09542APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
BU LDI NG PROJECT IDENTIFICATION
APPLICATION &PERMIT
BUILDING - ELECTRICAL- PLUMBING - MECHANICAL
PERMIT NUMBER
0954
L DIN G
AU'DIN
'
BUDDRESS
>.
OWNER 'S
NAME �jili-
C,jJ PHONE
OTY. ELECTRIC PERMIT FEE
PLAN CHECK VALIDATION
DATE OF APPLICATION
NAME Ac7oRs
QL 2.4 lc, No.
UTLETS-SWITCHES -RECEP 10.00/1.00
LIGHTING FIXTURES 10.00/1.00
ADD ESS RS
PHONE
PPLIANCES- RESIDENTIAL 4.00
PANELS 10.00
ARCHITKT
DR
ENGINEER
LIC. NO.
PANELS (OVER 200 AMP) 20.00
PLAN CHECK FEE P.C. NO.
SIGNSTRANS. 3.00
ARCH. OR
ADDRESS ENG.
ZIP
SPECIAL CIRCUIT 5.00
PERMIT VALIDATION
PAID
AUG. 2 31.985
ISSUANCE DATE
EMP. METER OR POLE INS. 20.00
APPLICANT'S
ADDRESS
MOTORS SEE FEE SCH.
SERVICE CHANGE 20.00
LICENSED CONTRACTORS DECLARATION
I hereby affirm that I am licensed under provisions of Chapter 9
(commencing will, Section 7000) of Division 3 of the Business and
I'micssions Code( and h y license is in full force_ ah�1d cited.
License Class _ Lic. Number
Dam Contractor
OWNER -BUILDER DECLARATION
I hereby affirm that I am exempt from the Contractor's License
Law forthe following reason, (See. 7031.5. Business and Professions
Code: Any city or county which ruluiresa permit to ell alter,
improve, demolish, or repair any structure, prior to its issuance, also
requires the applicant for such permit t0 file a signed statement that
he is licensed pursuant to the provisions of the Contractor's License
Law (Chapter 9 (commencing with Section 7000) of Division 3 0l the
Business and Professions Code) or that he is exempt therefrom and
the basis for (lie alleged exemption. Any violation of Section 7031,5
by any applicant fora permit subjects the applicant loacivil penalty
If not more than five hundred dollars ():
❑ as owner the property, omy employees my with wages as
L
their sole compensation, will do the work, and the structure is not
intended or offered for sale (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 docs such work
himself or through his own employees, provided That such improve-
ments or lot intended or offered for sale. If. bowevcq the building
or impris sold within one year of completion, the owner.
builder will hovementave the burden of proving that he Aid not build or fill-
prove for purpose ofsale.).
❑ 1, as owner of the property, run exclusively courmeting with
contractors tp construct the project (Sec. 7044, Business
an,] Professions Code: The Contractor's License Law does not apply
to an owner of properly who builds or improves thereon, and who
Contracts for such projects with a clumme or(s) licensed pursuant to
the Contractor's Llcease Law,
❑
reason 0Imo exempt under Sec. ,B.&P.C. Ibr this
TEMP. POLE 30.00
BL❑D ) �� u
e
MTC .
BUILDING PERMIT
INFORMATION
MISC. - REFER TO ORD
PERMIT ISSUANCEVALUATION
l O.QQ
$/FT.
ELEC. CONTR, LIC. NO.
ELETC.
TOTAL
RMIT TO
lt.�Ifjj 67
CITY. PLUMBING PERMIT FEE
ALTER -DRAIN & VENT -WATER (EA.) 5.00
6 6
YPE CONSTR.
BACK F LOW PROTECT. DEV ICE 4.00
OCC. GROu
RES. UNITS
DRAINS -FLOOR, ROOF, AREA, COND. 5.00
''11
FIXTURES - PER TRAP 5.00 'y
GAS - EA. SYSTEM -11 NC.4 OUTLETS 6.00 (j(f
SO. FT, FLOOR AREA
TOTAL ACREAGE
GAS - EA. SYSTEM -OVER 4 (EA.) 2.00
BUILDING USE
RE IND CON PB Omer
El El 1:1 El
.
INDUSTRIAL WASTE INTER30.00
LAWN SPRINKLERS - 1 INC 5 V.B. 6.00
ASSESSOR SPARCELNO.
LAWN SPRINKLERS - OVER 5 (EA.) 1.00
SEWER -SANITARY -STORM EA. 200ft/10.00
TRACT NO.
PARCEL NO.
WATER HEATER W/VENT 6.00 1 00
Owner Date
WORK ERS'COMPFINSATION DECLARATION
I hereby affirm that I have a certificate of consent to MI ... c,
or a certificate of Workers' Compensation Insurance• or a certified
copy thereof (Sec. 3800, Lab.CJ'
Policy No. Company
WATER SYSTEM 5.00
ACC.DATE
ACC. FILE NO.
WATER TREATING EQUIP. 5.00
ZONING
ENG. SITE NO.
MISC- REFER TO ORD. 1
❑ Certified copy is hereby furnished
Cert i(ied y�py is Olcd wish the city inspection division.
Appcam Yi �li"16 /1 •>
Cl: RTI FICAT H OF EX EM PTI ON PROM WORK ERS
COMPENSATION INSURANCE
(1his section need nor be completed if the perch it is for one
hundred dollars IS 100) or less.)
I certify that in the perfornhance of the work for which this per-
mil is issued, 1 shall not employ any person in ;my manner so as to
beconhe subject to the Workers' Compensation Laws of California.
Dmc Applicant
APPLICANT: If, eject making this rs' Compe of Ex-
NOTICE y10ou
emption, you should become e,hyou to rhe Workers' Ccomply with
provisions of the Labor Code, you mull forthwith comply with
such provisions or this permit shall be deemed revoked
CONSTRUCTION LENDING AGENCY
I hereby affirm that there is a constrrental, lending agency fin
the performance of He work for which this permit is issued (Sec.
3097, Civ.C.).
Lender's Name
FIRE SPRINK
Y❑ N❑
ENERGY T44
Y❑ N❑
PERMIT ISSUANCE 10.00 U
FLOOD ZONE
Y ❑ N❑
AL.UC.
Y ❑ N❑
PLG. CONTR. LIC. NO.
PLO
TOTAL Qu
CITV. MECHANICAL PERMIT FEE
FEE SUMMARY
BUILDING
ALTER OR ADD TO MECH. 5.00
APPLIANCE 5.00
.AIR HANDLING UNIT (TO 1000GF.M.) 4.00
PLAN CHECK
FEE
AIR HANDLING UNIT (OVER 10=C.EM.) 6.00
SEISMIC FEE
EXHAUST HOOD (WITH DUCT) 5.00
MICROFILM
HEATING UNIT (TO 100,000 B.T.U.) 8.00
Lender's Address
I certify that I have read this application and state that tile above
information is correct. 1 agree Io comply with all city and county
ordinances and state laws relating to building construction, and
hereby thoriec repute lar ties of this city to enter upon [h°
above herebymentionedrit property for inspection purposes.
(We) agree to save, indemnify and keep harmless the City of
Cupertino against liabilities, judgments, costs and expenses which
may in y w aceme aramst said City in consequence of the
g.
math o This rmil.�
i ns/hJ ��1--
HEATING UN IT (OVER 100,000 B.T.U.) 9.50
ELECTRIC
VENTILATION FAN (SINGLE) 4.00
BOILER-COMP13 H.P. or 100,000 B.T.U) 6.00
PLUMBING
BOILER -COMP (OVer 100.000 BTU) SEE FEE SCH.
MECHANICAL
MISC. - REFER TO ORD.
PERMIT ISSUANCE 10.00
CONST. TAX
MECH. CONT. LIC. NO.
MECH,
rorAL
TOTAL
r_�
Shg afore o Applicant ommic or ate
INSPECTOR COPY