C9297 4 i APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
BU I LDING PROJECT I DENTIFICATI ON PERMIT NUMBER
nUILOINc APPLICATION & PERMIT g297
FDOREss
BUILDING - ELECTRICAL-PLUMBING-MECHANICAL In
P AN CHECK VALIDATION
NAME _ QTY. ELECTRIC PERMIT FEE
P.ONE
-o T Ac R OUTLETS-SWITCHES-RECEP 10.00/1.00
NAME
LIC.NO, LIGHTING FIXTURES 10.00/1.00
CONTRACTORS
ADDRESS
CONTRACTOR
APPLIANCES-RESIDENTIAL 4.00
PHONE PANELS 10.00 DATE OF APPLICATION
ARCHITECTPANELS (OVER 200 AMP) 2066 PLAN CHECK FEE P.C.NO.
.
OR
ENGINEER
LIC.Na. SIGNS TRANS. 3.00
ADDRESS ENG. SPECIAL CIRCUIT 5.06 PERMIT VALIDATION
ZIP EMP.METER OR POLE INS. 20.00 FAAJ®
APPLICANT s MOTORS SEE FEE SCH.
ADDRESS AUG - 7. 1995
SERVICE CHANGE 20.00
w f O o LICENSED CON'T'RACTORS DECLARATION TEMP.POLE 30.00
¢ o s~a I hereby'afflrm That I am licensed under provisions of Chapter 9 �R56u2f4e'€7fAY'E'In�
w< w (commencing with but
7000)of Division 3 of the Businessand BLD ELECT. PLG. MECH.
F w z Professions Code,and my license is in full force and effect. ❑ ❑ ❑
Z 0 w - License Class Lic.Number
o to F 0 Date Contractor
¢ y s BUILDING PERMIT
¢ w u OWNER-BUILD17R DECLARATION
w ;LL y I hereby affirm that 1 am exempt from the Contractor's License
MISC.- REFER TO ORD INFORMATION
VALUATION S/FT.
u0a Law for the following reasfm.(Sec.703 1.5,Businessand Professions PERMIT ISSUANCE 10.00
r y0J Codc:Any city orcounty Which requiresa permit locomstR¢Lal@q t�EJ
or aa Q 2 improve,demolish,or repair any strucLLue,prior to its issuance,also ELEC.CONTR LIC..NO. ELEC.
LL qSZ is
requires the applicant for Such permit to file a signed statement Hurl TOTAL PERMIT TO If
in he is licensed pursuant to}}}}IIIIic provisions of file Contractor's License fI
r i
Law(Chapter 9(commenQ)ngwith Section 7000)of Division 3 of the
io Business and Professions 9ode)or that he is exempt therefrom andQTY. PLUMBING PERMIT FEE I
¢ H $ Hue basis for the alleged exemption.Any violation of Section 7031.5 STORIES vvE C NSTR.
d3 � by any applicant for a permit subjects the applicant toa civil penalty ALTER-DRAIN -WATER IEA.) 5.00 iE
.fact more than five hundred dollars(5500).):
❑ I,as owner of the property.Or my employees with wages us 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(Sea 7044, Business and Professions DRAINS-FLOOR,ROOF,AR EA,COND. 5.00
Code:The Contractor's License law does not apply to in owner of :r
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-
nmetsamnet lmmndeduroffered employ'eesale.provided
that Ithebuildinga'proe- GAS-EA.SVSTEM-11NC.40UTLETS 6.00
or in ino,meat is sold within one year of completion, the owner. GAS EASYSTEM-OVER 4(EA.) 2.00 BUILDING USE
buil der will have the burden of proving Hot he did not build or ire - .- RES IND CON PB Omar,
prove l'or purpose ofsale.). INDUSTRIAL WASTE INTER. 30.00
O I°as owner of the property,arm exclusively contracting with No] ❑ ❑ ❑ ❑
licensed contractors to construct the project(Sec. 7044,Business LAWN SPRINKLERS-1 INC 5 V.B. 6.00ASSESSORS PARCELNO.
and Professions Code The Contractor's License Law does not apply
to un owner of property who builds or improves❑hereon,and who LAWN-SPRINKLERS-OV ER 5(EA.) 1.00
contracts for such projects with a contractor)s)licensed pursuant to
time Contractor's License Law. SEWER-SANITARY-STORM EA.200ft/10.00 TRACT NO. PARCEL NO.
❑ I um exempt under Sec. ,B.&P.C.for this WATER HEATER W/VENT 6.00 -
reason
1 Owneyq 1, ;J. 7e ZEI.o Date WATER SYSTEM 5.00
ACG DATE ACC.FILE NOP
It WORKERS'COMPE-NSA'IION DECLARATION WATER TREATING EQUIP. 5.00
I hereby affirm thin I have u...p 1ncate of consent to self-insure.
I or a certificate of Workers'Compensation Insurance,or u eerlified ZONING ENG.SITE NO.
.- i copy Ihercof(Sec.3800,Lab.C.).
Policy No. Company
0 ❑ Cetliflnd copy is hereby furnished. FIRE SPRINK ENERGY T 24
Z Z ❑ Certified copy is filed with the city inspection division. MISC.- REFER TO ORD.
Q Applicant Y❑ N❑ I Y ❑ N❑
CCy CERTIFICATEOF EXEMPT ION PROM WORKERS' PERMIT ISSUANCE 10.00 FLOOD ZONE A.L.U.C.
LL > COMPENSATION INSURANCE PLG.CONTR. LIC.NO. PLG. v El N❑ v 1:1 N 1:1(Phis section need not be completed if the permit is for one TOTAL
hundred dollars(S 100)or less.)
0,0 I certify that in the performance of the work for which this per. QTY MECHANICAL PERMIT FEE FEE SUMMARY
Ly F- mit is issued, I shall not employ any person in any manner so as to
0 become subject to the Workers'Compensation Laws of Calit'ornia.
0 DO Date Applicant ALTER OR ADD TO MECH. 5.00 BUILDING
}` Uo NOII CE 'f0 APPLICANT: 11',after making this Certificulu of lix-
F Z emption,you should become subject to the Workers'Compensation APPLIANCE 5.00 PLAN CHECK
provisions of the Labor Code, you must lorthwith'comply with FEE
U such provisions 0r this permit shall be deemed revoked. AIR HANDLING UNIT(TO 10=C.F.M.) 4.00 4116 -7
CONSTRUCTION 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
the performance of the work for which this permit is issued(Sec. MICROFILM
3097,Civ.C.). I H EATING UN IT(TO 100,000 B.T.U.) 8.00
Lender's Name
Lender's Addle HEATI NG UN IT(OVER 100,000 B.T.U.)9.50 ELECTRIC
ss
1 echify that 1 have read this application and state that the above VENTILATION FAN (SINGLE) 4.00
• iul'o..Il Hion is correct. I rgreo to conmply with all city and eaunly PLUMBING
ordinances and state 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
above-mentioned properly for instaclion purposes. BOILER-COMP (Over 100,000 BTU)SEE FEE SCH. MECHANICAL
(We) agree to save, indemnify and keep harmless the City of MISC.- REFER TO ORD.
Cupertino against liabilities,judgments, costs and expenses which CONST.TAX ,
may in any way accrue against Said City in consequence of the PERMIT ISSUANCE 10.00 -
got,I of this permit. MECH.CONT. LIC.NO. MECH.
TOTAL 5'1
Sig eo App want/ fret. TOTAL
r ale
INSPECTOR COPY
I