C9175 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
BUILDING PROJECT IDENTI FICA. PERMIT NUMBERBTILDING APPLICATION & PEF&
ADDRESS
TOORE55
/ BUILDING -ELECTRICAL-PLUMBING-MECHANICAL 91 75
Own-H' - - - - - - PLAN CHECK VALIDATION
F NAME QTY. ELECTRIC PERMIT FEE
c c Rs OUTLETS-SWITCHES-RECEP 10.00/1.00
NAME .q -�^ req
,✓ f'_ Ltp!NcL ( .7 p� V q LIGHTING FIXTURES 10.00/1.00
A " /�(!3Q , PPLIANCES-RESIDENTIAL
ADDRESS "'11 T
l ��� ONE PANELS 10.00 DATE OF APPLICATION
OR
E PANELS (OVER 200 AMP) 20.00 PLAN CHECK FEE P.C.No.
ENGINEER
uc,NO SIGNS TRANS. r 3.00
AARCFEO ENG, SPECIALCIRCUIT - 5.00 PERMIT VALIDATION
ASS
ZIP EMP.METER OR POLE S. 20.00 PAID
ADDRESS IN
AMOTORS SEE FEE SCH.
ADDRESS q(r On(
T JE+ SERVICE CHANGE 20.00 JUL 23 1985
wo o LICE F.D CO N'1kACTORS DECLARATION TEMP.POLE 30.00
¢ Hj I hereby affirm that I am licensed under Provisions of Chapter 9 SG
Na o (commencing with Section 7000)of Division 3 of the Business and BLD L MEC .
F y z Professions Codq�pndmy license is in full force ad eft c
t^z o y- License Class�^l�tic Number
O Uatc y-� .q�V ` Contracto
¢ y f �.k : BUI ING P IT '
s¢ Q w ' OWNfi BUILUF.R DF:C AI'ION I ORMATION
xoA MISC.- REFER TO ORD
3 LL H I hereby affirm that 1 ante exempt from the Contractor's License 4p. VALUATION S/FT.
L'wLL0¢ Law for the following reason.(Sec.7031.5,Businessand Professions PERMIT ISSUANCE 10.00
fw Code:Any city orcoumy which requires a permit to construct, ,r
¢ ¢ Q O improve,demolish,or repair any structure.prior m its issuance,also ELEC.CONTE. LIC.NO. ELEC. / r
0 u requires Ilse applicant for suelt permit to the it signed stmcment that TOTAL Vol
IT TO
n w m helis licensed pursuant to the provisions of tile Contractor's License
ca z i Law;Chapter 9(commencing with Section 7000)of Division 3 of the
a Business and Professions Code)or that he is exempt therefrom and QTY. PLUMBING PERMIT FEE
P x O d the basis for the alleged exem tion.An
¢ 1-p g p yviolation of5ection 7031.$ STORIES TYPE CONSTR.
to by any applicant for a permit subjects the applicant to a civil penalty ALTER-DRAIN -WATER (EA.) 5.00
of not more than five hundred dollar,(5500).1:
❑ I,as owner of fire property,or my employees with wages as BACK FLOW PROTECT. DEVICE 4.00 OCC.GROUP RES.UNITS
their sole unnpensation,will do the work,and Ili,structure is not
intended or offered for sal, (Sec. 7044, Business and Professions r DRAINS-FLOOR,ROOF,AR EA,COND. 5.00
Code:The Contractor's License Law does not upply to an owner of
property who builds or improves thereon,and who does such work d FIXTURES-PER TRAP 5.00 SQ.FT.FLOOR AREA TOTA ACREAGE
r himself or through his own employees,provided that such improve-
mentsarenotintendedorofferedforsale.IL however,the building ' GAS-EA.SYSTEM-11NC.4 OUTLETS 6.0
or improvement is sold within one year of completion,tine owner- GAS-EA.SYSTEM-OVER 4 (EA.) 2.00
builder will have the harden of proving that he did not build nr inn BUILDING USE
prove for purpose of sale.). RE IND CON PB Other
❑ '1,as owner of the property,am exclusively contracting with INDUSTRIAL WASTE INTER. 30.00 ❑ ❑ ❑ ❑
licensed contractors to construct the project(Sce, 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-OVER 5(EA.) 1.00
contracts for such projects with a contractous)licensed pursuant to -
>- the Contractor's License Lau.. SEWER-SANITARY-STORM EA.200ft/10.00 TRACT NO. PARCEL NO.
❑ Itunexcmptundcr Scc. ,B.&P.C.tor tIli, WATER HEATER W/VENT 6.00
reason
Owner Date WATER SYSTEM 5.00
ACC.DATE ACC.FILE N0.
W'ONKERS'COMPENSATION DECLARATION WATER TREATING EQUIP. 5.00
1 hereby affirm that 1 have a certificate life......at to self-insure,
or it cerlificale of Workers'Compensation Insurance,or a certified ZONING ENG.SITE NO.
copy t hemof(Se,,3800,Lab.C.).
Policy No. Company ,
�� 11
❑ Certified copy ishcreby furnished. FIRESPRINK ENERGY T 24
_ z Z /❑-Certified co y is filed wi tib the city inspection division.
M ISC.- REFER TO ORD.
!] %APPlicant Y ❑ N❑ V ❑ N❑
~ rn PERMIT ISSUANCE 10.00
CC \./fl>k' ' TE OP Iixi%11'T O� FROM WORKERS' FLOOD ZONE A.L.U.C.
LOU > OMPCNSATION INSURANCE PLG.CONTE. ❑C.NO. PLG.'
a- 0Z (This section need not he compl,led if the permit is liter one TOTAL Y❑ NE] Y ❑ N❑
hundred dollars f S 100)or I.0
U O 1 certify that in the performance of the work for which this per. QTY. MECHANICAL PERMIT FEE FEE SUMMARY
> LL H mit is issued,I shall not employ any person in any manner w as to
O L) become subject to the Workers'Compensation Laws of California. BUILDING -19
Q. Date Applicant ALTER OR ADD TO MECH. 5.00
}
UO NOTICE '1'O APPLICANT: If,after making this Certificate of Ex-
f" ? emption,you should become subject to tare 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=CF.M.) 6.00 SEISMIC FEE !�
1 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,Cre C.I. - HEATING UNIT(TO 100,000 B.T.U.) 8.00000
Lender's Name 100,000 B.T.U.)9.50
Lender's AcidicHEATING UNIT(OVER• {�6 - ELECTRIC
I certify that I have read this application and state that the above VENTILATION FAN (SINGLE) 4.00
'an
nformation is Correct. I agree to comply with all city and county PLUMBING
ordinances and state laws relating to building construction, and BOILER-COMP13 H.P,or 100,000 B.T.U.) 6.00
hereby authorise representatives of this city to enter upon the BOILER-COMP (Over 100,000 BTU(SEE FEESCH. MECHANICAL
u bove mm�tioned property lot inspection purposes.
(Wc) agree to save, indemnify and keep haunlese til. City of MISC.- REFER TO ORD.
+ Cupertino against liabilities,judgments, costs and expenses which PERMIT ISSUANCE 10.00 CONST.TAX !L�
IF may in any way accrue against said City in consequence of the 777
granting of this permit. ------MECH.CONT. LIC.NO. MECH. /^
TOTAL / TOTAL qF�
s c
INSPECTOR COPY