09625 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
BUILDING PROJECT IDENTIFICATION PERMIT NUMBER
BUILDING APPLICATION & PERMIT �Q6��
ADDRESS
BUILDING - ELECTRICAL-PLUMBING-MECHANICAL
Ow ER's PLAN CHECK VALIDATION
NAME q QTY. ELECTRIC PERMIT FEE
l" PRONECONT
NAME OUTLETS OUTLETS-SWITCHES-RECEP 10.00/1.00
n LIC.NO. LIGHTING FIXTURES 10.00/1.00
ADDRESS
ons APPLIANCES-RESIDENTIAL 4.00
CO
q�� ' N PHONE T. PANELS (OVER 200 AMP) 20.00 PANELS 10.00 DATE OF APPLICATION
ARCHITEC/ ` � Rip "�.d� a PLAN CHECK FEE P.C.NO.
On .5 h
ENGINEER
LTC.No. SIGNS TRANS. 3.00 AI
ARCA ORESS ENG, SPECIAL CIRCUIT S.QQ PERMIT VALIDATION
ZIP TEMP. METER OR POLE INS. 20.00 SEP 0 4 1985
AMOTORS SEE FEE SCH.
ESS
ADDRDn EESS
P. _ _ -Q SERVICE CHANGE 20.00 City of Cupertino
02 LICENSED CONTRACTORS DECLARATION / TEMP.POLE 30.00
u I hereby affirm that I um licensed under provisions of Chapter 9 ISSUANCE DATE
Nz w (commencing with Section 7000)of Division 3 of the Business and
¢y g BLDG. ELECT. PLG. MECH.
F y z Professions Code,and my license is in full force and effect.
Z0 - License Clasxr[,2p j%ri;I.Lic.Number, L4Q,� 0/
0 r Dtdb-��ontractor_4.,&./r
-�-� BUILDING PERMIT
rc ¢ a OW. BUILDER DECLARATION
0 o U INFORMATION
w I- 1 hereby affirm That 1 am exempt from lire Contractor's License MISC.- REFER TO ORD
VALUATION $/FT.
F .. oQ Law fix the following reason.(Sec.7031.5,Businessand Professions PERMIT ISSUANCE 10.00
Code:Any city or county which requires a permit to construct'aIle"
QQQ2 improve, or repair any structure,prior to its issuance,also ELEC.CONTR. LIC.NO. ELEC.
R O u requires the applicant for such permit to file a signed statement that TOTAL PERMIT TO
A m he is licensed pursuant To The provisions ot'ihc Conlrlctor's LCU
irensc
zi Law(Chapter 9(commencing with Section 7000)ofDivision 3 of the
¢ Business and Professions Code)or that he is exempt therefrom and QTY. PLUMBING PERMIT FEE i
¢ r m the basis for the alleged exemption.Any violation of Section 7031.5 STORIES TYPE CONSTR.
ate _ by any applicant for a permit subjects the applicant to a civil penalty ALTER-DRAIN -WATER IEA.) 5.00
of not more than five hundred dollars(55000.):
❑ 1,as owner of the property,or my employees with wages as BACK F LOW PROTECT.DEVICE 4.00 OCC.GROUP RES.UNITS
their sole compensation,will do the work,and the structure is not
mended of offered for sole(Sec. 7044, Boincae unit Pnefcoions 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 5O.FT.FLOOR AREA TOTAL ACREAGE
himself ChtS re through his own employees.Provided that such improve.building
himself a throuot gh
oroffered for employees.pr lLhowever.che building GAS-EA.SYSTEM-11INC.4OUTLETS 6.00
or improvement is sold within one year of conlpleTion, - . .00 the owner- GAS-EA.SYSTEM OVER 4 (EA) 2
builder will have the burden of proving that he did not build or im- BUILDING USE
prove for purpose of sale.). INDUSTRIAL WASTE INTER. 30.00 E5 IND CON PS Omer
131,as owner of the property,am exclusively contracting with ❑ ❑ ❑ El
licensed contractors to construct the project(Sce. 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(or such projects with a contractors)licensed pursuant to
the Contractor's License Law. SEWER-SANITARY-STORM EA.2001t/10.00 TRACT No, PARCEL NO.
❑ 1 am exempt under Sec.-,B&P.C,for this WATER HEATER W/VENT 6.00
reason
Owner Date WATER SYSTEM 5.00 ACC.OATE ACC FILE No.
WORK ERS'COh1PENSA NON DECLARATION WATER TREATING EQUIP. 5.00
I hereby affrof that I have a certificate of consent to self-insure. ZONING
or u certificate of Workers'Compensation Insurance,or a certified ENG.SITE NO.
copy there fSec.3800,LAC) 7
1'oli<Y No?.tAgl�-Company `�a a
O �CertifiedreopY is hereby tarnished. FIRE SPRINK ENERGY T 24
Z Z ❑ Certified copy is filed with the city inspection division.
O Applicant MISC.- REFER TO ORD. YE] NE] Y ❑ IN
~ w
� - fliR'1'IPIGCTE o E E XENI PTION FROM WORKERS' PERMIT ISSUANCE 10.00 FLOOD ZONE A.L.U.C.
W � COhIPIiNSATION INSURANCE PLG.CONTR. LIC.No. PLG.
0. O This section need not be Completed if RtC permit is for one TOTAL Y❑ N E] Y iJ NC]
D Z hundred dollars IS 100)or less.)
U O 1 certify that in the performance of the work for which this per- CITY. MECHANICAL PERMIT FEE FEE SUMMARY
LL 1- mit is issued,I shall not employ any person in any manner so as to
Ow become subject to lire Workers Compensation Laws of California. BUILDING
y Date Applicant ALTER OR ADD TO MECH. 5.00
} to NOTICE 'r0 APPLICANI: If,after making(his Certificate of Ex-
h Z emption,you should become subject to lire 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=C.F.M.) 4.00
CONSTRUCTION I.I:NDING AGENCY AIR HANDLING UNIT(OVER 10=C.F.M.) 6.00 SEISMIC FEE
I hereby affirm that there is a construction lending agency for EXHAUST HOOD (WITH DUCT) 5.00 K
the performance of the work for which this permit is issued(Sec. MICROFILM
3097,Civ.CJ, HEATING UNIT(TO 100,000 B.T.U.) 8.00 y
Lender's Name �� �y --�+-rA��/
Lender's Addre../ HEATING UNIT(OVER 100,000 B.T.U.)9.50 ELECTRIC
I cemff-that fh`,dTcEd`tliis application and state that the above V ENTILATION FAN (SINGLE) 4.00 A[7J
. 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 100,0006.T.U.) 6.00
hereby authorize representatives of this city to enter upon the BOILER-COMP(Over 1011,000 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 pERM1T ISSUANCE 10.00 CONST.TAX
may in anyway accrue against said City in consequence of the /O on
granting of this permit MECH.CONT. LIC.NO. MECH
.
_ TOTAL TOTAL
i
< - rgn are o(Apphcabl or lt62 or Date O V
INSPECTOR COPY