09645 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
BU I LD ING PROJECT I DENT[FIC I PERMIT NUMBER
BDILDINGAPPLICATION & PERMIT �Q� A
(�
ADDRESS
BUILDING-ELECTRICAL-PLUMBING-MECHANICAL
OWNER'S PLAN CHECK VALIDATION
NAME
® QTY. ELECTRIC PERMIT FEE-
CONTRACTORS /NAME OUTLETS 10.00/1.00
} uc.No. LIGHTING FIXTURES 10.00/1.00
IONTRXCTORS
ADDRESS APPLIANCES RESIDENTIAL 4.00
DORE
FNONE _ � PANELS 10.00 DATE OF APPLICATION
Alf..ORCNrtEa PANELS (OVER 200 AMP) 20.00 PLAN CHECK FEE P.c.NO. -
IENGINEER
LIC,No. SIGNS TRANS. 3.00
ARCHORENG SPECIAL CIRCUIT 5.00 PERMIT VALIDATION
SS
ZIP ITEMP.METER OR POLE INS. 20.00 PAID
APPLICANT$ MOTORS SEE FEE SCH.
aooREss SERVICE CHANGE 20.00 AUG 29 1985 }
Doo LICENSED CONTRACTORS DECLARATION TEMP.POLE 30.00 ♦ tt11Q (���pp��,�{{��p
< u I hereby affirm [hat I am licensed under provisions of Chapter 9 CI lYl y50gWL`Eb'AN��
(commencing with Section 7000)of Division 3 of the Business and
a H BLDG. El PLG. MECH.
z D License H m z Professions Code,and my license is in full force and"effect .e ❑ ❑ ❑
HLicense Class /'t'/CZ-Lia Nom bcr
o y F Dalc_irrL ip. Contractar
a x E �WY��''���� BUILDING PERMIT
¢ ¢ ¢ OWNFR-BUILDER DECLARATION
o a U INFORMATION
w g LL y I heremy arino that 1 am exempt from the Contractors License MISC.- REFER TO ORD
.. Oa Law farthe followingrcason.(See 7031.5,Businessand Professions PERMIT ISSUANCE 10.00 vnwgnON
Code:Any city or eounry which requires a permit to construct,alter,
¢ ¢ Q O improve,demolish,or repair any structure,prior to its issuance,also ELEC.CONTR. LIG.NO. ELEC.
D¢ requires ti he applicant for such permit to file a signed statement that TOTAL ( PERMIT TO
E
m lie is licensed pursuant to the provisions of rhe Contractor's License �/
Law 9(commencingwith Section 7000)of Division 3 ofthe
io Business and Professions Code)or that he is exempt Ihcrrfrom and QTY. PLUMBING PERMIT FEE * Q �'Y F
the basis for the alleged exemplion.Any violation of Section 703L5 STORIES TYPE CONSTR.
u ; by any applicant for a permit subjects the applicant roe civil penally
-of not more than five hundred dollars(5500).): ALTER-DRAIN&VENT-WATER (EA.) 5.00
❑ 1,as owner of Die 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 ar offered for sale(Sec. 7044, Business and Professions DRAINS-FLOOR,ROOF,AR EA,COND. 5.00
Code:'fhe Contractor's License Law does not apply to no owner of
properly who builds or improves thereon,and who does such work FIXTURES-PER TRAP 5.00 SD,FT.FLOOR AREA TOTAL ACREAGE
himself re of intended
his own employees.Provided ev such improve- .
mems are through
ughhis or employeeffered for salerovfdcowevcglhcb...rusg GAS-EA.SYSTEM-11NC.40UTCETS 6.00
or improvement is sold within one year of completion,the owner- GAS-EA.SYSTEM-OVER 4 IEA.) 2.00 eua OtNG USE
builder will have the harden of pmWng tlml he did not build or im-
proveforpurposeofsale.l. INDUSTRIAL WASTE INTER3000 RES IND CON PB GOP,
. .
❑ 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.
andProfessions Code:The Contractor's License Law does not apply
to an owner of property who builds or improves[hereon.and who LAWN SPRINKLERS-OVER 5(EA.) 1.00
contracts lot such projects with a con[ractons)licensed pursuant to SEWER-SANITARY-STORM EA.200ft/10.00
the Contractors License Law. TRACT NO, PARCEL NO.
❑ I am eaeanpr under See ,B.&RC.for[his WATER HEATER W/VENT 6.00
reason
Owner Dare WATER SYSTEM 5.00
ACC.DATE ACC.FILE NO.
WORK ERS'COMPENSATION DECLARATION WATER TREATING EQUIP. 5.00
1 hereby affirm that 1 have a certificate ufconsent to self-insure.
oraeertilicale of Workers'Compensation Inst ranee ora certified ZONING ENG.SITE NO,
copy thereof(See.3800,Lab.C.)/
Policy No. Company
O Ccrtiliedcopy is he by u shed FIRE SPRINK ENERGY 24
Z Z i[.1.Cer[if• p�j EI wlrh [ ry inspection division.
O APPIiclmt A �r� JL, MISC.- REFER TO ORD. Y ❑ N❑ Y ❑ N❑
w CYRTIFICAFE OF EXEMPTION FROM WORKERS' PERMIT ISSUANCE 10.00 FLOOD ZONE A.L.U.O.
LU �_ COMPENSATION INSURANCE PLG.CONTR. LIC.NO. PLG.
a' ❑ ('Phis section need out be completed if the permit is for one TOTAL Y❑ N❑ Y ❑ N❑
2 hundred dollars($IGO)or less.)
U O 1 certily that in tire performance of the work fie which this per QTY. MECHANICAL PERMIT FEE FEE SUMMARY
LL F- our is issued.I shall not employ any person in any manner so as to
U w become subject to Ilse Workers'Compensation Laws of California.
a
Date-Applicant ALTER OR ADD TO MECH. 5.00 BUILDING
} N NOTICE TO APPLICANT: If,after making this Certificate of I',-
r 2 enmrion,you should become subject to the Workers'Compensation APPLIANCE 5.00 PLAN CHECK
provisions of the Labor Code, you must forthwith comply with FEE
U such provisions or this permit shall be deemed revoked. AIR HANDLING UNIT(TO 10MC.F.M.) 4.00
CONSTRUCTION LENDING AGENCY AIR HANDLING UNIT(OVER 10=C.F.M.) 6.00 SEISMIC FEE
I hereby affirm that there is a construction lending agency for EXHAUST HOOD (WITH DUCT) 5.00
the perfiommmvc of the work for which this permit is issued(See MICROFILM
3097,Civ.C.), HEATING UNIT(TO 100,000 B.T.U.) 8.00
Lender's Name HEATING UNIT(OVER 100,000 B.T.U.)9.50
Lender's Andress ELECTRIC
I cenity that I have read this application and state chat DIe abuvc VENTILATION FAN (SINGLE) 4.00 671
information is correct. I agree to comply with all city and county PLUMBING
ordinances and stare laws relating to building construction, and BOILER-COMP(3 H.P.or100,000B.T.U.) 6.00
hereby authorise roperty farcies ec this oily to enter upon ih° BOILER-COMP (Over 100,000 BTU)SEE FEE SCH. MECHANICAL
above-mentioned property for inspection purpoxs.
(We) agree to Save, indemnify and keep harmless the City of MISC.- REFER TO ORD.
Cupertino against liabilities,judgments, costs and expenses which CONST.TAX
may in any way accrue against said City in consequence of the PERMIT ISSUANCE 10.00
grantingaf rispermit. MECH.CONT. LIC.NO. MECH.
J ,,n ��jj�^ l _ TOTAL TOTAL /
5 gnaturc u Ap cant/Con tactor �Z$ate� $a
INSPECTOR COPY