09557 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
BU LDI NG PROJECT IDENTIFICATION PERMIT NUMBER
BUILDING APPLICATION & PERMIT
ADDRESS
BUILDING-ELECTRICAL-PLUMBING.-MECHANICAL 09557
OWNER'S PLAN CHECK VALIDATION
NAME QTY. ELECTRIC PERMIT FEE
•{. PHONE r
CONTReACTOR$
NAME �J OUTLETS-SWITCHES-RECEP 10.00/1.00
Lie No.3[ LIGHTING FIXTURES 10.00/1.00
DDRESS OR'
ADDRESS APPLIANCES-RESIDENTIAL 4.00
A
3z-zr
C C .,t, ,J PHONE PANELS 10.00 DATE OF APPLICATION
AR HITECT PLAN CHECK FEE P.C.NO,
OR PANELS(OVER 200 AMP) 20.00
ENGINEER
uc.No. SIGNS TRANS. 3.00
ARCH,
DD Ess ENG. SPECIAL CIRCUIT 5.00 PERMIT VALIDATION
ZIP ITEMP.METER OR POLE INS. 20.00 PAID
APPLICANT
DDRMOTORS SEE FEE SCH.
ADDRESS
SERVICE CHANGE 20.00 AUG 23 19g5
00 LICENSED CON'T'RACTORS DECLARATION TEMP.POLE 30.00
¢ v w 1 hereby affirm that I am licensed under provisionsof Chapter9 .C1g�,�N
mz commencing with Section 7000)of Division 3 of the Business and
¢ u BLDG. ELECT. PLG. H.
0 m i Professions Cls Cod; 'Ind my license is in full force un effect
z O m - License Claes Lic.NumberEl L1
o r O Dale r Caninetor
a Z E BUILDING PERMIT
c c a OWNER-BUILDER DE ARATI
a as MISC.- REFER TO ORD INFORMATION
w g y I hereby affirm that I am exempt from the Contractor's License
o ¢ Law for the following lesson.(Sec.7031.5,Busineasand Professions PERMIT ISSUANCE 10.00 VALUATION SIFT.
rLL Code:Any city or county which requirest permit to construct.alter,
� Q ¢ 0 improve,demolish,or repair any structure,prior to its issuance,also ELEC CONTR. . LIC.NO. ELEC.
sc iL m¢ requires the applicant for such permit to file a signed statement that TOTALtic P RMIT 0
he is licensed pursuant to the provisions of the Contractor's License
Law(Chapter 9(commencing with Section 7000)of Division3ofthe
4 O Business and Professions Code)or that he is exempt therefrom and OTY. PLUMBING PERMIT FEE I i / ) -
cr F $ tie basis for the alleged exemption.Any violation of Section 7031.5 STORIES TYPE CONSTR.
a3 � by any applicant for a permit Subjects the applicant toa Clvrl penalty ALTER-DRAIN -WATER IEA.) 5.00
of not more than Hive hundred dollars($500).):
❑ I,as owner of the property,or my employees with wages as BACK F LOW PROTECT. DEV ICE 4.00 OCC.GROUP RES.UNITS
their sole compensation,will do the 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 does such work FIXTURES-PER TRAP 5.00 so.FT.FLOOR AREA TOTALACREAGE
himself or through his own employees,provided that such improve-
ments 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-EA.SYSTEM-OVER 4 (EA.) 2.00
builder will have the burden of proving that he did nut tire
or im- BUILDING USE
prove for purpnscofs'nleJ. WASTE INTER30.00 RS IND CON PB Other
❑ 1,as owner of the property,am exclusively contracting with INDUSTRIAL . ❑ ❑ ❑ ❑
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 Contractor's License Law docs 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 contmctods)licensed pursuant to
the Contractor's License Law. SEWER-SANITARY-STORM EA.200ft/10.00 TRACT NO. PARCEL NO.
❑ l am exempt under Sec. .B,&P.C.for this WATER HEATER W/VENT 6.00
reason
Owner Dat, WATER SYSTEM 5.00 ACC.DATE ACC.FILE NO.
WORKHRS'COMPENSA'I[ON DECLARATION WATER TREATING EQUIP. 5.00
1 hereby affirm ilia[ 1 have a certificate of consent to xIf-insure.
^� or a ctificate of Workers'Compensation Insurance,or a certified ZONING ENG.SITE NO.
copy'therereof(Sec.3800,Lab.C.).
Policy No. Company
O ❑ Certified copy is hereby furnished. FIRE SPRINK ENERGY T 24
z 2 CertiHul py is filed i the city inspection division.
Q+ A lic", IOf MISC.- REFER TO ORD. Y❑ N❑ Y ❑ -N❑
CC~ mJ C. TIPIGC EPERMIT ISSUANCE 10.00 FLOOD ZONE A.L.U.C.
XEMPTION FROM WORKERS'
W > COMPENSATION INSURANCE PLG.CONTR. LIC,NO. PLG.
a- Z( This section need not be completed if the permit is for one TOTAL Y[:] C:]N Y [3 NE]
hundred dollars IS 100)or less.)
U O 1 certify that in tire performance of the work for which this per- QTY. MECHANICAL PERMIT FEE FEE SUMMARY
U_ H mit is issued, I shall not employ any person in any recliner sn as to
O () become subject to the Workers'Cont pensotion Laws of Laid....l t
Q. Date Applicant ILDI NG
>_ to
NOTICE APPLICANT: If,after making this Certificate of E. ALTER OR ADD TO MECH. 5.00
F 2 emption,you should become subject to the Workers'Compensation APPLIANCE 5.00 PLAN CHECK
prw'is me, 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
I hereby affirm that there is a construction Imlding 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 ITO 100,000 B.T.U.) 8.00
Lender's Nome HEATING UNIT(OVER 100,000 B.T.U.)9.50
Lender's Address ELECTRIC
A I certify that I have read this application and state that the above VENTI LATION 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.or 100,000 B.T.U.) 6.00
hereby aulhorize representatives of jus city to m,ar upon the
above-menlioned property for inspection purpoavBOILER-COMP (oyer 100,000 BTU)SEE FEE SCR. MECHANICAL
ms.
(We) agree to se, indemnify and keep harmless the City of MISC.- t REFER TO ORD.
Cupertino against liabilities,judgments, costs and expenses which CONST.TAX
may in any way accrue against 'd City in e'regience of the PERMIT ISSUANCE 10.00 1
granting of this perittl[. MECH.CONT. LIC.NO• MECH.
\ TOTAL TOTAL
Sig ' are ofA ntmclor Uat
INSPECTOR COPY