8282 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
BU LDI NG PROJECT I DENTI FICATI ON PERMIT NUMBER
BUILDING y APPLICATION & PERMIT
ADDRESS OT BUILDING -ELECTRICAL-PLUMBING-MECHANICAL 8282
OWrvER'a IDA
- PLAN CHECK VALIDATION
NAME �J�-QQrI'�v Tp'^',/( OTY. ELECTRIC PERMIT FEE
PHONE
CONTRACTORS UTLETS-SWITCHES-RECEP 10.00/1.00 v
/ L D LIGHTING FIXTURES 10.'00/1.00
CONTRA TOR's - PPLIANCES-RESIDENTIAL 4.00
ADDRESS
PHONE PANELS 10,00 DATE OF APPLICATION
ARCHITECT PL N CHECK FEE P.C.NO.
OR PANELS (OVER 200 AMP) 20.00
ENGINEER
LIC.NO. SIGNS TRANS. 3.00 1
ARCH.DR ENG. r PERMIT VALIDATION ,
ADDRESS I���� S- S.rC.i7yiC/s.,11.1V SPECIAL CIRCUIT 5.00 +.
Y illy EMP.METER OR POLE INS. 20.00 !JUL - lu85s
APPLICANT'S
ADDRESS 4 jpf S- 1+l42y A� MOTORS SEE FEE SCH'.
SERVICE CHANGE 20.00 City of Cupertino
o O LICIiNSED C'ONTRACT'ORS DIiCLARA'I'[ON TEMP.POLE 30.00 '-
¢ u. I hereby affirm that I am licensed under provisions of Chapter 9 ISSUANCE DATE
m G h (commencing with Section 7000)of Division 3 Of the Business and -• BLD ELECT. PLG. MECH.
r ti z Professions Code,and my license is in full force and effect +; ❑ ❑ ❑`
im License Class Lic.Number
F h r
Date Contractor
¢ y
'BUILDING PERMIT
c a LL a OWNER-BUILDER 0[CLA RATION
o a MISC.- REFER TO ORD INFORMATION
E:
;¢ w 1 hereby affirm that I am exempt 7 from the Contmetoi s License VALUATION $/FT.
Huo J Law for the following reason. 7031.5,Businessand Professions PERMIT ISSUANCE 10.00
Code:Any city or county which requires a permit to construct,alter,
rcQ ¢ improve,demolish,or repair any structure,prior to its issuance,also ELEC.CONTR. LIC.NO. ELEC.
Ii. requires the applicant for such permit to filen signed statement that TOTAL PE MI T
a w m w he is licensed pursuant to the provisions of the Contractor's License
H z a
Law(Chapter 9(Commencing with Section 7000)of Division 3 ofthe
Business and Professions Code)or that he is exempt therefrom and CITY. PLUMBING PERMIT FEE
¢ =0 the basis for the alleged exemption.Any violation of Section 7031.5 Tv
n3 by anyapplicant fora permit subjects the applicant ton civil penalty ALTER-DRAIN -WATER (EA.) 5.00
of col more than five hundred dollars(5500).1:
❑ 1,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 IRIES.UNITS
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 docs such work FIXTURES-PER TRAP 5.00 s0. L OR AREA TOTXUAtREAGE
himself or through his own employees,provided that such improve- Y
ments are not intended or offered for sale.If.however.the building GAS-EA.SYSTEM-1 INC.4 OUTLETS 6.00
or improvement Is sold within one year of completion, the owner-
buiWer will have the burden of proving flat he did not build or im- GAS-EA.SYSTEM-OVER 4 (EA.) 2.00 B DING USE
povc for purpose of sale.). STRIAL WASTE INTER30.00 RES $ND CDN PB Omer
I, INDUSTRIAL .as owner of the property,am exclusively contracting with El El 1:10
lie ed contractors to construct tlm project(Sec. 7044,Business LAWN SPRINKLERS- 1 INC 5 V.B. 6.00 ASSESSORS PARC E L NO.
and Professions'Coda:The Contractor's License hew does 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 contmetms)licensed pursuant to
the Contractor's License Law. SEWER-SANITARY-STO RM EA.200ft/10.00 TRACT NO. PARCEL NO.
❑ I am exempt under Sea ,N.&P.C.lin it,is WATER HEATER W/VENT, 6.00
reason
Owner �/ Date WATER SYSTEM 5.00 ACC.FILE NO.
W'oHK RS c MPEN-SAT nUICLARn DECLARATION WATER TREATING EQUIP. 5.00
I hereby affirm that I have a certificate of Consent to selhinsure' ZONING ENG.SITE N0.
or a Ccrlificutc of Workers'Compensation Insurance,or a certified
Copy l hereof(Sec.3800,Lab.C.). -
policy No. Company
O ❑ Certified copy is hereby furnished. FIRESPRINK ENERGYT-YJ
Z Z ❑ Certified copy is filed with the city inspection division. MISC.- REFER TO ORD.
O Applicant Y❑ N❑ Y ❑ N❑
I= CERTIFICATE OF EXEMPTION PROM WORKERS' PERMIT ISSUANCE 10.00 FLOOD ZONE A.L.U.C.
LU > COMPENSATION INSURANCE PLG.CONTR. LIC.NO. PLC.
CL 0 LIli, section need not be contpletcd\if the permit is fnr one TOTAL Y❑ N❑ Y ❑ N❑
::) Z If find red doll an,IS 100)or less)
U O I Certify that in the performance of file work for which this per CITY. MECHANICAL PERMIT FEE FEE SUMMARY
EL F mit is issued,I shall not employ any person in any manner so as to
Ow b me subject to the Workers'Compensation Laws of Culikaroia. BUILDING
094
UJ at°.� Apphcanl ALTER OR ADD TO MECN. 5.00
} w O1'ICE TO APPLICANT: If,after making itis Certificate of Hx-
F Z enlption,you should become subject to the Worker Compensation APPLIANCE 5.00 PLAN CHECK
provisions of the Labor Code, you fa est forthwith Comply with FEE
U such provisions or this permit shall be limited revoked. AIR HANDLING UNIT(TO 10,000C.F.M.) 4.00
CONSTRUCTION LENDING AGENCY AIR HANDLING UNIT(OVER 10=C.EM.) 6.00 SEISMIC FEE
1 hereby affirm that there Is a construction lending agency for EXHAUST HOOD(WITH DUCT) 5.00
file performance of the work for which this permit is issued fSec.
3097,Civ.C.). n HEATING UNIT(TO 100,000 B.T.U.) 8.00
Lender's Name If
Condor's Address HEATING UNIT(OVER 100,000 B.T.U.)9.50 ELECTRIC
I Certify that( ave read this application andstale that fte above VENTILATION FAN (SINGLE) 4.00
• information is correct. I agree to comply with all city and county PLUMBINIV
l ordinances and sInte laws relating to building construction, and BOILER-COMP(3 H.P.or 100,000 B.T.U.) 6.00
hereby authorize representatives of ([Us city to enter upon the BOILER-COMP (Over 100,000 BTU)SEE FEE SCH. MECHANICAL
ubova-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 said Cily 'n consequence of the PERMIT ISSUANCE 10.00
grant] go this permit. MECH.CONT. LIC.NO. MECH.
G TOTAL TOTAL
natlfso A nlfkontr:ftto e • '
INSPECTOR COPY