09527APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
BU LDI NG PROJECT I DENTI FICATI ON
APPLICATION &PERMIT
BUILDING - ELECTRICAL -PLUMBING -MECHANICAL
PERMIT NUMBER
09527
UIL E
A,DRENc
Bss
E
NAME tyq��"
PHONE ECJ /)_i(1
OTy- ELECTRIC PERMIT FEE
PLAN CHECK VALIDATION
DATE OF APPLICATION
NAME C R
ilg. rvo.
OUTLETS-SWITCHES-RECEP 10.00/1.00
LIGHTI NG FI XTU RES 10.00/1.00
ADDRESS
PHONE 1
APPLIANCES - RESIDENTIAL 4.00
PANELS 10.00
Anent le i
OR T
ENGINEER
LIC. NO,
PANELS (OVER 200 AMP) 20,00,
PLAN CHECK FEE P.C. NO.
SIGNS TRANS. 3.00
ARCH, Ess Erva
ZIP
SPECIAL CIRCUIT 5,00
PERMIT JN
W
AUG`.
G 23 1985
J
City of Cupertino
ISSUANCE GATE
BLDG. ELECT. PLG. MECH.
❑ ❑ ❑
EMP. METER OR POLE INS. 20.00
APPLICANT
MOTORS v SEE FEE SCH.
SERVICE CHANGE 20.00
LICENSED CONTRACTORS DECLARATION
1 hereby affirm that I am licensed under provisions of Chapter 9
'(commencing with Suction 7000) Of Division 3 of the Business ant]
Prot"soI15 C.I and my license is in full force and effect.
Licim Cl ss Lie. Number 9 P �r1
/R
Date(( Contractor-
OWNER -BUILDER DECLARATION
I hereby affirm thol I um exempt from the Contractor's License
Law for the following reason. (Sea 7031.5. Business and Professions
Code: Any city or county which requires a permit to construct, alter,
improve, demolish, or repair any shucture, Prior to its issuance, also
requires the applicant lot such permit to file a signed statement that
he is licensed pursuant to the provisions of the Contract.,', License
Law (Chapter 9 (commencing with Section 7000) of Division 3 of the
Business and Professions Code) or that he is exempt therefrom and
the basis for the alleged exemption. Any violation of Section 7031.5
by any applicant fora permit subjects the0N.); um toacivil penalty
of not more than or permitp li
dollars ( he applicant
❑ I, as owner of the property, or my employees with wages as
limit sole cam P'nsation, will do the work, and the ILmeture is not
intended or oll'cred for sale ISec. 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 it such work
himself or though his we employees, provided that such Inpuovc-
ments are not intended or offered for sale. If, however, the building
or improvement is sold within one year of completion, the owner-
builder will have the burden of proving that lie did not build or int-
Prove for purpose of sale.).
I, as owner of the property, am exclusively contracting with
licensed contract.,, to construct file p ject (Sec 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
contracts forsuch projects with a contractor(,) licensed pursuant to
the Contractor's License Law.
O l xnh exempt under See-, B.&P.C. for this
reason
TEMP. POLE 30.00
BUILDING PERMIT
INFORMATION
MISC. - REFER TO ORD
PERMIT ISSUANCE10 00
VALUATION
$/FT.
ELEC. CONTR. LIC. NO,
ELEC.
TOTAL
PERMIT TO
QTY- PLUMBING PERMIT FEE
ALTER-DRAIN-WATER(EA.) 5.00
STORIESYpE
CONSTR.
BACK FLOW PROTECT. DEVICE 4.00
OCC. GROUP
RES. UNITS
DRAINS -FLOOR, ROOF, AR EA, COND. 5.00
FIXTURES - PER TRAP 5.00 QO
GAS- EA. SYSTEM- 1 INC.4 OUTLETS 6.00 00
SO. FT. FLOOR AREA
TOTAL ACREAGE
_
GAS - EA. SYSTEM - OVER 4 (EA.) 2.00
BUILDING USE
E IN ❑N ❑ El
ASSESSORS PARCEL NO.
INDUSTRIAL WASTE INTER. 30.00
LAWN SPRINKLERS - 1 INC 5 00
V.B. . .
LAWN SPRINKLERS - OVER 5 (EA.) 1.00
SEWER -SANITARY -STORM EA. 200ft/10.00 UO
TRACT NO.
PARCEL NO.
WATER HEATER W/VENT 6.00 f OO
Owner Date
WORK ERS'C'OMPENSATION DECLARATION
I hereby affirm that I have a certificate of consent to wIf-insure,
or a Certificate of Workers' Compensation Insurance, or a certified
copy thereof(Sce. 3800, Lab.C.L
Policy No. Company
WATER SYSTEM 5.00 OD
ACC. DATE
ACC. FILE NO,
WATER TREATING EQUIP, 5.00
ZONING
ENG. SITE NO.
MISC.- REFER TO ORD,
AlCertified copy is hereby furnished.
Certified yoPy le filed with the city inspection division.
pena I'r �•� ,� g/3
FIRE SPRINK
YF] N[:]
ENERGY TQ4
Y❑ IN
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(This section need Be, be completed if the permit is for one
hundred dollars IS 100) or less J
I certify that in the performance of the work for which this per.
mit is issued, I shall not employ any person in any manner so as t.
bsconne subject to the Workers' Compensation Laws of California.
Date -Applicant
PERMIT ISSUANCE 10.00 OU
FLOOD ZONE
Y ❑ N �
A.L.U.C.
Y [] IN
PLG. CONTR, LIC. NO.
PLG
TOTAL 00
QTV MECHANICAL PERMIT FEE
FEE SUMMARY
BUILDING
ALTER OR ADD TO MECH. 5.00
NOTICE '1'0 APPLICANT: If, after making this Certificate of Ex-
emption, yon should become Subject to the Workers' Compensation
provisions of the Labor Code, you must forthwith comply with
such provisions or this permit shall be deemed revoked.
CONSTRUCTION L17NDING AGENCY
I hereby affirm that there is a construction lending agency for
the performance of the work fur whiclh this permit is issued (See.
3097, Co.C).
Lender's Name
Lender's Address
I certify that I have read this application and state that the above
information is correct. I agree to comply with all city and county
....finances and state Taws relating to building construction, anA
hereby authorize representatives this Clty to enter upon th°
above-mentioned property for inspecection purposes.
(We) agree to save, indemnity and keep harmless the City of
Cupertino against liabilities, judgments, costs and expenses which
may in any w accrue against Yid City in consequence of the
granting I'this clout.
_ APPLIANCE 5.00
PLAN CHECK
FEE
AIR HANDLING UNIT (TO 10MC.F.M.) 4.00
AIR HANDLING UNIT (OVER 10MC.F.M.) 6.00
SEISMIC FEE
EXHAUST HOOD (WITH DUCT) 5.00
MICROFILM
HEATING UNIT ITO 100,000 B.T.U.) 8.00
HEATING UNIT (OVER 100,000 B.T.U.)9.50
ELECTRIC
VENTILATION FAN (SINGLE) 4.00
BOILER-OOMP(3 H.P. or 100,000 B.T.U.) 6.00
PLUMBING
OU
g0I LER-COMP One, tXL... BTU) SEE FEE SCH.
MECHANICAL
MISC. - REFER TO ORD.
PERMIT ISSUANCE 10.00
CONST. TAX
MECH. CONT. LIC. NO.
MECH.
TOTAL
TOTAL
Sh c AppBcunt/ ontoWIN, Uate-
INSPECTOR COPY