8449 (3) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
BU LDI NG PROJECT 1 DENTI FICATI ON PERMIT NUMBER
BLILDING APPLICATION & PERMIT
U •C�_G/r I�"yA.1A-il+..GClrfl_ BUILDING - ELECTRICAL-PLUMBING-MECHANICAL 844.9
OWNER'S - PLAN CHECK VALIDATION
-" NAME QTY. ELECTRIC PERMIT FEE PAtp
~' �CPHONE
• CONTRACTORS
NAMEUTLETS-SWITCHES-RECEP 10,00/1.00
LIC NO. LIGHTING FIXTURES 10.00/1.00 MAY � 0 1989
CONTRACTOR'S APPLIANCES-RESIDENTIAL 4.00 .j
ADDRESS .City of Cup Gino
PHONE PANELS 10.00 DATE OF APPLICATION
0
GT TtA �� PANELS (OVER 200 AMP( 20.00 PLAN CHECK:EE P.C.NO.
VENN EVIL.LE- t�m��G'ruS SIGNS TRANS. 3.00 °'
nnneFnS9 rNG. �' SPECIAL CIRCUIT 5.00 PERMIT VALIDATION i
Cl-
zIP EMP. METER OR POLE INS. 20.00 /
APPuc rs MOTORS SEE FEE SCH. 110+^
ADDRESS
SERVICE CHANGE 20.00
woo LICENSED CONTRACTORS DECLARATION TEMP.POLE 30.00
a1 hereby affirm that I am licensed under provisions of Chapter 9 ISSUANCE DATE
y i (commencing with Section 7000)of Division 3 of the Business and
a RLD ELECT. PLG. MECH.
H H on
i Professis Code,and my license is in(all force and effect
❑ ❑ ❑
Z 0 m - License Class Lie.Number
Z
- 1)atc Contract.,
a m BUILDING PERMIT
¢ ¢ a OWNER-BUILDER DECLARATION
a a= O MISC.- REFER TO ORD INFORMATION
K
1 hereby affirm that 1 am exempt from the Contractor's License
VALUATION $/FT.
H u. oa Luw for the following reason.(Set,703 1.5.BLIsinessand Professions PERMIT ISSUANCE 10.00
Code Any city or county which requires a permil to consHuct,alter,
¢ 0 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 slocnienl that TOTAL
mPE MIT TO
u w hi e licensed Personal to the provisions of the Contractor's License I
Law(Chapter 9(commencing with Section 7000)of Division 3 of the
ce a Business and Professions Code)or that he is exempt therefrom anA QTY. PLUMBING PERMIT FEE0 1 f7 12S
K F ca G the basis for the alleged exemption.Any violation of Section 7031.5 STORIES - TYPE CONSTR.
a- : by any applicant for a permit subjects the applicant to a civil penalty
I
.feet more than five hundred dollars(5500).): ALTER-DRAIN&VENT-WATER (EA.1 5.00
❑ 1,as owner of the property,or my employees with wages as ggCK FLOW'PROTECT. DEVICE 4.00
their sole compensation,will do the work,and the "citare is not t OCC.GROUP RES.UNITS
intended or offered for sale (Sec. 7044, Business and Professions DRAINS-FLOOR,ROOF,AREA,COND- 5.00
Code:The Commctor's License Law docs not apply to an owner of -
propertywhobuildsorimprovesthereon,and who docs such work FIXTURES,,PER TRAP 5.00 SO.FT,FLOOR AREA TOTALACREAGE
.. himself or through his own employees,provided that such improve
merits are not intended or offered for sale.If,however,the building GAS-EA.SYSTEM-11NC.40UTLETS 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 if.. . - . .
. BUILDING USE
,lro for purpose0 sale.). INDUSTRIAL WASTE INTER. 30.00 RES IND CON PB Out,
I,as .Per of the property',am exclusively contracting with ❑ ❑ ❑ ❑ ❑
Ii ed contractors to construct the project(Sec. 7044,Business LAWN SPRINKLERS- 1 INC 5 V.B. 6.00 ASSESSORS PARCEL NO.
d Profess ions Cudct'1'he Contractor's License Law docs not apply
ap an owner of property who builds or improves thereon,and who LAWN SPRINKLERS-OVER 5(EA.) 1.00
cnntraels for such projects with a contrxetoos)Iiemtsed pursuant to
the Cnmmernr's License Law. SEWER-SANITARY-STORM EA.200ft/10.00 TRACT NO. PARCEL NO.
Wre exempt un der Ser.-,B.&P.C.for this WATER.HEATER W/VENT - 6.00
reason k
Owner Umar; WATER SYSTEM 5.00 ACC.DATE ACC.FILE NO.
WORKI:RS'CObIPENSATION DECLARATION WATER TREATING EQUIP. 5.00
1 hereby affirm that I have a certificate of consentto self-insure. ZONING
ora cerlificate of Workers'Compensation Insurance or a certified ENG.SITE NO.
copy lherco(t Sec.3800,Lab.CJ.
Percy No. Company
O 0 Cenilied copy is hereby furnished. FIRE SPRINK ENERGY T 24
Z ZO Applicant OCifiied copy is riled with the city inspection division. MISC.- REFER TO ORD. y
❑ N❑ v ❑ N❑
CC CERTIFICATE OF FXEMP'rlON FROM WORKERS' PERMIT ISSUANCE 10.00 FLOOD ZONE A.L.uc.
LU > COh1PF-NSATION INSURANCE PLG.CONTR. LIC.NO. PLG. Y❑ N❑ Y F] NE]
( This section need not be completed if tire Permit is for one TOTAL
hundred dollars IS 100)or less.)
U O 1 ccrtily that in the performance of the work for which this per, CITY. ,MECHANICAL PERMIT FEE FEE SUMMARY
LL I- mit is issued, I OnIl not cntploy any person in any manner so as to
Uw hecome subject to the Workers'Compensation Laws of California. BUILDING
IS. D:un Applicant ALTER OR ADD TO MECH. 5.00
} w NOTICE TO APPLICANT: If,alter making this Certificate of Es.
F Z entption,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 10=C.F.M.) 4.00
CONSTRUCTION LENDING AGENCY AIR HANDLING UNIT(OVER 10=C.F.M.) 6.00 SEISMIC FEE 5
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
r 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
Lender's Address ELECTRIC
I certify that I have read this application and nate that the above VENTILATION FAN (SINGLE) 4.00
information is correct. I agree to comply with all city and county PLUMBING
ordinances and slate laws relating to building construction, and BOILER-COMP(3 H.P.of 100,000 B.T.U.) 6.00
hereby authorize representatives of this City to enter upon the BOILER-COMP(Over 100,000 BTU)SEE FEE SCH. MECHANICAL
above-mentioned properly for inspection purposes.
(We) agree to save indemnify and keep harmless the City Of MISC.- REFER TO ORD.
Cupertino against liabilities,judgments, costs and expenses which PERMIT ISSUANCE 10.001CONST.TAX
may in any way accrue against said City in con segoento of the
granting W this permit. MECH.CONT. LIC.NO, MECH.
TOTAL
c„'-t'" TOTAL .- �•Ct
1"G 'Sigtl'aluapli ;'h .ntreclor Uatc
INSPECTOR COPY