09644 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
BU LD1 NG PROJECT I DENTI FIC - PERMIT NUMBER
BWLDING APPLICATION & PERMIT 09644
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7 4BUI LDING-ELECTRICAL-PLUMBING-MECHANICAL
OWNER'S PLAN CHECK VALIDATION
NAME OTY. ELECTRIC PERMIT FEE
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NAMERAcroBs UTLETS-SWITCHES-RECEP 10.00/1.00
Cuc.No. LIGHTING FIXTURES 10.00/1.00
ADD Ess 04�410 "APPLIANCES 4.00
PHONE PANELS 10.00 n DATE OF APPLICATION
ARC IT cr I
OR PANELS (OVER 200 AMP) 20.00 PLAN CHECK FEE IP.C.NO.
ENGINEER
LIC.No. SIGNS TRANS. 3.00
ARCH OR ENG, SPECIAL CIRCUIT 5,00 PERMIT VALIDATION
SS
ZIP EMP.METER OR POLE INS. 20.00 A
APPLICANT'S MOTORS SEE FEE SCH. �AO�
ADDRESS
SERVICE CHANGE 20.00 AUG 2 9 1985
0 O LICENSED CONTRACTORS DECLARATION TEMP.POLE 30.00
v I hereby ff,. that 1 am licensed under provisions of Chapter 9 CI
a, A w (commencing with Section 7000)of Division 3 of the Business and
Q wBLDG. ELECT. MECH.
F w z Professions Code,end my license is in fall force and effect, ❑ ❑ ❑
z 0 m - License Class C/GL Lie.Number 9/4,[� � ,
o z o Date L/ Contractor-�1_4_ !F '
a m B (LDING PERMIT
of ¢ ¢ OWNER-BUILDER DECLARATION
o d 0 INFORMATION
W 3 m 1 hereby affirm that I aur,exempt from the Contractor's License MISC.- REFER TO ORD
•FLLOJ Law for the following Reason,(See,7031,5,Business and Professions PERMIT ISSUANCE 10.00 VALUATION
as Code Any city or county which requires a permit to construct,alter,
QQ ¢ p improve,demolish-or repair any structure,prior to its issuance,also ELEC.CONTR. LIC.NO, ELEC,
O Mrequires the applicant for such permit to file a signed statement that TOTA PERMIT TO
w he is licensed pursuant to the provisions of the Contractor's License -
H z as f D
Law with Section 7000)oivision 3 ofthe /
e Business and Professions Code)or that he is exempt therefrom and OTV. PLUMBING PERMIT FEE
F ve the basis for the alleged exemption.Any violation of Section 7031.5 TORIES TYPE CONSTR.,
p3m by any applicant for a permit subjects the applicant toacivil penalty ALTER-DRAIN -WATER'(EA.) 5.00
final more than five hundred dollars($500).):
❑ 1,as owner of the property,or my employees with wages as BACK F LOW PROTECT. DEVICE 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 DRAINS-FLOOR,ROOF,AR EA,COND. 5.00
Code:'Phc 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 or throughhis own employees,provided that such improve-
mentsarenollnlended or offercdfor saleif.however,the budding GAS-EA.SVSTEM-11NC.40UTLETS 6.00
or improvement is sold within one year of completion,the owner- GAS-EA.SYSTEM-OVER 4 (EA.) 2.00
builder will have the burden of proving that he did not build or ire- BUILDING USE
prove for purpose ofsele.). INDUSTRIAL WASTE INTER. 30.00 Rs IND CON PB Omer
❑ 1,as owner of tire properly,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 Professions Code:The Contractor's License Low 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 contractors)licensed pursuant to
the Contractor's Licarse Law. SEWER-SANITARY-STORM EA.200ft/10.00 TRACT NO. PARCEL NO.
❑ lam exempt mtdcr See ,B.&P.C.for this WATER HEATER W/VENT 6.00
rea5a11
Owner Date WATER SYSTEM 5.00 ACC.DATE. ACC.FILE NO.
WORKERS'COMPENSAT'ION DECLARATION WATER TREATING EQUIP. 5.00
I hereby affirm that I have a certificate of consent to self-insure. ZONING ENG.SITE NQ
or a certificate of Workers'Compensation Insurance,or a certified
copy thereof(Sec 3500,Lab.C.I -
- Policy No. Company �_�.Sy !S
0 yl Certified copy is herebyfurors d. FIRE SPRINK ENERGY T-24
Z Z. Certified o)+ filed�i�th the/�J'ty inspection division. MISC. - REFER TO ORD.
FZ O Applicant 121_1„ ;ig Y❑ N❑ V ❑ N❑
CC 9, CERTII/F`I'CCATIi OF EXEMPTION FROM WORKERS' PERMIT ISSUANCE 10.00 FLOOD ZONE A,L.UD.
LU > COMPENSATION INSURANCE PLG.CONTR. LAC,NO. PLG. v El N❑ Y E) N❑
4' 0 ffhis section need not be completed if the permit is for one TOTAL
Z hundred dollars($100)or less
U O 1 certify that in the performance of the work for which this per- OTY. MECHANICAL PERMIT FEE FEE SUMMARY
D1, F mit is issued,I shall not employ any person in any manner so as to
O L) become subject to the Workers Compensation Laws of California. BUILDING
Q. Dae npphwnt ALTER OR ADD TO MECH. 5.00
} ED NOTICE,TO APPLICANT: If,after making this Certificate of Ex-
F 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
V such provisions or this permit shall be deemed revoked. AIR HANDLING UNIT(TO 10=CF.M-) 4.00
CONSTRUCT ION LENDING AGENCY AIR HANDLING UNIT(OVER 10MC.RM.) 6.00 SEISMIC FEE
I hereby affirn+ that there is a construction lending agency for EXHAUST HOOD(WITH DUCT) 5.00
tire 3097,Civ.C.)nce of the work IMICROFILM
'or which this permit is issued(Sec. HEATING UNIT(TO 100,000 B.T.U.) 8.00
Lender's Name
Lender's Address H EATI NG U N IT(OV ER 100,000 B.T.U.)9.50 ELECTRIC C /
I certify that l have read this application and state that the above VENTILATION FAN (SINGLE) 4.00
information n correct. 1 agree i comply with all city and county BOILER-COMP(3 H.P.or 100,000 B.T.U.) 6.00 PLUMBING
eminences and store laws relating to building 1 city and a and my
hereby authorize representatives of this city to enter upon the BOILER-COMP (Over 100,000BTU)SEE 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 1000 CONST.TAX
may in any way acerae against said City in consequence of the .
granting of this permit MECH.CONT. LIC.NO. MECH.
��� d 7 TOTAL TOTAL �
are A i ' t tractor a[
INSPECTOR COPY