9169 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY 4ayg�
BUILDING PROJECT IDENTIFICATION PERMIT NUMBER
BUILOING
ADDRESSAPPLICATION & PERMIT ^� 69
b
BUILDING-ELECTRICAL-PLUMBING-MECHANICAL y
R' PLAN CHECK VALIDATION
NAME OTY. ELECTRIC PERMIT FEE
T
WNAME EP
• C�APHONE
" UTLETS-SWITCHES-REC10.00/1.00
1 LIc.No. • LIGHTING FIXTURES 10.00/1.00
NIRA oR's
ADDRESS APPLIANCES-RESIDENTIAL 4.00
IT
PANELS 10.00 DATE OF APPLICATION
L ECT PANELS (OVER 200 AMP) 20,00 PLAN CHECK FEE P.C.NO.
OR
ENGINEER
LIC.NO. SIGNS TRANS. 3.00
ARCH EOR Enc. SPECIAL CIRCUIT 5,00 PER MITxA��1t$ON
ADDRSzip EMP. METER OR POLE INS. 20.00 �� �y t
APPLI
ICADDRESS TE MOTORS SEE FEE SCH. JUN 2 11985 1
SERVICE CHANGE 20.00
o O LICENSED CONTRACTORS DECLARATION TEMP.POLE 30.00 City of Cupertino
G u W I hereby uflirm that I am licensed undei provisions of Chapter 9 ISSUANCE DATE
w Q n (commencing with Section 7000)of Division 3 of the Business and j1 BLDG. ELECT. PLG. MECH.
F w i Professions Code.and my license is in full force and effect. i ❑ ❑
i3O m - License Class_G 3.t.Lia Number E1 I55'1
r.0 N F Dutc � Contructnr �
Y ¢ ¢
OWNER-BUILD ER DECLARATIO�JiO� BUILDING P R IT
a eINFORM ION
" MISC.- REFER TO ORD
K
S LL 1 hereby affirm that I am exempt from the Contractor's License VALUATION - $/FT.
I-
cOj Law for the following reason.(Sec.7031.5.Bussxn
sined Professions PERMIT ISSUANCE 10.00
Code:Any city or coumy which requires a permit to construct,alter,
Qp ¢ p Improve,demolish,Or repair any structure,prior to it$issuance,also ELEC.CONTR. LIC.NO. ELEC.
0 M requires the applicant for such permit to file a signed statement that TOTAL PERMIT TO
n w m m he is licensed pursuant to the provisions of the Contractor's License
r i a Law(Chapter!)(commencing with Scam.7000)ofl)ivision Sol'the
a Business and Professions Code)or that he is exempt therefrom and QTY. PLUMBING PERMIT FEE 41 w4
H p the basis for Ore alleged exemption.Any violation of Section 7031.5 ST RI TYPE CONSTR.
a_ by any.applicant for a perms subjects the applicant too civil penally ALTER-DRAIN -WATER IEA.) 5.00
of not more than five hundred dollars(S50OL)
❑ Las owner of the property,or my employees with wages as BACK FLOW PROTECT. DEVICE 4.00 OCC.GROUP RES.UNITS
sole compensation,will do the work.and the structure is not
' intended or offered for sale (See. 7044, Business and Professions DRAINS-FLOOR,ROOF,AR EA,COND. 5.00
Code:The Contractor's License Law does not apply to an owner of
properly 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
forint are not intended.,offemd l'ur sale,If,however,the building GAS-EA.SYSTEM-11NC.4OUTLETS 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 in,- . . .
- BUILDING USE
prove for purpose ofsele.). INDUSTRIAL WASTE INTER. 30.00 REs IND CON Pe Omer
❑ L 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.
and Professions Code:The Contractor's License Law does not apply
to an owner of property who builds or improves thereon,and who LAWN SPRINKLERS-OV ER 5(EA.) 1.00
contracts for such projects with a contracmrts)licensed pursuant to
tire Contractor's License Law. SEWER-SANITARY-STORM EA.2001t/10.00 TRACT NO. PARCEL NO.
❑ 1 Jilt exempt under Sec,-,B&P.q.for this WATER HEATER W/VENT 6.00
reason
Owner Date WATER SYSTEM 5.00
ACC.DATE ACC.FILE NO,
WORK I;RS'COkiPENSATION DECLARATION WATER TREATING EQUIP. 5.00
I hereby al'ftnn that I have a certificate of consent to self-insure, -
or a certificate of Workers'Compensation Insurance,ora certified ZONING ENG.SITE NO.
copy thereof(See.3800,Lab.C.). µ 1a�
policy Na Company
O C�-ee77K his hereby furnished. FIRE SPRINK ENERGY T-24
Z 0O CrrtiOrd Lropy is filed with the city inspection division.nt MISC.- REFER TO ORD. Y❑ N❑ Y ❑ N❑
~ ua PERMIT ISSUANCE 10.00 FLOOD ZONE A.L.0 c.
CIiR'I'l IzICA'1'E OF EXEMPTION FROM WORKERS'
LU - COMPENSATION INSURANCE PLG.CONTR. LIC.NO. PLG. �D El ❑, ❑ ❑
IL O (This section need not be completed if the permit is for one TOTAL Y N v N
Z) Z hundred d.11urs IS 100)or less.)
L) O 1 certify Olin in the performance.f the work For which this per- QTY. MECHANICAL PERMIT FEE FEE SUMMARY
U_ U mit is issued, I shall not employ any person in any manner so as to
become subject to the Workers'Compensation Laws of California BUILDING
0 y Date Applicant ALTER OR ADD TO MECH. 5.00
} W 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
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 ImWing agency for EXHAUST HOOD(WITH DUCT) 5.00
the performance of-the work for which this permit is issued(Sec. MICROFILM
3097,Civ.C.L HEATING UNIT(TO 100,000 B.T.U.) 8.00
Lender's Name HEATING UNIT(OVER 100,000 B.T.U.)Lender's Address ELECTRIC
1 certify that 1 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
ordinances and state laws relating to building construction, and BOILER-COMP(3 H.P.or 100,000 B.T.U.) 6.00
hereby auflnouc representatives of this city t. enter upon the BOILER-COMP Over 100,000 BTU)SEE FEE SCH. MECHANICAL
above-mentioned property for inspection purposes.
(We) agree to save, indemnify unit keep harmless the City of MISC.- REFER TO ORD.
Cupertino against liabilities,judgments, costs andexpenses which PERMIT ISSUANCE 10.00 CONST.TAX
may in any way accrue against said City in consequence of the
granting of this penniL MECH.CONT. LIC.NO. MECH.
-
TOTAL
s� .re n""phLa�icnn r "� baa prll TOTAL
INSPECTOR COPY