9267 (2) APPLICANT TO FILL IN INFORMATION W N RED LINES - USE BALL POINT PEN ONLY
BUILDING PROJECT I DENTI FICATION PERMIT NUMBER
GGILDING APPLICATION & PERMIT 9267
ADDRESS 0]62)ING - ELECTRICAL-PLUMBING-MECHANICAL
OPIUI PLAN CHECK VALIDATION
•
NAME QTY. ELECTRIC PERMIT FEE
PHONE
oN RAc oR
NE UTLETS-SWITCHES-RECEP 10.00/1.00
LION LIGHTING FIXTURES 10.00/1.00
TRACTOR' APPLIANCES 4.00
VCI�TECT
RE55PHONEPANELS 10.00 DATE OF APPLICATIONPANELS IOVER ZOO AMP) 20.00PLAN CHECK FEE P.C.NO.ON
ENGINEER
' LIC.No. - SIGNS TRANS. 3.00 PEI
AARC H,OR DDRESS ENG. SPECIALCIRCUIT 5,00 FERMI IOATION
ZIP TEMP.METER OR POLE INS. 20.00 JUL 12 ?985
APPLICANT'S MOTORS SEE FEE SCH.
ADDRESS
SERVICE CHANGE 20.00 City Of Cupertino
woar o LICENSED CONTRACTORS DECLARATION TEMP.POLE 30.00
¢ v I hereby affirm that I am licensed under provisions of Chapter 9 ISSUANCE GATE
a
h G vWAi ICommrncing'wifh Section 70001 of Division 3 Of[he Business and
D z BLDG. ELECT. P G MECH.
F Professions Codi and my cense is i I full 10a. rid e��eL't. ❑ ❑ ❑
Z.0 o w - License Class_ � Lic.Numberaiy ' t�rGr
o are Contractor T�
a Y s -a BUILDIN ERMIT
¢ ¢ w 4 OWNER-BUILDER DECLARA'f1ON INFO ATION
o d U MISC.- REFER TO ORD
K
3 LL N 1 hereby all-ion That I am exempt Gore the Contractor's License VALUATION $/FT.
H .. o a Law for the following reason.(Sec.7031.5.BGSIOesSand PD CYoc RS PERMIT ISSUANCE 10.00
Code:Any city or county which requires a permit to construct,alter,
¢ ¢ Q 0 improve,demolish,or repair any structure,prior to its issuance,also ELEC.CONTR. LIC.NO. ELEC.
- 0, requires the applicant for such permit to file a,signed statement that TOTAL PE MIT TO
a w m" he is licensed Pursuant to the provisions of the Contractor's License
Hz i
Law(Chapter 9(commencing with Section 7000)of Division 3 of the
a Business and Professions Code)or that he is exempt therefrom and QTY. PLUMBING PERMIT FEE
IS o the basis fur the alleged exemption.Any violation of Section 7031.5 STOR 5 I VEE CONSTR.
by any applicant for a permit subjects the applicant to a civil penalty ALTER-DRAIN&VENT-WATER (EAJ 5.00
of riot more than five hundred dollars(4500)):
❑ I,as owner of the property,or my employees with wages as 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,CONO. 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 workFIXTURES-PER TRAP S.00 ' SO.FT.FLOOR AREA TOTALACREAGE
• himself or through his own employees.Provide)that such intl?rove-
merits are not intended or offered for sale.l L however,the budding GAS-EA.SYSTEM-1INC.40UTLETS 6.00
or improvement is sold within one year of completion,the owner- GAS-EA.SYSTEM-OVER 4 (EA.) 2.00 BUILDING builder will have the burden of proving that hNG 115E
e did not build or ire- E IND GNG PB Opnee
prove for purpose of salol. INDUSTRIAL WASTE INTER. 30.00
❑ I,as owner of the property,am exclusively'contracting with ❑ ❑ ❑ ❑
licensed contractors m construct the project(Sec.7044,Business LAWN SPRINKLERS-1 INC 5 V.B. 6.00 ASSESSORS PARCEL NO.
and Professions Code:The Contractor's License Law does not apply
to or owner of property who builds or improves thereon.and win LAWN SPRINKLERS-OVER 5(EA.) 1.00
contracts for such projects with a contractons)licensed pursuant to SEWER-SANITARY-STORM EA.200ft/10.00
the Contractor's License Law. {. TRACT NO. PARCEL NO.
❑ I am exempt under Sec. .B.&P.C.for this WATER HEATER W/VENT 6.00
reason
Owner Date WATER SYSTEM 5.00 ACC.DATE ACC.FILE NO.
W'ORKERS'COMPENSATION DECLARATION WATER TREATING EQUIP. 5.00
I hereby affirm that I have a certificate ofconsent to self-insure.
or a certificate of Workers'Compensation Insurance,or a certified ZONING ENG.SITE NO,
copy thereof(Sce.3800,Lab.C.).
Policy No. Com pony
❑ C ified '.PY,' res urnished FIRE SPRINK ENERGY T24
Z Zcritic c p d witl the ity inspection division.
0 AvlMISC.- - REFER TO ORD.
nl Y ❑ N❑ Y ❑ N❑
WCIER PICATIE OP IiXENP(ION FROM WORKERS' - PERMIT ISSUANCE 10.00 FLOOD ZONE A.L.uc.
LU 5; COIIPIENSATION INSURANCE PLG.CONTE. LIC.NO. PLG.
CL O (This section need not be completed if the permit is for One TOTAL V F] E] [D E]
:D Z hundred dollars(5100)or less)'
U O 1 certify flint in the performance of the work for which this PCr- OTY. MECHANICAL PERMIT FEE FEE SUMMARY
LL U mit is issued,I shall not employ any person in any manner so as to
become subject to the W'orkeri Compensation Laws of California.
DID Dna Applicant ALTER OR ADD TO MECH. 5.00 BUILDING
} m NOTICE TO APPLICANT': If,atter making this Certificate of Ex-
F Z emmption,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 ITO 10=C.F.NL) 4.00
CONSTRUCTION LENDING AGENCY AIRHANDLING UNIT(OVER IQOOOC.F.M.) 6.00 SEISMIC FEE .
1 hereby affirm that there is a construction lending agency for EXHAUST HOOD )WITH DUCT) 5.00
the performance of the work for which this permit is issued(Sec. MICROFILM
3097,Civ.C.L HEATING UNIT(TO 100,000 B.T.U.) 8.00
Lender's amNne
Lender's aness U.)HEATI NG UNIT(OVER 100,000 B.T. 9.50 - ELECTRIC
1 certify that I have read this application and state that the above VENTILATION FAN (SINGLE) 4.00
information n correct. I agree to comply with all city and courtly PLUMBING
ordinances formatio and state laws relating to building construction, and BOILER-COMP(3 H.P.or 100,000 B.T.U.) 6.00
herchy authoritc representatives of this city In enter upon the
utiuBOILER-COMP IOver 100,000 BTU)SEE FEE SCH. MECHANICAL
ve-mentioned property for inspection purposes.
(WC) agree to save• indemnify and keep harmless the City of MISC.- REFER TO ORD.
Cupertino against liabilities,judgments. costs and expenses which CONST.TAX
[,ly it any w' ace against said City in consequence of the PERMIT ISSUANCE 10.00
o n of er MECH.CONT. LIC.NO. MECH.TOTAL ' TOTALgnator of pPlcant Contractor a[
INSPECTOR COPY