09523 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
BUILDING PROJECT I DENTIFICATI ON PERMIT NUMBER
ADDRESS APPLICATION & PERMIT 995 3
AUILDIN
Z Peep t �f BUILDING - ELECTRICAL-PLUMBING-MECHANICAL
OWNER'S ^�,�/ PLAN CHECK VALIDATION
NAME ry QTY. ELECTRIC PERMIT FEE
AeA/ ICN PHONE _
•, crony
NA.E UTLETS-SWITCHES-RECEP 10.00/1.00
NAME �d
L A NZA V/7 U/h IC.NO, LIGHTING FIXTURES 10.00/1.00
corvTRAcroR'sAPPLIANCES-RESIDENTIAL 4.00
a4 ' 1/L k I AL PHONC ,r .7v/0/ PANELS 10.00 DATE OF APPLICATION
ARCHITECT PANELS (OVER 200 AMP) 20.00 PLAN CHECK FEE P.C.NO.
on O
ENGINEER
uc.NO SIGNS TRANS. 3.00
ARCH.08 ENG. SPECIAL CIRCUIT 5.00 PERMIT VALIDATION
ZIP EMP.METER OR POLE INS. 20.00 PAID
APPLICANTS - MOTORS SEE FEE SCH.
ADDRESS
SERVICE CHANGE 20.00 UG 2 3 1985
o o LICENSED CONTRACTORS DECLARATION TEMP.POLE 30.00 �.
a coo I hereby affirm that I am licensed under provisions of Chapter 9 CIISSJ�Npppwirlo
G w (commencing with Section 7000)of Division 3 of the Business and BLDG. ELECT. PLG. MECH.
H o z Professions C c,' my license is in full forayy,�u f'- ❑ ❑ ❑ ❑
z a' Lux,S, ss Lic.Nwnbcr
o H w Dulc _]1�_�_Contructor
BUILDING PERMIT
in o' w ¢ OWNER-BUILDER DECLARATION
U INFORMATION
H:
3 u e• I hereby Al'inn that I am exempt from the Cnn tractor's Liccnsc MISC.- REFER TO ORD
uo J Lawlor the following reason (Sec.703 t.5,Business and Professions PERMIT ISSUANCE 10.00 VALUATION
� - Code:Any city or county which requiresa permit to construct,alter,
R2 Q improve,demolish,or repair any structure,prior to its issuance,also ELEC.CONTR. LIC.NO. ELEC.
- e requires the applicant for such permit to file a signed statement that TOTAL
d an m w he is licensed pursuant to the provisions of the Contractor's License P RMIT TO
rz > Law(Chapter 9(commencing with Section 7000)of Division 3 of Otc
er Business and Professions Code)or that he is exempt therefrom and QTY. PLUMBING PERMIT FEE
¢ r $ Oro basis for the alleged exemption.Any violation of Section 7031.5 STORIES T PE CONSTR,
a3 _ by any applicant for a permit subjects the applicant ton civil penalty ALTER-DRAIN&VENT-WATER (EA.) 5.00
of not more than five hundred dollars(5500).1:
❑ 1,as owner of the property,or my employees with wages as BACK FLOW PROTECT. DEVICE 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,CONO. 5.00
Code:The Contractor's License Law does not apply to in owner of
property who builds or improves thereon,and who does such work FIXTURES-PER TRAP 5.00 � .sa.Pr.FLOOR AREA TOTAL ACREAGE
. nenshimself re of rote his own employees,provided that such improve- OV
norms are through his or offered res,or provided that S.themprovg GAS-EA.SYSTEM-1 INC.4OUTLETS 6.00
or improvemmut is sold within one year of completion, the owner- GAS-EA.SYSTEM-OVER 4(EA.1 2.00 BUILDING USE
holder will have the burden of proving Had Int dal not build or hit-
muvemrvurposeofsale.). INDUSTRIAL WASTE INTER. 30.00 RES IND CON PB Omer
❑ I,ns ower'of the P,.,city.ant cxclusivclY contracting with ❑ ❑ ❑ ❑ ❑
licensed contractors to constru" the project(Sec. 7044,Business LAWN SPRINKLERS- 1 INC 5 V.B. 6.00 ASSESSORS PARCEL NO.
and Professions Code:The Contractors License Law docs not apply
to in owner of property who builds or improves Herron.and who LAWN SPRINKLERS-OVER 5(EA.) 1.00
contracts lou such projects with a cornmeolgsl licensed pursuant to ! SEWER-SANITARY-STORM EA.200ft/10.00 Off/
file Contractors License Law. 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 00 ACC.DATE ACC.FILE NO,
WORK ERS'CONPENSAT'ION DECLARATION WATER TREATING EQUIP. 5.00
1 hereby affirm that 1 have a certificate of consent to self-insure, ZONING
-�/ or a certificate of Workers'Compensation Insurance,or a certified ENG.SITE NO.
copy thereof(Sec.3800,Lab.CJ.
Policy No. Company
O ❑ Certified copy is hereby furnished. FIRE SPRINK ENERGY T-24
Z Z J' CdOified o hitd witl� the city inspection division.
O Applicant �`f Its f MISC.- REFER TO ORD. Y ❑ N❑ . v ❑ N❑
CCN CEk1'IPICA'I'fS OF EXEMPTION PROM WORKIiRS, PERMIT ISSUANCE 10.00 /O i! FLOOD ZONE A.L.U.C.
LU > CObIPEN'SATION INSURANCE PLG.CONTR. LIC.NO. PLG. U Y❑ NE] Y E] N❑
CL 0( This section9�2 need not be completed if tike profit is for one TOTAL
hundred dollars IS 100)or less I
U O -..-.I certify that in the performance of the work for which this per- QTY MECHANICAL PERMIT FEE FEE SUMMARY
IL U mitis,issued,I shall not employ any person in any manner so as to
become subject to the Workers'Compensation Laws of California.
Go Date Applicant ALTER OR ADD TO MECH. 5.00 BUILDING
} W NOTICE TO APPLICANT: If,after making this Certificate of Ex-
F 2 entption,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 I0=C.F.M,) 4.00
CONST RUCTION LENDING AG17NCY AIR HANDLING UNIT(OVER 10MC.F.M.) 6.00 SEISMIC FEE
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 MICROFILM
3097,Cie.C.). HEATING UNIT(TO 100,000 B.T.U.) 8.00
Lender's Nance HEATING UNIT(OVER 100,000 B.T.U.)Lender;Address ELECTRIC
I certify that I have read this application and slate that the above VENTILATION FAN (SINGLE) 4.00
• information is correct. I agree to comply with all city'and county PLUMBING 00
ordinances and state laws relating to building construction, and BOILER-COMP(3 H.P.or 100,000 B.T.U.) 6.00
hereby authorize representatives of this city to enter upon tic 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 PERMIT ISSUANCE 10.00 CONST.TAX
tray in any way accrue against said City in consequence of the
granlingofthis permit MECH.CONT, LIC.NO. MECH.
85 TOTAL TOTAL
Signature of licanl/Contractor Date
$ INSPECTOR COPY
I