C8579 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
BU LDI NG PROJECT IDENTIFICATION PERMIT NUMBER
auILOINc APPLICATION & PERMIT
ADDRESS 'a,Ow 5 BUILDING-ELECTRICAL-PLUMBING-MECHANICAL Q
IN/lfdI ECK VALIDATION
. /
NAME qq DP
TV. ELECTRIC PERMIT FEE //''�iI VV
PHONE
NAMENACroRs ,L U
uc.NO.
TLETS-SWITCHES-RECEP 10.00/1.00 AI�/
1 1985
370. LIGHTING FIXTURES 10.00/1.00
AGDDRESS TORS APPLIANCES 4.00 ity of Cupertino
PHONE PANELS ` 10.00 DATE OF APPLICATION
0..CRITECT PANELS (OVE_ 200 AM_PI1' 20.00 y PLAN CHECK FEE P.C.NO.
/• ` ENG INEEP
(' uc.rv0. SIGNS TRANS. 3.00
.y. ARCH.OR ENG, PERMIT VALIDATION
ADDRESS SPECIAL CIRCUIT 5.00
a zm TEMP. METER OR;POLE INS. 20.00 IoI V
5f �
APPLICANT S � }U(
- '
ADORES MOTORS - SEE FEE SCH.
SERVICE CHANGE 20.00
0 o a LICENSED CONTRACTORS DECLARATION TEMP.POLE - 30.00
IS
U w• I hereby affirm that I am licensed under provisions of Chapter 9 ISSUANCE DATE
w a c 1 (commencing with Section 7000)of Division 3 of the Business and BLD ELECT- PLG. MECH.
H m z Professions Code,and my license is in full forte and effect. ❑ El z 0 m - - License Class Lie Number
O I-;w- .Date Contractor
Qyf
¢ re ¢ OWNER-BUILDER DECLARATION / BUILDING PERMIT
al,
d O INFORMATION
wg h 1 I hereby affinr that I am exempt frons Ole Contractor's License MISC.- REFER TO ORD
LL o ¢ Law for the following reason,(Sec.7031.5,Rusinessmil Professions V $/FT.
r(- 0� Code:Any city or county which requires a PERMIT ISSUANCE 10.00
q permit to construct,
re ¢ ¢ p improve,demolish,or repair any structure,prior to its issuance,also ELEC.CONTR. LIC.NO. ELEC.
a - ¢ requires the applicant for such permit to file a signed statement that TOTAL
M
m he is licensed punsunnt to the provisions of the Contractors License * MIT TO
H z r Law(Chapter 9(e.asmencing with Section 7000)of Division 3 ofthe _ •'[�\j
¢ Business and Professions Code)or that he is exanpt th,nefirommid CITY. PLUMBING PERMIT FEE
athe basis for the alleged exemption.An
eaFo 6 p y'violation of$ec1i0n 703 L5 STORIES TYPE CONSTR.
ea 5- by any applicant for a permit Subjects the applicant toa civil penalty ALTER-DRAIN -WATER IEA.( 5.00
of not more Ota.dive hundred dollars(85001.):
❑ I,as owner of the property,or my employees with wages as BACK FLOW PROTECT. DEVICE 4.00 OCC.GROUP BEs.UNITS
sole compensation,will do the work,and thc structure is not
intended or offered for sale (Sec. 7044, Business and Professions DRAINS-FLOOR,ROOF,AREA,COND. 5.00
Code:'rhe 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 ARE. TOTALACREAGE
himself or through his own employees,provided that such improve-
martsare not immndedorofferedfor sale.If,however the budding GAS-
EA.SYSTEM-71NC.40UTLETS 8.00
oI improvement is sold within one year of completion,Ole owner- GAS EASYSTEM OVER 4 IEA) 2.00
builder will have the burden of proving that he dirt not build or int- - . - .
- BUILDING USE
prove or purpose ofsale,). I I INDUSTRIAL WASTE INTER. 30.00 S IND CON PB GOP,
I,as owner of the property,am exclusively contracting with El El EDI' d contractors to construct the pmjeet(Sec. 7044,Business LAWN SPRINKLERS-1 INC 5 V.B. 6.00 ASSESSORS PARCEL N0.
1 Pm fcsoons Code:The Contractor's Licedse Law does nut apply
to an owner odproperty who builds or improves thereon,and who LAWN SPRINKLERS-OVER 5(EA.) 1.00 r ,
contracts for such projects with a cona-actor(s)licensed pursuant to SEWER-SANITARY STORM EA.200ft/10.00
S the Contractors License Law. TRACT NO. PARCEL NO.
eaSl)11❑ lam exe pt under ,BAP.C.for this WATER HEATER W/VENT 6.00
y f
owner ' Date WATER SYSTEM 5.00 ACC.DATE ACC.FILE NO
.�
WORKIiR CONPIiNSATION DECLARATION WATER TREATING EQUIP, 5.00 i1
I hereby affirm sal I have a certificate ofc.ns,.t to self-insure,
or a certificate of orkers'Compensation Insurance,or a certified ZONING ENG.SITE NO.f
r copy th ereof(Sec.3R00,Cc . ).
I'nNa Cormqmnpany_
0 fied copy -
Certiishereby'twits FIRE SPRINK ENERGY T-24z Z ❑ Certified copy is filed with the the city inspection division. MISC.- REFER TO ORD.
O Applicant y ❑ N❑ y ❑ N❑
may' CERTIFICA'I'Ii OF E XEMPI'ION 17ROM WORKERS' PERMIT ISSUANCE 10.00 FLOOD ZONE A.L.U.C.
LU > COMPF-NSAT'ION INSURANCE PLG.CONTR. LIC.NO. PLG,
CL ❑ 1'fhis section need not be completed if the permit is for one TOTAL V❑ N❑ V❑ N❑
::) Z hundred dollars(S 100)or less.)
U O 1 certify that in the performance of the work for which this per- CITY. MECHANICAL PERMIT FEE FEE SUMMARY
LL I- mit is issued,I shall not employ any person in any manner so as to
become subject to the Workers'Compensation Laws of CdhIornia.
DID Date-Applicant BUILDING
} N NOTICE TO APPLICANT: If,after making this Certificate of Ex-
emption,you should become subject to Ole Workers'Compensation APPLIANCE 5.00 PLAN CHECK
•provisions`of the Labor Code, you must tilrthwith comply with FEE
CJ such provisions or this permit xhall be dcenud revoked. AIR HANDLING UNIT(TO 10)000C.F.M.) 4.00
CONSTRUCTION LENDING AGENCY AIR HANDLING UNIT(OVER 10=C.EM.) 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.CJ. Al HEATING UNIT(TO 100,000 B.T.U.) 8.00
Lender's Name- HEATING UNIT(OV ER 100,000 B.T.U.)9.50
Lender's Address ELECTRIC
I certify that I have read This application and state that the aboveIBOILER-COMP(3H.P.orlOO,000B.T.U.I
ENTILATION FAN (SINGLE) 4.00
• information is correct. 1 agree to comply with a"city and county PLUMBING
ordinances and state laws rClai Ing to building construction, and 6.00hereby authorize representatives ec this city to eter upon theILER-COMP (Over 100.000 BTU)SEE FEE SCH. MECHANICAL
above-mentioned property forinspof thi purposes.(Wc) agree to s;Wyq, indemnify and keep harmless the City ofISC.- REFER TO ORD.
Cupertino aga601
I.,'es, dgrleo[s, costs and expenses which CONST.TAX
may in any ue Inst widCiy in conseyuence of thePERMIT ISSUANCE 10.00
granting of thi . MECH.CONT. LIC.NO. MECH.
v TOTAL TOTAL
Sig re of Applica /Contractor 56P
INSPECTOR COPY