9453 (3) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
BUILDING PROJECT IDENTIFICATION PERMIT NUMBER
BUILDINGAPPLICATION & PERMIT
AODREsse,7/9Jr D Oak &C / Z. BUILDING-ELECTRICAL-PLUMBING-MECHANICAL 9453 t
OWNER'S C' /_L - PLAN CHECK VALIDATION
• E p / QTY. ELECTRIC PERMIT FEE 7 9-2. /�
Aar�f�6 i�v tl�a PHONE
CONTRACTORS UTLETS-SWITCHES-RECEP 10.00/1.00
i r LIC.NO. /I LIGHTING FIXTURES 10.00/1.00
CONTR 9TOR's
ADDRE APPLIANCES-RESIDENTIAL 4.00
\
/k 46 51O PRONE - ANELS 1G.QQ t PATE OF APPLICATION
ORRCRiTELT PANELS (OVER 200 AMP) 20.00 PLAN CHECK FEE P.C.NO.
ENGINEER
uc.No. SIGNS TRANS. 3.00
•ADDRESS ENG. SPECIAL CIRCUIT 5,00 PERMIT VALIDATION
ZIP EMP.METER OR POLE INS. 20.00 PA@7
APPLICANT'S MOTORS SEE FEE SCH.
ADDRESS (x r r�
SERVICE CHANGE 20,00 Y1985
1
0 BE zTEMP.POLE 30.00
L, 0 o LICENSED CONTRACTORS DECLARATION p ty �p p rs�.�
a it. I hereby affirm that I am licensed under provisions of Chapter 9 VIS`3UA55 CL/upwin /
waw (commencing with Section 7000)of Division 3 of the Business and a ELE T. PLG. MECH. 2t
r H z Professions Code,and my license is in full force nd eff L ❑ ❑
z O License Cltic.Number
2 z Date Contractor
a y E BU I G PERMIT
¢ ¢ a OWNIi R-BUILDER DECLARAT ON
o d u IN ORMATION
w ; N I hereby affirm that I am exempt from the Contractor's Licenn, MISC.- REFER TO ORD
LLoa I-uw for the lbllnwin g noon.(Sea.7031.5,Iiuslmessrnd Professions PERMIT ISSUANCE 10.00 11 i- VALUATION $/FT.
Code Any city or county which reyuiresu purnlit ioeonstrucLulteq
IF ¢ 2 improve,demolish,or repair any structure,prior to its issuance,also ELEC.CONTR. LIC.NO. ELEC.
A wo u requires the applicant for such permit to file a signed statement that TOTAL - ERMIT TO
m he is licensed pursuant to the provisions of the Contractor's License
H z r
Law(Chapter 9(conrmeacing with Section 7000)of Division 3 o fit"
a Business and Professions Code)or that he is exempt therefrom and DTV. PLUMBING PERMIT FEE ✓ `
¢ =$ the basis for Orn alleged exemption.Any violation of Section 7031.5 STORIES TYPE CONSTR.
u , by any applicant for a permit subjects the applicant toa civil penalty ALTER-DRAIN& VENT-WATER (EA.) 5.00
of not more than five hundred doliars(E5 Off.)'.
❑ I,as owner of the property,or my employees with wagesas BACK FLOW 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,AREA,COND. 5.00
Code:The Contractor's License Law does mol 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 through his own employees,provided that such improve-
ments are not intended or offered for sale.If,however.the budding GAS-EA.SYSTEM-I INC.4 OUTLETS 6.00
or improvement is sold within one year of completion, - . -OVER 4 IEA.) 2.
the owner- GAS EASYSTEM 00 BUILDING USE
builder will have the burden of proving that he did no[build or im- RES IND CON PB Omer
prove for purpose of the.l. INDUSTRIAL WASTE INTER. 30.00 ❑ ❑ ❑ ❑
❑ L as owner of the property,ant exclusivelyrojecSe contracting with
licensed contractors Io construct the priced (Sec.7044,of Ippls LAWN SPRINKLERS-1 INC 5 V.B. 6.00 ASSESSORS PARCEL NO.
to Professions Code:The who
build,o License Law does not apply
to an owner of property who builds tr improves thereon,and who LAWN SPRINKLERS-OVER 5 IEA.) 1.00
......
on trans for such License
with a contracros(sl licensed pursuant to
the Contractor's Liccnsc Law. SEWER-SANITARY-STORM EA.2001t/10.00 TRACT No. PARCEL NO.
❑ lam exempt under Sec ,B.&PLC.for this WATER HEATER W/VENT 6.00
reason
Owner Date WATER SYSTEM 5.00
ACC.DATE ACG FILE NO.
WORKERS'COMPCNSAI'ION DECLARATION WATER TREATING EQUIP. 5.00
I hcrehy of.... that 1 have a critical,of consent to self-insure' ZONING ENG.SITE NO.
or a certificate of Workers'Compensation Insurac�erti
nce,or a ticd
copy thereof(Sec.3800,Lab CA
Policy No. parry
O ❑ Certified copy creby furnished.
FIRE SPRINK ENERGY T2<
Z Z ❑ Certified p s filed with th• c' Inspection division. MISC.- REFER TO ORD.
0. Applicant MISC. ❑ NE] y E] No
CC'N CBRTIFICATEOP EXEMPTION FROM RKERS' PERMIT ISSUANCE 10.00 FLOOD ZONE AL.U.C.
W > '.� COMPENSATION INSURANCE- PLG.CONTR. LIC.NO. PLG.
d O (Phis section need not be completed it'the pirnut is for one TOTAL Y[:] N❑ Y ❑ N❑
Z hundied'dollurs(5100)or less.)
0 O 1 certify that in the performance of the work for which this per. QTY. MECHANICAL PERMIT FEE FEE SUMMARY
LL U mit is issued.I shall nottmploy any person in any manner so as to
become subject to the Workers''Compensation Laws of California �O
n Date ApplicantALTER OR ADD TO MECH. 5.00 BUILDING
} En NOTICE TO APPLICANT: If,after making this Certificate of Ex-
F 2 emption,you should become subject to the Workers'Compensation APPLIANCE 5.00 PLAN CHECK
U such provisions ovisions or or his permithe Labor shall be deemedou must f+.thwill,revoked comply with AIR HANDLING UNIT(TO 10=C.F.M.) 4.00 FEE
PL'
CONS'T'RUCTION LENDING AGENCY AIR HANDLING UNIT(OVER 10p00C.F.M.) 6.00 SEISMIC FEE
1 hereby affirm that there is a construction lending agency for EXHAUST HOOD(WITH DUCT) 5.00
he performance of lire work for which this permit is issued(Sec. MICROFILM "t
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
Len der's Ad dress ELECTRIC
I certify that I have read this application and state that the above VENTILATION FAN (SINGLE) 4.00
• information is correct. I agree to comply'with all city and county PLUMBING
drdinances and state laws relating to building construction, and BOILER-OOMP(3 H.P.or 100,000 B.T.U.) 6.00
hereby authon.o, rcPresenmtives of this city to enter upon the BOILER-COMP (Over 100,000 BTU)SEE FEE SCH. MECHANICAL
above-mentioned property for inspection purposes.
(WeI ogre o save, indemnify and keep harmless the City o1' MISC.- REFER TO ORD.
Cupertino � m st liabilities,juJgment costs and expenses which PERMIT ISSUANCE 10.00 CONST.TAX
may in arty ay accrue against Sri ity in consequence of the
i grand g t of
permit MECH.CONT. LIC.NO. MECH.
-//.Sor TOTAL r/lr_- �
Si a re ol'Appiicanl/Contractor Date ,' �K4J
. INSPECTOR COPY
-