYSTEM 5.00 ACC.DATE ACC.FILE No.
WORKERS'COMPEN'SATION DECLARATION WATER TREATING EQUIP. 5.00
1 hereby affirm that I have a certificate of consent to self-insure,
or a certificate of Workers'Compensation Insurance,or a certified ZONING ENG.SITE NO.
copy
thereof(See 3800,Lab.C.)
Policy NO.¢.Qyypy lslmpaay
0 Cer ified Copy is s Filed l'with t FIRE SPRINK ENERGY T-24
Z Z ❑ Certified copy is filed with the city inspection division MISC.- REFER TO ORD.p ApplicantYE] N YE] NE]
CC = CERTIPICATIi OP EXEMPTION PROM WORKERS' PERMIT ISSUANCE 10.00 FLOODZONE A.L.UA.
LU > COh1PENSATION INSURANCE PLG.CONTR. LIC.No. PLG.
CL Z CFlux section need not be completed if the permit is for one TOTAL Y❑ NE] Y E] N❑
hundred dollars(S 100)or less.)
U O 1 certify that in Ore Performance of the work for which this per- CITY. MECHANICAL PERMIT FEE FEE SUMMARY
EL 1- mit is issued, 1 shall not employ any person in any manner an as to
Q w become subject to the Workers'Compensation Laws of California.
y Date Applicant ALTER OR ADD TO MECH. 5.00 BUILDING
} W NOTICE'TO APPLICANT: If,after making this Certificate of Ex-
F ? eruption,you should become subject to the Workers'Compensation APPLIANCE 5.00 PLAN CHECK_
previsions 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=C.F.M.) 4.00
CONSTRUCTION LENDING AGENCY AIR HANDLING UNIT(OVER 101MC.F.M.) 6.00 SEISMIC FEE
I hereby affirm that there is a construction.lending agency for EXHAUST HOOD (WITH DUCT) 5.00 •e. ,
the performance of the work for which this permit is issued(Sec. --/-- MICROFILM
3097,Ce.C.). HEATING UNIT(To 100,000 B.T.U.) 8.00 D
Lender's Name
Lender's Addressp ,moi G //- e HEATI NG UN IT(OVER 100,000 B.T.U.)9.50 ELECTRIC
I certify that l have re d llhls applic rb`,mFAnt"tl�t the above VENTILATION FAN (SINGLE) 4.00 D. n
:monammn is correct. I agree to comply with all city and county - PLUMBING
ordinances and state laws relating to building construction. and B6ILER-COMP(3H.P.or100,000B.T.U.) 6.00
hereby aulhoriie representatives of this city to enter upon the BOILER-COMP(over 100,000 BTU(SEE FEE SCAT above-mentioned property for inspection purposes. MECHANICAL
(We) agree to save, indemnify and keep hairless 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 ,x1
granting of this permit MECH.CONT. LIC.NO. MECH.
TOTAL
". g -ore of APP hunt Cnbttactor _ -Date
n TOTAL
INSPECTOR COPY