09621 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
BU LDI NG PROJECT 1 DENTI FICATI ON PERMIT NUMBER
ADOREasAPPLICATION & PERMIT 09621
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I BUILDING-ELECTRICAL-PLUMBING-MECHANICAL n / �_a... .-..R/
NAMER'a _ E- PLAN CHECK VALIDATION
NAME QTY. ELECTRIC PERMIT FEE
vHONE
NOMERAcroRs UTLETS-SWITCHES-RECEP 10.00/1.00
Ci 10�" LIC.NO.
LIGHTING FIXTURES 10.00/1.00
ADD"ESs rolls PPLIANCES-RESIDENTIAL 4.00
PANELS 10.00 DATE OF APPLICATION
RCHIiacT• / L Aad y�3 PLAN CHECK FEE / P.C.NO.
OR 3( PANELS (OVER 200 AMP) 20.00 f
ENGINEER
LIC.NO. SIGNS TRANS. 3.00
ARCH Oil ENG. SPECIAL CIRCUIT 5,00 PER JMON
ZIP EMP. METER OR POLE INS. 20.00 ,1
nPPLICA 4
Ts MOTORS SEE FE_ E SCH. SEP Q .1985
J--��y � SERVICE CHANGE 20.00
Foo LICENSED CONTRACTORS DECLARATION TEMP.POLE 30.00 CILJ of Cn
pertinD
o U I hereby ailinn that I am licensed under Provisions of Chapter9
y a n (commune ng with Section 7000)of Division 3 of the Business and ISSUANCE DATE
BLDG. ELECT. PLG.
F y z Professions Code,and my license is in(all force and effect ❑ ❑ ❑
o z to o License Clash-9n Z 9 a Lic.Number
Uam--99_�s 9-A-art Contractors
a y Q I d 9 9-3.8J BUILDING'PERMIT
a: a ar OWNER-BUILDER DECLARATION 1
X 3 LL I- 1 hereby affirm that I am exempt from the Contractor's License MISC.- REFER TO ORD INFORMATION
on Law for the following reason.(Sec.7031.5.Business and Professions PERMIT ISSUANCEVALUATION $/FT.
Code:Any city or county which requires a permit to construct,alter, 10.00
am Y ELEC.CONTE. LIC.NO.
a, Q Q improve,demolish,or repair any structure,prior to its issuance,also ELEC.
a. - a, requires the applicant tar such permit to file a signed statancnl that TOTAL PERMIT TO
K
m he is licensed pursuant to the provisions of the Contractor's License
F z r
Law(Chapter 9(commencingwifh Section 7000)of Division3olthe
a Business and Professions Code)or that he is exempt therefrom and QTY. PLUMBING PERMIT FEE
r the hasis for the alleged exemption.Any violation of Section 7031.5 STORIES TYPt CONSTR.
a ; by any applicant for u permit subjects the applicant to a civil penalty ALTER-DRAIN&VENT-WATER (EA.) 5.00
of not mom than five hundred dollars($500).)'
❑ I,as owner of the property,or my employees 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 DRAINS-FLOORROOFAREA,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 re through his own employees,provided Ihaf such improve.
menus me through
or employeesale.l(,ed that such
building GAS-EA.SYSTEM-1INC.4OUTLETS 6.00
ar improvement is sold within one year of completion,the Over -
builder will have the burden of proving that he did not build or ire- GAS-EA.SYSTEM-OVER 4(EA.) 2.00 BUILDING USE
prove for purpose ofmh,.)' m
INDUSTRIAL WASTE INTER3000 REs IND CON PB Cohen
❑ I,as owner of tire . .
e property,am exclusively contracting with ❑ i] ❑ ❑
licensed contractors to construct the project(Sec. 7044,Business LAWN SPRINKLERS- 1 INC 5 V.B. E,00 ASSESSORS PARCEL NO.
and Professions Code:The Contractor's License Law does nm apply
to an owner of property who builds or improves thereon,and who LAWN SPRINKLERS-OVER 5 IEA.) 1.00
contracts for such projects with a contractorls)licensed pursuant to
One C'ontractor's License Law. SEWER-SANITARY-STORM EA.200ft/10.00 TRACT NO. PARCEL NO.
❑ 1 a exempt under Sec.-,L&P.C.for this reason WATER HEATER W/VENT 6.00
Own`', Date WATER SYSTEM 5.00 ACC.DATE ACC.FILE NO,
WORKERS'COMPENSATION DECLARATION WATER TREATING EQUIP. 5.00
I hereby offinn that 1 have n cart,fi,are of consent to S,IGinunc,
or a certificate of Workers'Compensation Insurance,or a certit'ied ZONING ENG.SITE NO.
copy thereof(Sec.3800,Lab.C.l., ,
P.1 No. •Cmnpany -
O VCertil'''ie�is hereby I'urnislnd. ,
Z Z ❑ Certified copy is fled with tine city inspection division. FIRE SPRINK ENERGY T 24
- FO Applicant MISC.- REFER TO ORD. YE] N[] I Y [:] NE]
CC CER'1'117ICATE OF IiKEMPTION FROM WORKERS' PERMIT ISSUANCE 10.00 FLOODZONE A.L.U.C.
W COMPENSATION INSURANCE PLG.CONTE. LIC.NO. PLG.
CL O (This section need not be completed if the permit is for one TOTAL Y N� Y❑ NC]
U O hundred dollars IS 100)or less)
I certify that in the performance 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 tine Workers'Compensation Laws of California.
a Date Applicant ALTER OR ADD TO MECH. 5.001BUILDING
>- W NOTIC17 TO APPLICANT: If,after making this Certificate of Ex-
F 2 empfion,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 10MC.F.M.) 4.00
CONST'RUC'TION 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 -6-cc
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 -ep
Lender's Name- /pct--e- a w
Lender's AAAre ,�{-Q-/q' s'L•p p..�� p r�o. HEATING UNIT(OVER 100,000 B.T.U.)9.50 ELECTRIC
I certify that 194-edd timt�ppRAMR and state that the above VENTILATION FAN (SINGLE) 4.00
ordinances n correct. I agree to comply with all city and county O� PLUMBING
ordinances and state lows relating to building construction, and BOILER-COMP(3 H.P.or 100,000 B.T.U.) 6.00
hereby authorim representatives of this city to enter upon the BOILER-COMP(Ova,100,000 BTU)SEE FEE SCH.
/ above-mentioned property for inspection purposes. MECHANICAL
(We) agree to saves indemnify and keep harmless the Cit'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 "q
granting of this permit. MECH.CONT. LIC.NO. MECH.
4 TOTAL TOTAL
Igo col Applicant Cutts for ` ate
INSPECTOR COPY