8595 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
• , BU LDI NG PROJECT I DENT]FICATI ON - PERMIT NUMBER
aDILDING APPLICATION & PERMIT
ADDRESS
2oboJ BUILDING -.ELECTRICAL-PLUMBING-MECHANICAL • 8595
Lo
OWNER'S PLAN CHECK VALIDATION
AME CITY. ELECTRIC PERMIT FEE
? RLfrrJ� A$/OC" PHONE
CONTRACTS
NAME 4l6-(o 6-Lha7- fJdeOUTLETS-SWITCHES-RECEP 10.00/1.00
uc.N LIGHTING FIXTURES 10.00/1.00 S-
f-ONTRACTOR'S
�• AOOREss U PPLIANCES-RESIDENTIAL 4.00
�1J ICVJ PHNf PANELS 10.00 DATE OF APPLICATION
OgcloTec -
PANELS (OVER 200 AMP) 20.00 PLAN CHECK FEE P.O.NO.
ENGINEER
LIC.NO. SIGNS TRANS. 3.00
ARCH.OR ENG, - PERMIT VALIDATION
ADDRESS SPECIALCIRCUIT 5.00
ZIP EMP. METER OR POLE INS. 20.00 _
APPLICANT'S - MOTORS'?•-IL _S- SEE FEE SCH.
APPLICA
DDRESS -
O O 8 N. EV /� jl - SERVICE CHAN E 20.00
, 00 LICENSED CONTRACTORS DECLARATION - TEMP.POLE 30.00
¢ o U I hereby affirm that I am licensed under provisions of Chapter 9 '� R K l.V ISSUANCE DATE
¢ T (commencing with Seotion 7000)of Division 3 of the Business and
Ci ¢ y 7 BLDG. ELECT. PLG. MECH.
H y z Professions CoJc, nd�y license is in full forceuy �
zom Date--Class Car Number JEl El El
O z H ° Date_ Contractor MAY
tt�� •I p
M Y Ems' MAY 8 - 1985 - BUILDING PERMIT -
¢ ¢ ¢ OWNERBUILUF D ARATION
o it v INFORMATION
x 3: ¢ H I hereby affirm that I am ex t from the Contractor,License . MISC.- REFER TO ORD
so .. o J Law for the following reason.(Sec.7031,5.Businessand Professions o npertino .1&00 VALUATION S/FT.
H _ PERMIT ISSUAN I
Ew12 improve,
demolish,
countywhichrequtresa permit its issuance,
hcq
to ¢ ¢ o improve,demolish,or repair any structure,prior to its issuance,also ELEG CONTR. LIC.N0. ELEC. �7
O oc requires the applicant far such permit to File a signed statement that Y L TOTAL /.S PERMIT TO
wAs he is licensed pursuant to the provisions of the Contractors License /
r ¢ Q Law(Chapter 9(comerencie,with Section 7000)of Division 3 ofthe
E 4 o Business and Professions Code)or that he is exempt therefrom and CITY. PLUMBING PERMIT FEE ' /
¢ r$ the basis for the alleged exemption.Any violation ofSection 7031.5 1 STORIES TYPE CONSTR.
agby any applicant for a permit subjects the applicant to a civil penalty ALTER-DRAIN -WATER (EA.) 5.00
of not more than five hundred dollars($500f),
❑ h 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 or improves thereon,and who does such work FIXTURES-.PER TRAP 5.00 SO.PT.FLOOR AREA TOTAL ACREAGE
menta are not hrough
ownemployees,for sale.
if,ed ever,the
improve- GAS-EA.SYSTEM-1 INC.4 OUTLETS 6.00
meats are not intended or offered for sale.IL however,the building
or improvement is sold within one year of completion,the owner- GAS-EA.SYSTEM-OVER 4 (EA.) 2.00
builder will have the burden of proving that he did not build or im- BUILDING USE
prove for purpose of sale.). INDUSTRIAL WASTE INTER. 30.00 RES IND CON Pe Omer
❑ 1,as owner of lire properly,am exclusively contracting with ❑ ❑ ❑ ❑ ❑-•
licensed contractors to 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 ao owner of property who builds or improves thereon,and who LAWN SPRINKLERS-OVER 5(EA.) 1.00
contracts for such projects with a contractods)throwd punuant to SEWER-SANITARY-STORM EA.2008/10.00
the Contractor's License Law. TRACT NO. PARCEL NO.
❑ I am exempt under Sec. .B.&P.C.1'or this WATER HEATER W/VENT 6.00
reason
Owner - Date WATER SYSTEM 5.00 ACC.OATE ACC.FILE NO,
WORK ERS'COMPENSATION DECLARATION WATER TREATING EQUIP. 5.00
1 hereby allirri that I have a certificate ofconsent to self-insure.
or a cel ificate of Workers'Compensation Insurance,or a Certified ZONING ENG.SITE NO.
copy thereof(Sec.3800.Lab.C.L
lam' Policy No. - Company
O D Certified copy is hereby furnished. FIRE SPRINK ENERGY T 24
Z qZZ 1*9'CertYe copy is filed with the city inspection division. MISC.- REFER TO OR D.
-•CI Applicant Y ❑ N❑ Y ❑ N❑
cc w _RTIPICATE OP I?XEMPTION FROM WORKERS' PERMIT ISSUANCE 10.00 FLOOD ZONE A.L.0 G
W - COMPENSATION INSURANCE. PLG.CONTR. LIC.NO, PLG.
CL Z m
(This section need not be completed if the pern [:]il'is for one TOTAL Y N❑ Y[:] ❑
N
hundred dollars IS 100)or less.)
U O 1 certify that in the performance of the work for which this per C,TY. MECHANICAL PERMIT FEE FEE.SUMMARK
LL F- mit is issued,I shall not employ any person in any manner so as to
Ow become subject to the Workers'Compensation Laws of California. BUILDING
CL Datc Applicant ALTER OR ADD TO MECH. 5.00
} N NOTICE TO APPLICANT: If,after making this Certificate of Ex" .
entption,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 10=C.F.M.) 4.00
CONSTRUCTION LENDING AGENCY AIR HANDLING UNIT(OVER IOAOOC.F.M.) 6.00 SEISMIC FEE
I 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.). HEATING UNIT(TO 100,000 B.T.U.) 8.00
Lender's Name HEATI NG UNIT(OV ER 100,000 B.T.U.)9.50 7�-7 Ser
Lender's Address ELECTRIC dd
1 certify that 1 have read this application orad state that the above VENTILATION FAN (SINGLE) 4.00
ordinances n correct. I agree to comply with all city and county PLUMBING
ordinances and stain laws relating c m building l city and c, and BOILER-COMP(3 H.P.or 100,000 B.T.U.) 6.00
hereby authorize representatives of this city to enter upon the BOILER-COMP Over 100,0008TU)SEE FEE SCH. MECHANICAL
above-mentioned property for inspection purposes.
.(we) agree to save, indemnity 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 City in consequence of the PERMIT ISSUANCE 10.00
gra of[his
per
it . MECH.CONT. LIC.NO. TOTAL
-� TOTAL
Signa reof Applicant/Contractor Date -
OFFICE COPY
I