9155 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES'- USE BALL POINT PEN ONLY
BU I LDING PROJECT IDENTIFICATION PERMIT NUMBER
ADIL.ING APPLICATION & PERMIT 9155
GORE as BUILDING-ELECTRICAL-PLUMBING -MECHANICAL
OWNER a PLA K VALIDATION
NAME - OTY- ELECTRIC PERMIT FEE
PHDNE JUN
181985
®' NAME ncroa , UTLETS-SWITCHES-RECEP 10.00/1.00
94 0 UC.No. LIGHTING FIXTURES 10.00/1.00 City Of Cupertino
r, o 'S APPLIANCES 4.00
ADDRESS
REss '
_ PHONE PANELS 10.00 DATE OF APPLICATION
- A L R r
OR PANELS (OVER 200 AMP) 20.00 PLAN CHECK FEE D.C.NO.
ENGINEER
uc.No. SIGNS TRANS. 3.00
ARCA,os ENG. SPECIALCIRCUIT 5,00 PERMIT VALIDATION
ZIP EMP.METER OR POLE INS. 20.00
APPIL MOTORS SEE FEE SCH. I
ADDRESS V ( '
SERVICE CHANGE 20.00
61
02 LICHNSTi DCON'r RACTORS DECLARATION TEMP.POLE 30.00
a o v I hereby affum Thal I am licensed under provisions of Chapter 9 ISSUANCE DATE
h Q (commencing u'itlt Section]000)of Division 3 of the Business and BLDG. ELECT. PLG. MECH.
H m0. Professions Code,and my license is in full force and effect.
Q i u o license Class-�• f.0..__Lic Number ❑ ❑
H m H j Datc6 .�_r�Cmnmctor �t
a mBUILDING PERMIT
a w a OWNER-BUILDER DECLARATION INFORMATION
0 t 0 MISC.- REFER TO ORD
w 5 u w 1 hereby ul'linn that I um exempt from the Contractor s License VALUATION E/FT.
HLLo J Law for the following reason.(Sec.]03LS.Business Professions PERMIT ISSUANCE 10.00 V'
Code:Any city or county which esquires a permit to const'nin alteq
EE Q Q Approve,demolish,or repair any structure,prior l0 Its Issuance,also ELEC.CONTR. LIC.NO. ELEG
O ¢ requires the applicant for such permit to file a signed statement that 0 TOT PERMIT TO
P w es he is licensed pursuant to the provisions of the ComrtCtor's License
FZQ
Law(Chapter 9(commencing with Section 7000).1Division 3 ofthe V I.
E i O Business and Professions Code)or first he is exempt therefrom and QTY. PLUMBING PERMIT FEE YJE•�
ti o the basis for the alleged exemption.Am, violation of8ecflon 7031.5 STORIES TYPE CONSTR.
by any applicant for a permit subjects the applicant to d civil penalty gLTER-DRAIN -WATER IEA.) 5.00
of not more than five hundred dollars(5500).):
❑ I,as owner of lire properly,or myemployees with wages as BACK FLOW PROTECT. DEVICE 4.00
their sole compensation,will do the work,and the structure is not OCC.GROUP RES-UNITS',,
intended or offered for sale(Sec. 7044, Business and Professions DRAINS-FLOOR,ROOF,AR EA,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,FT.FLOOR AREA TOTAL ACREAGE
himself mentsare not
hde ownemployees,for sale.
if,however,
the
improve- GAS-EA.SYSTEM-11NC.40UTLETS 6.00'
menet are not intended or offered for sale.If,ed that the building
or improvement is sold within one year of completion,fire owner- GAS-EA.SYSTEM-OVER 4 (EA.) 2.00
builder will have the burden of proving that he did not build or int- BUILDING USE
prove for purpose of sale.). INDUSTRIAL WASTE INTER. 30.00 R IND CON PB Omer
❑ I,as owner of the property,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 PoRessions Code:The Contractor's License Law does not apply
to an owner of property who builds or improves thereon.and who LAWN SPH I N KLERS-OVER 5 (EA.) 1.00
contracts for such projects will,a contract.,(.,)licensed pursuant 10
the Contractor's License Law. SEWER-SANITARY-STORM EA.2006/10.00 TRACT NO. 'PARCEL NO.
❑ I am exempt under Sec. ,B.&P.C.for Wit WATER HEATER W/VENT 6.00 s'
sawn
Owner Date WATER SYSTEM 5.00 •1.
ACG DATE ACC.FILE NO.
- WORKERS'COMPENSATION DECLARATION WATER TREATING EQUIP. 5.00
1 hereby affirm But I have a certificate of consent to selbi.sure.
or a certificate of Workers'Compensation Insurance,or a certified
ZONING ENG.SITE NO.
copy fhereol- Sce.3800,Lab.C.).
Policy No. Company
O ❑ Cetlilied copy is hereby furnished. FIRE SPRINK ENERGY T 24
Z Z ❑ Certified copy is filed with the city inspection division. MISC.- REFER TO ORD.
O Applicant Y❑ N❑ Y ❑ N❑
CC CER'I'IFICAI'Ii OF EXEMPTION FROM WORKERS' PERMIT ISSUANCE 10.00 FLOOD ZONE A.L.UC.
LU > COMPENSATIONINSURANCE PLG.CONTE, LIC.NO. PLG.
CL Z ('Phis section need not be completed it'The permit is for one TOTAL Y E] NE) Y [D NE]
hundred d.11ms($100)or cSO
U O I certify that in the performance of the work for which this per, OTY. MECHANICAL PERMIT FEE FEE SUMMARY
LL F ,,it is issued,I shall not employ any person in;Ary ommv,us a.,io
U become subject to the Workers'Compensation Laws of California.
U y Dates Yn.�FAPplicant ALTER OR ADD TO MECH. 5.00 BUILDING
} W NOTiCIi TO PPLICAN'T: If,15fw m 'in tis Cy ti icme of lix-
Z emption,you should become subject to the Workers'Comprnsation APPLIANCE 5.00 PLAN CHECK
Provisions of the Labor Code, you most forthwith comply with FEE
U such provisions or this permit shall he deemed revoked. AIR HANDLING UNIT(TO 10MOC.F.NL) 4.00
CONS'rRUCr1ON LENDING AGENCY AIR HANDLING UNIT(OVER IQOOOC.F.M.) 6.00 SEISMIC FEE
- I hereby affirm that there is a consirucfion lending agency for EXHAUST HOOD(WITH DUCT) 5.00
fire 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
Lender's Addre HEATING UNIT(OVER 100,000 B.T.U.)9.50 ELECTRIC
ss
1 certify that I have read this application and stale that the above VENTILATION FAN (SINGLE) 4.00
• in fonnutun, is n11,11. I agree t.comply with all city and county PLUMBING
(3
ordinances and state laws relating to building construction, and BOILER-COMPH.P.or 100,000 B.T.U.) 6.00
hereby arrthorDe representatives of this city to enter upon the BOILER-COMP (Over 100,000 BTLD SEE FEE SCH. MECHANICAL
above-mentioned property for inspection purposes.
(WC) agree to save, indemnify and keep harmless the City of MISC.- REFER TO ORD.
Cupertino against liabilities,judgments, costs :mil expenses which CONST.TAX
may in any way accrue against said City in consequence of The PERMIT ISSUANCE 10.00
granting of this Penni[. MECH.CONT. LIC.NO. MECH.
OTAL TOTAL �J�
air
Sig t t e p ca r OV' D,t ''�11 �I
INSPECTOR COPY