9418 (3) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
BUILDING PROJECT IDENTIFICATION PERMIT NUMBER
BUILDING APPLICATION & PERMIT ^ �
AOOTEss33, Id y
BUILDING-ELECTRICAL-PLUMBING -MECHANICAL
OWNER'$ PLAN CHECK VALIDATION
DTV. ELECTRIC PERMIT FEE +r'
corvMErRAcroRs UTLETS-SWITCHES-RECEP 10.00/1.00 V O�
NA
LIC.NO. LIGHTING FIXTURES 10.00/1.00
CONTRACTORS PPLIANCES-RESIDENTIAL 4.00
PHONE PANELS 10.00 DATE OF APPLICATION
ARCHITECTPANELS (OVER 200 AMPI 20.00
PLAN CHECK FEE P.C.NO.
OR
ENGINEER
uc.NO SIGNS TRANS. 3,00
ADCH.RESS ENG. SPECIAL CIRCUIT S,QQ PERMIT VALIDATION
AOOHR PAID
AID
ZIP TEMP.METER OR POLE INS. 20.00 A
APPLICANTS MOTORS SEE FEE SCH.
ADDRESS AUG - 5 1985
SERVICE CHANGE 20.00
o
o LICENSED CONTRACTORS DECLARATION TEMP.POLE 30.00
¢ u u I herebyaffirm that I am licensed under provisions of Chapter 9 City SU NCE I �0
' p s ISSUANCE DA
Nrt w (commencing with Section 7000)of Division 3 of the Business and BLDG. ELECT. PLG. MECH.
F m z profession,Code,and my license is in full force and effect ❑ O ❑
z o u, - License Class Lic.Number
o rfF o Date Contractor
a y E BUILDING PERMIT
¢ ¢ w a OWNER-BUILDER DECLARATION
o A O MISC.- REFER TO ORD INFORMATION
wU- I- I hereby affirm that I am exempt from the Contractor's License
u_ D 1 Law for the following reason.(Sec.7031.5.Busmessand Professions PERMIT ISSUANCE 10.00 VALUATION
� - Code:Any city orcounty which requires a permit 10 construct,alter,
icu,¢0 improve,demolish,Or repair any 5truclum.prior to its issuance,also ELEC.CONTE. LIB.NO. ELEC.
D¢ requires the applicant for such permit to file a signed statement that TOTAL PERMIT TO
o. w m n he is licensed pursuant to the provisions of the Contractor's License
HZQ Law(Chapter 9(commencing with Section 7000)ofDivision 3 ofthe 3 _ I�/EZ
4 o Business and Professions Code)or that he is exempt therefrom and QTV. PLUMBING PERMIT FEE
¢ H o the basis for the alleged exemption.Any violation of Section 7031.5 STORIES TYPE CONSTR.
ate _ by any applicant for a permit subjects the applicant to a civil penalty ALTER-DRAIN&VENT-WATER (EA.) 5.00
of not more than five hundred dollars($500).):
❑ 1,as owner of the property,or my employees with wages as BACK FLOW PROTECT. DEVICE 4.00 DCC.GROUP RES.UNITS
their sole compensation,will do the work,and the structure is not
intended or oft'ered.fur sale (Sec 7044, Business and Professions DRAINS-FLOOR,ROOF,AREA,COND. 5.00
Code:'fie Contractor's License Law does not apply to on owner of
property who builds(a Imioo eo theROn,and who does$ilei work FIXTURES-PER TRAP 5.00 SO.FT.FLOOR AREA TOTAL ACREAGE
himself re through his own employees,provided that such imprrve-
mentsmsello througot h
or en,loyces,ffered for rae. i,however,ded that
budding GAS-EA.SVSTEM-11NC.40UTLETS' 6.00
or improvement is sold within one year of completion,the owner- GAS-EA.SYSTEM-OVER 4 IEA.) 2.00 BUILDING USE
builder will have the burden of proving that he did not build or im-
proveforpurposeofsalc.l. INDUSTRIAL WASTE INTER3000 RES IND CON P9 Other
t� . .
I,as owner of the property,am exclusively contracting with El El E] - 1:1IicEnsed contractors to construct the project(Sec. 7044,Business LAWN SPRINKLERS- 1 INC 5 V.B. 6.00 ASSESSORS PARCEL NO.
and Professions Code:"I'he 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 forsuchLiceneLwithacontrectortsl licensed pursuant to SEWER-SANITARY-STORM EA.200ft/10.00 TRACT NO. PARCEL NO.
the Contractor's License Law.
❑ Iamcxcmptundcr Sec. ,B.&P.C.forthis WATER HEATER W/VENT 6.00
Ito
reason
Ownir Date WATER SYSTEM 5.00
ACC.DATE ACC FILE N0.
WORK ERS*COMPENSATION DECLARATION WATER TREATING EQUIP. 5.00
I hereby affirm tial I have a certificate of consent t0 sel Flnsutc, ZONING ENG.SITE NO.
or a certificate of Workers'Compensation Insurance,or a certified ,
copy thereof(Seo.3800,Lab.C.).
Policy No. Company
Q O. Certified copy is hereby furnished. FIRE SPRINK ENERGY T 24
Z Z ❑ Certified copy is tiled with the city inspection division
O Applicant MISREFER TO ORD. Y ❑ N❑ Y ❑ N❑
i m CIi R'I'u'ICA'I'Ii OI°EXEMPTION FROM WORKERS' PERMIT ISSUANCE 10.00 FLOOD ZONE A.L.U.C,
LLI ��+ COMPENSATION INSURANCE PLG.CONTE, LIC.NO. PLG. !N Y El N❑ v El NEIn• 0 ('Phis section Iced not be completed if thu permit is for one TOTAL
�'Z hundred dollars IS 100)or Its,)
lu.o' I certlty that in the perlimnanee of the work for which this per- OTY. MECHANICAL PERMIT FEE FEE SUMMARY
LL 1-" not is issued, I shall not employ any person in any manner so as to
U becione subject to the Workers'Compensation Laws of California.
Go Untc Applicant ALTER OR ADD TO MECH. 5.00 BUILDING
} W NOTICE TO APPLICANT: If,after making this Certificate of Ex.
(_ Z emption,you should become subject to the Workers'Compensation APPLIANCE 5.00 PLAN CHECK
provisions of the Labor Code, you must forthwith comply with FEE
U such provisions or this permit shall be deemed revoked. AIR HANDLING UNIT(TO 10JUOC.F.M.) 4.00
CONSTRUCTION LENDING AGENCY AIR HANDLING UNIT(OVER 10MCC.F.M.) 6.00 SEISMIC FEE
I hereby affirm that then is a construction lending agency for EXHAUST HOOD (WITH DUCT) 5.00
the
peiv
r MICROFILM
rmance of the work for which this permit is issued(Sec. HEATING UNIT(TO 100,000 B.T.U.) 8.00
Lender's Name
Lender's Address HEATING UN IT(OVER 100,000 B.T.U.)9.50 ELECTRIC
I certify that I have read this application and state that the above VENTILATION FAN (SINGLE) 4.00
• information is correct. 1 agree to comply with all city and county BOILER H.P.or 100,000 B.T.U.) 6.00 PLUMBING aQ
ordinances and state laws relating to building construction, and
hereby authorize representatives of this city to enter upon the BOILER-COMP (Over 100,000 BTU)SEE FEE SCH. MECHANICAL
above-mentioned property for inspection purposes.
(Wa) agree to save, indemnify and keep harmless the City of MISC.- REFER TO ORD.
Cupertino againstliabilities,judgments, costs and expenses which PERMIT ISSUANCE 10.00 CONST.TAX
may in any way accrue against City in ,sequence of the
'Gulling of this pert .t MECH.CONT. LIC.NO. MECH.
\ _ TOTAL TOTAL
ol'Appb ant' o tr Cron ate y
INSPECTOR COPY