9270 (3) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
BUILDING PROJECT IDENTIFICATION PERMIT NUMBER
BUILDING APPLICATION & PERMIT
ADDRESS _
DING - ELECTRICAL-PLUMBING-MECHANICAL 9270
OWNER'S PLAN CHECK VALIDATION
rvnmE OTY. ELECTRIC PERMIT FEE
PHONE
NAMpRAcroRs OUTLETS-SWITCHES-RECEP 10.00/1.00
. LD.NO. LIGHTING FIXTURES 10.00/1.00
co TRAC .0
, APPLIANCES 4
ADDRESS
J
all
PHONE q PANELS 10.00 DATE OF APPLICATION
/j{ ARCHI C PLAN CHECK FEE P.C.N0:1
_ PANELS (OVER 200 AMP) 20.00
ENGINEER k�"t?
LIC.NO. SIGNS TRANS. 3.00
aADDREOR SS zea SPECIAL CIRCUIT 5.00 PERMIT VALIDATION
EMP.METER OR POLE INS. 20.00
PAID
A 'Wfs - MOTORS SEE FEE SCH.
ADDRESS
SERVICE CHANGE 20.06 JUL. 121988
° TEMP.POLE 30.00
F o LICENSED CON DECLARATION
I hereby affirm that I an,licensed under provisions of Chapter 9t 155 T4 t
w< w '(commencing with Section 7000)of Division 3 of the Business and I / - BLDG. ELEC L .
H w Professions Code,and my license is in full force and effect. -
z0m
Q /W License Class E-IV Lit.Number 154g4p
r Date !9 Contctor.
• I �s ra
a , X
BUILDING PERMIT
2 0 w OWNER-BUILDER UL'CLA RATION INFORMATION
E:
°a H1 hereby affirm that I an.exem t lion. the Contractor',License MISC.- REFER TO ORD
3 u y y 4 P VALUATION
F u O j Law for the following reason.(Sect 7031.5.Business and Professions PERMIT ISSUANCE 7
m � Code:Any city or County which requires a perm It toconstrucLultaq
2 Q Q improve,demolish,or repair any structure,prior to its issuance,also ELEC.CONTR. LIC.NQ IF
u w ° u requires the applicant for such permit to file a signed statement that TOTAL PERMIT TO
m m he is licensed pursuant to the provisions of the Contractor's License
H z < Law(Chapter 9(commencingwith Section 7000)of Division3ofthe
Z 4 ° Business and Professions Code)or that he is exempt therefron.and DTV. PLUMBING PERMIT FEE
I- m the basis far the alleged exemption.Any violation of Section 7031.5 STO TYPE CONSTR.
dam _ by any applicant I.,a permit subjects the applicant We.,it penalty ALTER-DRAIN -WATER (EA.) 5.00
of not more than five hundred dollars($500).):
❑ I,as owner of the property,or my enl Ployees with wages as BACK F LOW PROTECT. DEV ICE 4.00 OCC.GROUP RES.UNITS
their sole compensation.will do the work,and the structure is not
intended or offered for sale(Sec. 7044, Business and Professions DRAINSIFLOOR,ROOF,AREA,COND. 5.00
Code:'rhe Contractor's License Law does not apply to an owner of
e, property who builds or improves thereon,and who docs such work FIXTURES-PER TRAP 5.00 SD.FT.FLOOR AREA TOTALACREAGE
menu,
himself or through his own employees,provided that such.improve-
meatsarenotintendedorofferCoyeesa provided
that such
building GAS-EA.SV$TEM-11NC.40UTLETS 6.00
or improvement is sold within one year of con.pletion'the owner- GAS-EASYSTEM OVER 4 (EA.) 200
builder will have the burden of proving that he did not build or im- . - . . BUILDING E
prove lot purpose ofsale.). INDUSTRIAL WASTE INTER. 30.00 RES IND CO PB Other
D I,as owner of the property,am exclusively contracting with ❑ ❑ ❑ ❑
licensed contractor, to construct the project(Sec. 7044,Business LAWN SPRINKLERS- 1 INC 5 V.B. 6.00 ASSESSO)TS FHCEL 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 1
contracts for such projects with a contractions)licensed pursuant to
the Contractor's License Law, SEWER-SANITARY-STORM EA.200ft/10.00 TRACT NO. PARCEL NO.
O I am exempt under Sec ,B.&P.C.for this WATER HEATER W/VENT 6.00
reason
Owmer Date WATER SYSTEM 5.00 ACC.DATE ACG FILE NO.
WORK 17RS'COM PF.NSATION UEC3-ARATION WATER TREATING EQUIP. 5.00 'If -
1 hereby affirm that I have a certificate of consent to self-insure. ZONING
or a certificate of Workers'Compensation Insurance,or a certified ENG.SITE NO.
copy thereof(Set.3800,Lab.C.).
policyNo. Campuny_ �+�-Qod_2Lz"+).g_
O ❑ Ce iifie copy is hereby urni ed. FIRE SPRINK ENERGY T"24
Z Z ❑ Sertifi copy is f e w'1/the city inspection divisiory
O (Applicant +�-�2�5" MISC.- REFER TO ORD. Y❑ N❑ Y ❑ N❑
EC W �/ Cli IPIC -X 1PIION PROM WORKERS' PERMIT ISSUANCE 10.00
FLOOD ZONE A.LU.L.
LU - NI P Ii NS ION INSURANCE PLO.CONTR. LIC.NO. PLG.
CL 0 CL Z (This section need not be completed if the permit is for one TOTAL Y El NEI Y El NEI
hurried doll...($100)or less)
U O 1 certify that in the pertormalice of the work for which this per- OTY. MECHANICAL PERMIT FEE FEE SUMMARY
LL I- mit is issued,I shall not employ any person in any manner so as to
U become subject to the Workers'Con.pensulion Lew%Of California.
0 y Date Applicant ALTER OR ADD TO MECH. 5.00 BUILDING
} U) NOTICE'1'0 APPLICANT It,after making this Certificate of Ex-
? emption,you should become subject to the Workers'Compensation APPLIANCE 5.00 PLAN CHECK
provisions of the Labor Code, you most forthwith comply with FEE
U such provisions or this permit shall be decn.ed revoked. AIR HANDLING UNIT(TO 10)000C.F.NL) 4,00
CONS]RuC'r1ON 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
3t, performance of the work for which this permit is issued(Sec. HEATING UNIT(TO 100,000 B.T.U.) 8.00 MICROFILM
Lender's Name HEATING UNIT(OVER 100,000 B.T.U.)9.50
Lender's Address ELECTRIC
1 certify that 1 have read this application and state that the aboveBOILER-COMP(3 H.P.or 100,000 B.T.U.) 6.00 VENTILATION FAN (SINGLE) 4.00
• information is correct, 1 agree to comply with all city and county PLUMBING
ordinances and state laws relating to building construction, and
hereby authorize representatives of this city to enter upon the BOILER-COMP (Over 100,000BTU1SEE FEESCH. 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 PERMIT ISSUANCE 10.00 CONST.TAX
may in any way accrue against said City in consequence of the
ge"Ung Of is pe... MECH.CONT. LIC.NO. MECH.
\I TOTAL TOTAL
Signature ppt n r stat
INSPECTOR COPY