10723 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
BUILDI NG PROJECT I DENTI FICATION PERMIT NUMBER
BDILOINc APPLICATION & PERMIT
ADDRESS n-
/ C- (97- BUILDING - ELECTRICAL-PLUMBING-MECHANICAL 0
_ ' NERSPLAN CHECK VALI
JrDATION
• NAME ,,,, ,� QTY. ELECTRIC PERM IT FEE
PHONE
CONT� ' /� 1 -
RAcTOHs UTLETS-SWITCHES
NAME -RECEP 10.00/1.00
y uc.NO. / -L LIGHTING FIXTURES 10.00/1.00
CONTRACTORS PPLIANCES'-RESIDENTIAL 4.00
ADOREss /]] '
PHONE -9,S -J PANELS J_ O, 10.00 DATE OF APPLICATION
ARCHITECT PANELS (OVER 20 AMP) 2(1.00 PLAN CHECK E .NO.
OR
ENGINEER
LIC.NO, SIGNS TRANS. 3.00
Anon Ess EN SPECIAL CIRCUIT 5.00 PER ATION
DYV ZIP EMP.METER OR POLE INS. 20.00 QA
I ^'
APPULANTS MOTORS SEE FEE SCH. JAN 1
X'AOOREss � 1986
s e SERVICE CHANGE 20.00 P
F o o LICENSED CONTRACTORS DECLARATION rhe ��CuPertl
�1(I
tc�s I hereby affirm hat I am licensed under provisions of Chapter 9 �/ ISSUANCE DATE
G< (commencing with Section 7000)of Division 3 of the Business and BLOC. ELECT. LG. MECH.
iProfessions Code d license is in full fore egdc(fe L
z o`� - License Class - Lic.Numberl_c-( [_] ❑ ❑
0 v, H Date Contractor-
< y s BUILDING PERMIT
tC w u OWNER-BUILDER DECLARATION INFORMATION
a 0 a MISC.- REFER TO ORD
w 3: LL H I hereby affirm that I am exempt from the Contractor's License VALUATION 5/FT.
LL o Law for the following o nim.(Scc.7031.5,Businessund Pfofessioms PERMIT ISSUANCE 10.00
Code:Any city or County which requires a Penni,to construct,elmq
¢ E. improve, or repair any structure,prior to its issuance,also ELEO.CONTR. LIC.NO.
EL
0 u requires the applicant for such permit to file a signed statement that N L.! / Z TE
OTA 'R IT TO
w$ he is licensed pursuant to the provisions of the Con true to is License
Law(Ch apter 9(coni me Heingwit h Sect inn 7000)o f U iv inion 3 of t he
- rt Business and Professions Code)or that he is exempt therefrom and OTY. PLUMBING PERMIT FEE
the Innis for the alleged exemption.Any violation of Section 7031.5 STORIES TYPE CONSTR.
u ; - by any applicant for a permit subjects the applicant too civil penalty ALTER-DRAIN -WATER IEA.) 5.00
of not more than five hundred dollars(5500).):
❑ I,as owner of the property,or my employees with wages is BACK F LOW PROTECT. DEVICE 4.00 PCC.GROUP RES.UNITS
their mile compensation,will do,he work,and the structure is not
intended or offered for sale (Sec. 7044, Business and Professions DRAINS-FLOOR,ROOF,AREA,COND. 5.00
Code:The Contractor's License law does not apply to an owner of
. property who builds or improves thereon,and who docs such work FIXTURES-PER TRAP 5.00 SEE FT.FLOOR AREA TOTAL ACR FAGE
himself or through his own employees,provided•tlut such improve
ments are not intended or offered for sale.If,howevu,the building GAS-EA.SYSTEM-I INC.4 OUTLETS 6.00
or improvement is sold within one year of completion,the owner- GAS-EA.SYSTEM-OVER 4 (EA.) 2.00 BUILDING USE
builder will have the burden of proving that he did not build or im-
ProvefurtorposeOfmle.). - INDUSTRIAL WASTE INTER. 30.00 . RES IND CON PB omn
❑ I,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 Contractors 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 contractors)licensed pursuant to
the Contractor's License Law. SEWER-SANITARY-STORM EA.200ft/10.00 TRACT NO. PARCEL No.
❑ l um exempt'under Sec.-,BAP.C.for this WgTER HEATER W/VENT 6.00
a on
Owner Dam WATER SYSTEM 5.00 ACC.DATE ACG FILE-NO
.
WORKERS'COMPENSATION DECLARATION WATER TREATING EQUIP. 5.00
I hereby affirm that I have a certificate of Consent to self-insure. ZONING ENG.SITE NO.
or a certificate of Workers'Compcnsa_tion Insurance,or a certified -
copy thereof(Scc.3800.Iab:CJ.
Policy No. Company
0 D Cetlifiedcopyisherebyfumished. FIRE SPRINK ENERGY T-24
Z Z ' Cert 6 dad th 'ty inspection division.
0 Applicant Y N V N MISC.- REFER TO ORD. ❑ ❑ ❑ ❑
w CERTIFICATE OF EXEMPTION FROM WORKERS' PERMIT ISSUANCE 10.00 FLOOD ZONE A.L.U.C.
W > COMPENSATION INSURANCE PLG.CONTE! LIC.NO. PLG. y❑ N❑ Y[:] N[_]1 O This section need not be completed if the permit is for off TOTAL
Z) Z hundred dollars IS 100)or lees.)
U O - 1 certify that in the performance of the work for which this per- OTY MECHANICAL PERMIT FEE FEE SUMMARY
U.+ I- mit is issued,I shall not employ any person in any manner so as to
0 become subject to the Worker'Compensation Laws of California.
O w Dace Applicant ALTER OR ADD TO MECH. 5.00 BUILDING
} 55NOTICI7 TO APPLICANT: If,.after making this Certificate of Ex- -
? 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
C,.) such provisions or this permit shall be deemed revoked. AIR HANDLING UNIT(TO 10MCF.M.) 4.00
CONSTRUCT ION LENDING AGENCY AIR HANDLING UNIT(OVER 10=CF.M.) 6.00 SEISMIC FEE
I hereby of min 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.). HEATING UNIT(TO 100,000 B.T.U.) 8.00
Lender's Name
Lender's Address HEATI NG UNIT(OVER 100,000 B.T.U.)9;50 ELECTRIC
. I Certify that l 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 authorize mpresentatives of this city to enter upon the BOILER-COMP Over 100,000 BTU)SEE FEE SCH. MECHANICAL
above mentioned property 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 - CONST.TAX
may in any.way accrue,against said City in mnse9ucnce of the PERMIT ISSUANCE 10.00
granting of this penniL MECH.CONT. LIC.NO. MECH. 1
TOTAL TOTAL
Signature of Applicant/ ontractoraU to '� V
OFFICE COPY