8529 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
BUI LD1 NG PROJECT I DENTI FICATI ON PERMIT NUMBER
BUILDING - APPLICATION & PERMIT 58529
ADDPE55
BUILDING-ELECTRICAL-PLUMBING -MECHANICAL
los PLAN CHECK VALIDATION
NAME DTV. ELECTRIC PERMIT FEE
/. 4�.. PHOrvE
name " T Rs OUTLETS-SWITCHES-RECEP 10.00/1.00
Q LIC.No. 45�/'1 LIGHTING FIXTURES 10.00/1.00
AT ACfoR's
AD - -DRESS PPLIANCES-RESIDENTIAL 4.00 II
AONA
L
OR E /A -� I PANELS 10.00 DATE OF APPLICATION
aCHTET " PANELS (OVER 200 AMP) 20.00 s PLAN CHECK FEE P.C.NO.
ENGINEER
LIC.No. SIGNS TRANS. 3.00
aRCH.OR ENG. PERMIT VALIDATION
ADDRESS SPECIAL CIRCUIT 5.00 r
ZIP EMP. METER OR POLE INS. 20.00
APPLICANT
Nr$
ADD MOTORS SEE FEE SCH. IJ UN 5
SERVICE CHANGE 20.00 1985
o o_i� LICENSED CON TRACTORS DECLARATION TEMP.POLE 30.00 /r+p1/ ((11' ((������pppp��{{
a Ci ij I hereby affirm that I am licensed under provisions of Chspter 9Z to - C(tfSSLf r1LlEsW(?If�U
(conumcri wilh Section 7000)of Division 3 of the Business and BLDG. ELECT. PLC. MEG .
i Professions Code,and my license is in full force and effect.
z o=- License Class Lic.Number
o m H w Dute Comraclor�_
-�yOL� /v'�-�� BUILDING PERMIT
¢ ¢ w OWNER ILUER DECLARATION INFORMATION
3.e. N I hereby affirm thubl am exempt from the Contractor's License MISC.- REFER TO ORD
S u VALUATION S/FT.
to H u o J Law for the following reason.(Sec.7031.5,Business and Professions /PERMIT ISSUANCE 10.00
0 Code:Any city orl0hlnlY which requires a permit tomnstrmeLalieq
¢ ¢ a 0 improve,demolish,or mpuirmy structure,prim to its issuance,also FLEC.CONTR. LIC.NO. FLED.
O w requires the applicant for such permit to file usigned statement IhaY TOTAL PERMIT TO
A w m w he is licensed persumn to the provisions of the Contractor's License
F z a Law(Chapter 9(commencing with Section 7000)of Division 3 optthe
i D Business and Professions Code)or thatfr
he is exempt thereom and OTY. PLUMBING PERMIT FEE 49f (A
¢ H the basis for the alleged exemption.Any violation of Section 7031'5 STOR E CONSTR.
n ;� by any applicam for a permit subjects the applicant o a civil penalty ALTER-DRAIN -WATER (EA.) 5.00
of not more than five hundred dollars($5001.):
❑ 1,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,COND. 5.00
Code:The Contractor's License Law does not apply to an owner of
property who builds m improves thereon,and who does such work F IXTURES-PER TRAP 5.00 SQ.FT.FLOOR AREA TOTAL ACREAGE
himself or through his own employees,provided that such improve-
ments are not intended or offered for sale.If,however,the building
or imPYovemem,is sold within one year of completion,the owner- GAS-.EA..S�YSTEM_OVER 4 IE_A.I_ _ 2.00 _
' builder will twee the burden of provirig'lhaYhe did not build or ire- _ . .t. - BUILDING USE
prove for purpose ofsale.). INDUSTRIAL WASTE INTER. 30.00 E I IND 'CON' PB 'Other
❑ 1,as owner of the property,am exclusively contracting with ❑ ❑ ❑ ❑
(' licensed contractors to construct the project(Sec. 7044, Business LAWN SPRINKLERS- I INC 5 V.B. 6.00 ASSESSORS PARCEL NO.
and Professions Code:The 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
IH contracts for such projects with a contractons)licensed pursuant to
the Contractor's License Law. SEWER-SANITARY-STORM EA.200ft/10.00 TRACT NO. PARCEL NO.
rea❑onl um uxcmpt under Sec. .B.&1'.C.for this WATER HEATER W/VENT 6.00
Owner Date WATER SYSTEM 5.00 ACC.DATE ACC.FILE NO.
WORKERS'COMPENSATION DECLARATION WATER TREATING EQUIP. 5.00
I hereby affirm that l have acertificate ofconsent to self-insure' ZONING
or a certificate of Workers'Compensation Insurance,or a certified ENG.SITE NO.
hopy thcr AOp�,L .0). �J���a4�'
x r Cr Iii, funu,,H FIRE SPRINK ENERGY T24
Z Z ❑ ,Certified Copy is tiled with the city inspection division.
O
Applicant /(/,n / MISC.- REFER TO ORD. Y ❑ N❑ Y ❑ No
m
CERTIFICATE EXEMPTION FROM WORKERS' PERMIT ISSUANCE 10.00 / FLOOD ZONE AT.U.C.
LL > COMPENSATION INSURANCE PLO.CONTR. LIC.NO. PLG. Y❑ N❑ Y❑ NE]O (This section need not be completed if the permit is for one TOTAL
Z hundred dollars IS 100)or leuJ
UIO I certify that in the perliumance of the work for which this per- DTV. MECHANICAL PERMIT FEE FEE SUMMARY
mit is issued,I shall not employ any person in any runner so as to
LL IF-
U become subject to the Workers'Compensallon Laws of California. -
�' a Date Applicant ALTER OR ADD TO MECH. 5.00 BUILDING
N NOTICE TO APPLICANT: If,after making this Certificate of , -
FI'Z eniption,you should become subject to the Workers'Compensation APPLIANCE '5.00 PLAN CHECK
provisions of the Labor Code, you must forthwith comply with FEE
CJ 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 10=C.F.M.) 6.00 SEISMIC FEE
I hereby affirm that linen is a construction lending agency for EXHAUST HOOD (WITH DUCT) 5.00
the performance of the work for which this Perot it is issued(Sec. MICROFILM
3097,Civ.C.). H EATING UN IT(T0.100,000 B.T.U.) 8.00
Lenders Name HEATING UNIT(OVER 100,000 B.T.U.)Lender's Names ELECTRIC
I certify that I have read this application and state that the above VENTILATION FAN (SINGLE) 4.00
information is correct. I agree to comply with all city and county PLUMBING
ordinances and stale laws relating to building construction, and BOILER-ODMP(3 H.P.or 100,000 B.T.U.) 6.00 r 0(J
hereby authorize representatives of this city to enter upon the BOILER-COMP (Over 100,000 BTU)SEE FEE SCH. MECHANICAL
above-mentioned properly for inspection purposes.
(We) agree to save, indemnify and keep harmless the City of MISC.- REFER TO ORD.
Cupertino against liabilities,judgments„costs aoll expenses which PERMIT ISSUANCE 10.00 CONST.TAX
may in.any way accrue against said City in Consequence of the
granting f this permit. t' MECH.CONT. LIC.NO, MECH.
TOTAL TOTAL
N /
Signal eb(A hca t/ ontram r U /(/
1 INSPECTOR COPY L