8713 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
BU LDI NG PROJECT IDENTIFICATION PERMIT NUMBER
III LDING APPLICATION & PERMIT
ADREss
/\ i BUILDING-ELECTRICAL-PLUMBING-MECHANICAL �
94
0 ry A`71 3
��'VVV PLAN LIDATION
NAME OTY, ELECTRIC PERMIT FEE
1� i/ RDNE MAY 2 41965
CONTRACTORS AMEUTLETS-SWITCHES-RECEP 10.00/1.00
x LIC No. LIGHTING FIXTURES ,o.Oon.Do 2 - City of CuDerino
co T A Toms APPLIANCES- 4.00
ADDRESS IV/.J`
19.3 13
HONE PANELS 10.00 DATE OF APPLICATION
A c IT cr PANELS (OVER 200 AMP) 20.00 PLAN CHECK FEE P.C.No.
OR
ENGINEER
LIC.NO. SIGNS TRANS. 3.00
ADDDDRESS EN¢ SPECIAL CIRCUIT 6.00 PERMIT VALIDATION
ZIP TEMP.METER OR POLE INS. 20.00
APPLICANTS MOTORS SEE FEE SCH.
ADDRESS
SERVICE CHANGE 20.00 fI{�
w02 LICENSED CONTRACTORS DECLARATION TEMP.POLE 30.00
a u 0 t I hereby affirm that I am licensed under provisions of Chapter 9 ISSUANCE DATE
H< h (commencing with Section 7000)of Division 3 of the Business and BLDG. ELEC PLG. MECH.
H m z Professions Code,and my-I¢ense is in full force and effect. ❑
z0 o - License Class Liu Number
o z r Date Contractor f`��,��,�C'{
m a ¢ OWNIiktl U1LDER DECLA RATIOR eTC BUI DI G PERMIT -
Ie w u INFORMATION
w ;n y 1 hereby affirm that 1 am ex em it from the Contractor's License MISC.- REFER TO ORD VALUATION SIFT.
FLL0 j Law for the following reason(Sec.703 L5,Business Professiuox PERMIT ISSUANCE 10.00
w0 Code:Anycity orcounty which requiresa permit to construct,alter, 19
s- improve,demolish,or repair any structure,prior to its issuance,also ELEC.•CONTR. LIC.NO. ELEC.
K m u requires the applicant for such permit to file a signed smlement that TOTAL/� PERMIT TO
n w he is licensed pursuant to tte provisions of the Contractor's License
H z i
Law(Chapter 9(commcncingwith Suction 7000)of Division 3 of the
F 4 o Business and Professions Code)or that he is exempt therefrom and OTY. PLUMBING PERMIT FEE
X r o the basis for the alleged exemption.Any violation o(Section 7031.5 STORIES TYPE CONSTR.
dam 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 dollars(S500)J:
❑ I,us owner of the property,or my employees with wages as BACK F LOW PROTECT. DEV ICE 4.00
their sole compensation,will do the work,and the structure is not OCC.GROUP. RES.UNITS
intended or offered for sale lSec. 7044. Business and Professions DRAINS-FLOOR,ROOF,AR EA,COND. 5.00
Code:The 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 AREA TOTAL ACREAGE
• himself re through his own employees,provide)tel such insprove-
hats are through his oroffeTedemplo employees,
or L.provided
flicr.Ihcbuilding \ GAS-EA.SYSTEM-11NC.4OUTLETS 6.00
or improvement is sold within one year of completion,the owner- GAS-EASYSTEM-OVER 4 IEA.) 2.00 sulLol G USE
builder will have the burden of proving that he did not build or in, . RES IND PB anter
pro I'or purpose of sale). INDUSTRIAL WASTE INTER3000 1:1 ED 1:1 11I,as owner of the properly,um exclusively contracting with . .
licensed contractors to construct the project(Sec. 7044, Business LAWN SPRINKLERS- 1 INC 5 V.B. 6.00 ASSESS ARCEL NO.
and Professions Code:,'he Contractor's License Law does not apply
to ua owner of property who builds or improves thereon,and who LAWN SPR IN KLERS-OVER 5 (EA.) 1.00
contracts Ior such projects with u cool rectoAs)licensed pursuant to
the Contractor's License Law. SEWER-SANITARY-STORM EA.200ft/10.00 TRACT NO. PARCEL NO.
❑ lam exempt under See ,tl.&BC.(or this WATER HEATER W/VENT 6.00
reasol
Owner Date WATER SYSTEM 5.00
ACC.DATE ACC.FILE NO,
WORKERS'COMPENSA'f ION DECLARAT ION WATER TREATING EQUIP. 5.00
1 hereby affirm that I have a certificate of consent to self-insure, ZONING ENG.SITE NO.
or a certificate of Workers'Compensation Insurance,or a certified
copy thereof(Sec.3800,Lab,C.).
Policy No. Company r PC 1 Q aL 7
O ❑ Certified copy is hereby f A^ybed,
FIRE SPRINK ENERGY T24
Z 2 ❑ Certified copy is filed will the city inspection division. MISC.- REFER TO ORD.
O Applicant Y[] NE] YE] NE]
CC NCERTIFICA11:017 EXEMPTION FROM WORKERS' PERMIT ISSUANCE 10.00 1 FLOOD ZONE A.L.u.c.
111 > COMPENSATION INSURANCE PLG.CONTR. LIC,NO. PLG. Y N Y N
CL 0 1 Phis 'section need not be completed if the permit is for one TOTAL
hwtdreal dollars IS 100)or less I
U O 1 certify that in the performance of the work for which this per- OTY. MECHANICAL PERMIT FEE FEE SUMMARY
LL F mil is issued.I shall not employ any person in any manner so as to
Ow become subject to the Workers'Compensation Laws of California. BUILDING
Q. Date Applicant ALTER OR ADD TO MECH. 5.00
} W NO1'ICI:TO APPLICANT: If,after making this Certificate of Ex-
Z 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
U such provisions or this permit shall be deemed revoked. AIR HANDLING UNIT(TO 10,000QF.M.) 4.00
CONSTRUCTION LENDING AG ENCY AIR HANDLING UNIT(OVER 10=C.F.M.) 6.00 SEISMIC FEE
I hereby affirm thal Imre is a construction lending agency ITT EXHAUST HOOD(WITH DUCT) 5.00
the petornsance of the work for which this permit is issued(Sce. MICROFILM
3097,Civ.C.). HEATING UNIT(TO 100,000 B.T.U.) 8.00
Lender's Name HEATING UNIT(OVER 100,000 B.T.U.)Lender's Address ELECTRIC
I certify that I have read this application and state that the above VENTILATION FAN (SINGLE) 4.00
. information n correct 1 agree to comply with a0 city and county PLUMBING
ordinances and slain laws relating to building l city and co andmy BOILER-COMP(3 H.P.or 100,000 B.T.U.) 6.00
hereby authorize representatives of this city to enter upon the BOILER-COMP IOver 100,000 BTU)SEE FEE SCH. MECHANICAL
above-mentioned property for Inspection purposes.
(We) agree to rove, indemnify and keep harmless the City of MISC,- REFER TO ORD.
Cupertino against liabilities,judgments, costs .,,it expenses which CONST.TAX
may in any way accrue against sn'd.City in consequence of the PERMIT ISSUANCE 10.00
•unling ft is pennlL MECH.CONT. LIG NO. MECH.
`J TOTAL TOTAL
Signa re 1 Contr r IAH,
INSPECTOR COPY
• I