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APeLICANT TO FILL IN INFORMATION WITHIN RED LINES -- USE BA -MMINT PEN ONLY
BUILDING PROJECT IDENTIFICATION
APPLICATION & PERMIT:
275 BUILDING - ELECTRICAL- PLUMBING - MECHANICAL
PERMIT NUMBER
n 4A
u
s q.51RE .
OWNER'S f `/-(^
NA E
PHONE
QT'Y. ELECTRIC PERMIT FEE
PLAN CHECK VALIDATION
CONTRACTOR'S
NAME UTLETS-SWITCHES -RECEP 10.0011.00
a NO.C2SM
DATE OF APPLICATION
LIGHTING FIXTURES 10.00/1.00
ADDReAs Rs
PHONE. 7J
PPLIANCES- RESIDENTIAL 4.00
PANELS '• 10.00
ARL ITEcrPANELSORENGINEER
LIC. NO-
OVER 200 AMP) 20,00
PLAN CHECK FEE P.C. NO.
SIGNS TRANS_ 3.00
ARCH. ENG.
ADDRESS SPECIAL CIRCUIT 5,00 FERMI ON
TEMP. METER OR POLE INS, 20.00ZIP QoC AUG 2 3 1985APPLICANT'S
ADDRESS
MOTORS SEE FEE SCH,
SERVICE CHANGE. 20.00
LIt1nt of CupertIflo
LICENSED CONTRACTORS DECLARATION TEMP, POLE 30.00
I hereby affirm that I am licensed under provisions of Chapter 9
commencing with Section 7000) of Division 3 of the Business and
Professions Cod and icense is in full fore f ec
License Class Lic. Number
ISSUANCE DATE
BLDG.
0
ELECT. L MECH,
Dale Contractor
OWNER -BUILDER DECLARATION
1 hereby affirm that I am exempt from the Contractor's License
Law for the following reason. (Sec, 7031,5,13usinessandProfesdons
Code' Any city or county which requires a permit to construct, alter,
improve, demolish, or repair any structure, prior to its issuance, also
requires the.applicant for such permit io file a signed statement that
he u licensed pursuant to the provisions of the Contractor's License
BUILDING RMIT
INFORM TION
MISC. - REFER TO ORD
VALUATION SIFT.
PERMIT ISSUANCE 10.00
ELEC. CONTR. LIC. NO. ELEC.
TOTAL RMIT TO.
QTY. PLUMBING PERMIT FEE
Law (Chapter 9 (commencing with Section 7000) of Division 3 of the
Business and Professions Code) or that he is exempt therefrom and
the basis for the alleged exemption. Any violation of Sect ion 7031.5 IES T PE CONSTR.
by any applicant fora
hundred
dollars $
500).
he licanttoacivilpenalty
of not more than five hundred dollars (SS00).): ALTER -DRAIN BI VENT -WATER (EA.) 5,00
1, as owner of the property, or my employees with wages as
their sole compensation, will do the work, and the structure is not
BACK FLOW PROTECT. DEVICE 4.00 OCC. GROUP RES. UNITS
DRAINS -FLOOR, ROOF, AREA, COND. 5,00intendedorofferedforsale (Sec. 7044, Business and Professions
Code: The Contractor's License Law does not apply to an owner of
property who builds or improves thereon, and who does such work
himself or through his own employees, provided that such improve-
ments are not intended or offered for Sale. If, however, the building
FIXTURES PER TRAP 5.00 SQ FT. FLOOR AREA TOTAL ACREAGE
GAS- EA, SYSTEM -1 INC.4 OUTLETS 6.00
or improvement is sold within one year of completion, the owner-
builder will have the burden of proving that he did not build or im-
for purpose of sale.).
13 1. as owner of the property, am exclusively contracting with
GAS - EA. SYSTEM - OVER 4 (EA,} 2.00 BUILDING USE
q IND CON PB Oencr
El1. 1:1 11INDUSTRIALWASTEINTER. 30.00
LAWN SPRINKLERS - 1 INC 5 V.B. 6,00licensedcontractorstocorkstrucLtheproject (Sec. 7044, Business
and Professions Code: The Contractor's License Law does not apply
to an owner of property who builds or improves thereon, and who
11
ASSESSORS PARCEL NO.
LAWN SPRINKLERS -OVER 5 (EA,) 1,00
contracts forsuch projects with a contractor(s) licensed pursuant to
the Contractor's License Law. SEWER SANITARYSTDRM EA. 200ftl10.D0 0 TRACT NO. PARCEL NO.
lam exempt under Sec. B.&P.C. for this WATER HEATER W/VENT 6.00
reason
Owner Date WATER SYSTEM 5.00 ACC. DATE. ACC. FILE NO.
WATER TREATING EQUIP, 5.00WORKERS'COMPENSATION DECLARATION
1 hereby affirm that I have a certificate of consent to self -insure,
or a certificate of Workers' Compensation Insurance. or a certified ZONING ENG, SITE NO.
copy thereof (Sec. 3800, Lab -C.).
Policy No. Company
FIRESPRINK
Y E] N
ENERGY T-24
Y 0 NQ
Certified copy i5 hereby furnished.
pliPCertified
c¢py is firmedwith eity inspection division.
Apant frslr%fir-ice MISC. - REFER TO ORD.
CERTIFICATE OF EXEMPTION FROM WORKERS' PERMIT ISSUANCE 10-00160f) FLOOD ZONE A.L.U.C.
PLG. CONTR. LIC. NO. PLG. /t!]
TOTAL &
COMPENSATION INSURANCE
This Section need not be completed if the permit is for one
Y [] N Y [:] N
QTY. MECHANICAL PERMIT FEE FEE SUMMARY
hundred dollars (S 100) or less-)
I certify that in the performance of the work far which this per
mit is issued, I shall not employ any person In any manner so as to
BUILDING
become subject to the Workers' Compensation Laws of California,
Date Applicant
NOTICE TO APPLICANT: If, after making this Certificate of Ex-
ALTER OR ADD TO MECH, 5.00
APPLIANCE 5.00 PLAN CHECKemption, you should become subject to the Workers' Compensation
provisions of the Labor Code, you must forthwith comply with
such provisions or this permit shall be deemed revoked.
FEEAIRHANDLINGUNIT (TO 10)000C,F.M.I 4.00
AIR HANDLING UNIT (OVER 10PWC.F,M.) 6.00 SEISMIC FEECONSTRUCTIONLENDINGAGENCY
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.
3097,Civ.C.).
MICROFILM
HEATING UNIT (TO 100,000 B.T.U.) 8.00
HEATING UNIT (OVER 100,000 B.T.U.)9.50 ELECTRIC
Lender's Name
Lender's Address
I certify that I have read this application and state that the above
information is correct, l agree to comply with all city and county
ordinances and state laws relating to building construction, and
VENTILATION FAN (SINGLE) 4.00
PLUMBING IQv
BOILER COMP (3 H.P. or 100,000 B,T.U.I 6.00
BOILER -COMP (Over 100,000 BTU) SEE FEE SCH. MECHANICALherebyauthorizerepresentativesofthiscity -to enter upon the
above-mentioned property for inspection purposes.
MISC. - REFER TO ORD. We) agree to save, indemnify and keep harmless the City of
Cupertino against liabilities, judgments, costs and expenses which
may m any ay accrue against said City in consequcncc of the
gra I of permit.
CONST. TAXPERMITISSUANCE10.00
MECH. CONT. LIG. NO, MECH,
TOTAL
TOTAL
gnat re f ppircant Contract nate
OFFICE COPY