8535 (3) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
BUILDING PROJECT I DENTIFICATION
PERMIT NUMBER
BUILDING APPLICATION & PERMIT
ADDRESS 535
od
DING-ELECTRICAL-PLUMBING-MECHANICAL
OWNERS PLAN CHECK VALIDATION
NAME TY. ELECTRIC PERMIT FEE
vnorvE
CON TRACTORS UTLETS-SWITCHES-RECEP 10.00/1.00
LIC,No, ILIGHTING FIXTURES 10.00/1.00
r.ONr a oR App LIANCES-RESIDENTIAL 4.00
PHONE - PANELS 10.00
OGATE OF APPLICATION
RRGHIr cr PANELS (OVER 200 AMP) 20.00 PLAN CHECK FEE P.C.NO.
ENGINEER
' LIC.No. SIGNS TRANS. 3.00 P 4i
ARCHEOR ENG SPECIAL CIRCUIT ,- 5:00 1 PERMIT VALIDATION
ADDRSS
ZIP EMP. METER OR POLE INS. 20.00 'JUN 5 19@b
aoonAPPLICANT'a MOTORS SEE FEE SCH. t1
ESSss
SERVICE CHANGE 20.00 .City of Cupertino
o
'09 LICENSED CONTRACTORS DECLARATION TEMP.POLE 30.00
Q u u 1 hereby affirm that I am licensed under provisions of Chapter 9 ISSUANCE DATE
Hz err (commencin g with Section 7000)of Division 3 of the Business and
a A BLDG. ELECT. PLG. MECH
H i I'nsfcssions Col a y license is in full for a
License Claxs Lie Number
r O Date Contractor
a m E BUILDING PERMIT
¢ a 6 IT
DIiCLA ATI
¢o i u INFORMATION
w ; y 1 hereby affirm th t am exempt from the Contractor's License MISC.- REFER TO ORD
Hu0 J Lawforthefollowin eason.(Sec.7031.5.Businessand Professions PERMIT ISSUANCE 10.00 VALUATION $/FT.
y
Code:Any city or county which requires a permit to conMruct'aher.
a p improve,demolish,m repair any structure,prior In its is u15U ELEC.CONTR. LIC.NO. ELEC.
ai or- O ¢ or,mors the ap,heant for such permit to file a signed stah n.0 that TOTAL
w m he is licensed pursuant to the provisions of tire Contractors Liernse PERMIT TO
F z r Law(Chapter 9(commencing with Section 7000)of Division 3 ofthe
a Business and Professions Code)or that he is exempt therefrom and OTY. PLUMBING PERMIT FEE
X I- $ the basis for the alleged exemption.Any violation of SectioR]031.5 5 O TVP CONSTR.
d ; by any applicant for a permit subjects tire applicant penalty ALTER-DRAIN -WATER (EA.) 5.00
of not more than five hundred dollars(55001.1:
❑ I,as owner of the property,or my employees with wages us BACK FLOW PROTECT. DEVICE 4.00 OCC.GROUP RES.UNITS
their sole compensmion,will do the work,and the structure 1s not
intended or offered for sal,(Sce. 7044. Business and P'cl',ssions DRAINS-FLOOR,ROOF,AREA,COND. 5.00
Code 'File 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 50,FT,FLOOR AREA TOTALACREAGE
himself or through his own employees,provided that such improve- GAS-EA.SYSTEM-1INC.4OUTLETS 6.00
mems are not intended or offered for sale.If,however,the building
or improvement is sold within one year of completion,the owner- GAS-EA:PSV STEM=OVER 4'IEA.) }2.00 BUILDING USE
builder will have the burden of proving that he did not build or im- RES IND CON PB Other
Prove for purpose w uh,'), INDUSTRIAL WASTE INTER. 30.00
❑ 1,us owner of the property,ma excl UIively e01111mting with El ❑ ❑ 11 11licensed 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 an owner of property who builds or improves thereon,and who LAWN SPRINKLERS-OVER 5(EA.) 1.00
contracts for such projects with a contmetor(s)licensed pursuant to -
theContructor'sLicenseLaw. SEWER-SANITARY-STORM EA.200ft/10.00 TRACT NO, PARCEL NO.
❑ I am CXCMPI 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(IRKERS'COMPENSA'f ION DECLARATION WATER TREATING EQUIP. 5.00
I hereby affirm that I have a certificate of consent to self-insure, ZONING ENG.SITE NO.
or a certificate of Workers'Compenvtion 11 sumo 0.or a rtified
I copy there If C
Policy No
❑ C° - _ 1 FIRE SPRINK ENERGY T 24
Z Z Certified ecopy is filed with the city inspection division.
F D Int MISC- REFER TO ORD. Y ❑ N❑ Y ❑ .N❑
N CER IIE : E ISXEMPI'ION FROM WOR K Ii RS' PERMIT ISSUANCE 10.00 FLOOD ZONE A.L.U.C.
LU > COMPENSATION INSURANCE PLG.CONTR. LIC.NO. PLG
0 (This Section need not be completed if the permit is for one TOTAL Y❑ IN Y❑ N❑
hundred dollars IS 100)or less.)
U O 1 certify that in the performance of the work for which this per- QTY. MECHANICAL PERMIT FEE FEE SUMMARY
ELL U mit is issued,I Shull not employ any person in any manner so as to
become subject to the Workers'Compensation Laws of California.
u Dat, Applicant BUILDING
} to NOTICE 'FO APPLICANT: If,after making this Certificate of Ex- ALTER OR ADD TO MECH. 5.00
♦- Z emption,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 loch provisions or this permit shall be deemed revoked. AIR HANDLING UNIT(TO l0=CF.NL) 4.00
CONSTRUCTION LENDING AGENCY AIR HANDLING UNIT(OVER 10=C.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 HEATING UNIT(OVER 100,000 B.T.U.)9.50
Lenders Address - 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 slate laws relating to building construction. and BOILER-COMP(3 H.P.or 100,000 B.T.U.) 6.00
hereby authorim representatives of this city to enter upon the 801 LER-COMP (Over 100,000 BTU)SEE FEE SCH. MECHANICAL
above-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 ace against said City in consequence of the PERMIT ISSUANCE 10.00
grant g df this per it, MECH.CONT. LIC.NO. MECH.
TOTAL TOTAL
S Ana o Applict/Contrac or Date
INSPECTOR COPY
I