9264 (2) APPLICANT TO FILL IN INFORMATION WIT IN RED LINES - USE BALL POINT PEN ONLY
BUILDING PROJECT IDENTIFICATION PERMIT NUMBER
BUILDING APPLICATION & PERMIT
ADDRESS
/D2� B NG - ELECTRICAL-PLUMBING-MECHANICAL 9264
g..?%
PLAN CHECK VALIDATION
QTY. ELECTRIC PERMIT FEEorvE OUTLETS-SWITCHES-RECEP 10.00!1.00i sec.No.J LIGHTING FIXTURES 10.00/1.00
Jpy/ PPLIANCES-RESIDENTIAL4.00
PHONE PANELS 10.00 DATE OF APPLICATION
sr
OR PANELS (OVER 200 AMP) 20.00 PLAN CHECK FEE P,C.NO.
ENGINEER
LIC.NO SIGNS TRANS. 3.00
ARCHESS OR ENG. SPECIAL CIRCUIT 5,00 PERMIT VALIDATION
ZIP EMP.METER OR POLE INS. 20.00 A
AMOTORS - SEE FEE SCH. p^�D
ADDRESS rs ADDRESS
SERVICE CHANGE 20.00 JUI
w o o LICGNSED CONTRACTORS DECLARATION TEMP.POLE 30.00 ` 12 1985
a v w I hereby affmn That I am licensed under provisions of Chapter 9 ISSUF Q^TE,
m (colmnencing with Section 7000)of Division 3 of the Business and
G w BLDG. ELEC .
r m z Professions Code,and mill ease is in full fore nd effscL M1
Z, o m - License Class_.C.�_� Lic.Number Ge l
4 I-w Date Contractor
¢ y f
BUILDING,PERMIT
¢ ¢ a OWNER-BUILDER DECLARATION
A o a u INFORMATION
w3 LL H 1 hereby affirm that 1 um exempt from the Contmclor's License MISC.- REFER TO ORD
u_ Ov, Law for the following reason. 7031.5.Businessand Professions pERMIT ISSUANCE 10.W VALUATION $/FT.
Code:Any city or counly which requires a pernin to consmmt,xlter
¢ Q p improve,demolish,or repair any structure,prior to its issuance,also ELEC.CONTR, LIC.NO. ELEC.
iL DLL requires the applicant fur such permit to file a signed statement that TOTAL ERMIT TO
w m he is licensed pursuant to the provisions of Cunmelon's License -
z ¢ Law(Chapter 9(commencing with Section 7000)of Division 3 ofthe
4 D Business and Professions Code)or that he is exempt therefrom and OTY. PLUMBING PERMIT FEE
¢ H p the basis for the alleged exenpllion.Any violalion of Section 7031.5 ST RIES PE CONSTR.
u ;m by any applicmv for a permit subjects lheapplicanl to civil penally
of not more than five hundred dollars($500).1: ALTER-DRAIN& VENT-WATER (EA.) 5.00
❑ I,as owner of we property,or my employees with wages us BACK FLOW PROTECT. DEVICE 4.00 OCC.GROUP RES.UNITS
their sole compensation,will do lire work,and Um sl ruclure is not
intended or offered for sale (Sec. 7044, Business and Professions DRAINS-FLOOR,ROOF,AREA,COND. 5.00
Code: The Conoactoi s Li vu,,Law docs not apply to an owner of
Property Who guilds or improves[hereon,and who does such work FIXTURES-PER TRAP S.OD SQ FT.FLOOR AREA TOTAL ACREAGE
himself or through his own employees,provided Ihm such improve-
ntcutsarenorintendedorofferedIn,sale.If,however the building GAS-EA.SYSTEM-1 INC.4 OUTLETS 6.00
or improvement is sold within one year of completion, the owner- GAS-EASYSTEM-OVER 4(EA ( 200
builder will have the burden of proving that he did . . .
not build or ire- BUILDING USE
prove for purpose of,ec). INDUSTRIAL WASTE INTER. 30.00 RE IND CON PB Other
Ba
❑ I,as owner of lire property, l exclusively erm Uncliny with ❑ ❑ ❑ ❑
licensed contractors of construct the Prgfeet(Sec. 7044,Business LAWN SPRINKLERS-1 INC 5 V.B. 6.00 ASSESSORSPARCELNO.
and Professions Code The Contractor's License Law does not apply
to an owner of properly w90 builds or improves thereon,and who LAWN SPRINKLERS-OVER 5(EA.) 1.00
contracts for such projects with a contractors)licensed pursuant to
the Contractor's License Law, SEWER-SANITARY-STORM EA.200ft110.00 TRACT NO. PARCEL NO.
❑ lam exempt under Sec. ,0.&I'.C.lix this WATER HEATER W/VENT 6.00
reason
Owner Dale WATER SYSTEM 5.00
ACC.DATE ACC.FILE NO.
WORK ERS'COMPISNsn'1'ION DECLARATION
WATER TREATING EQUIP. 5.00
I hereby affirm that I have a certificate ofconsent to self-insure. ZONING „ ENG.SITE NO.
or a certificate of Workers'Compensation Insurance,or a certified
copy thereof(Sec.3800.La b.C.). t
Policy No. Company
O ❑ Certificate.p here Urn' It. FIRE SPANK ENERGY T 24
Z 2 Uy�tificd p l l the itY' nspemion division.
O Aub 1,aa, 6' e �.v- - MISC.- REFER TO ORD. Y❑ N❑ Y ❑ N❑
LO CERTIFICATE OF EXEMPTION FROM WORKERS' PERMIT ISSUANCE 10.00 FLOOD ZONE A.L.U.C.
W > COAIPI�NSATION INSURANCE PLG.CONTR. LIC.NO. PLG.
d V❑ N❑ Y ❑ N❑
o (This section need not be Completed if the permit is for one TOTAL
:D Z hundred dollars IS 100)or less.)
U O 1 certify that in the performance of(be work for who this per. CITY. MECHANICAL PERMIT / FEE FEE SUMMARY
LL I- ntil is issued,I shall not employ any person in any manner so as to
O w become subject m the W'orkers'Compensation Laws of California. BUILDING
OL [)arc Applicant' ALTER OR ADD TO MECH. 5.00
} m NOTICE '1'0 APPLICAMI': If,after making this Certificate o�Qk,-
F Z emption,you should become subject to the Workers'Cumpeasa(ion APPLIANCE 5.00 PLAN CHECK
provisions of the Labor Code, you most forthwith comply with FEE .
U such provisions or this permit shall be deemed revoked. AIR HANDLING UNIT(TO 10SMCF,M)' 4.00
CONSTRUCTION LENDING AGENCY AIRHANDLING 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 NamAddr HEATING UNIT(OVER 100,000 B.T.U.)9.50
Lender's Address ELECTRIC
I certify that I have read this application and state Him the above VENTILATION FAN (SINGLE) 4.00
information is correct. I agree to comply with all oily and manly PLUMBING
ordinances and stale laws relating to building construction, 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 10000OBTU)SEE FEESCH. MECHANICAL
above-mentioned properly for inspection purposes.
(We) agree to saw, indcomify and kccp harnilo, the City of MISC.- REFER TO ORD.
Cupertino against liabilities,judgments, coals and "Perot,which PERMIT ISSUANCE 10.00 CONST.TAX
may i any way accrue gains) said City in ronscquence of the
grat ng f illi nil. MECH.CONT. LIC.NO. MECH.
„ y TOTAL TOTAL
S •na co ,M wail.- tractor D' c '
INSPECTOR COPY