09623 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
BUILDING PROJECT I DENTIFICATI ON PERMIT NUMBER
BUILDING APPLICATION & PERMIT
ADDRESS
BUILDING - ELECTRICAL-PLUMBING-MECHANICAL
O NER'B - PLAN CHECK VALIDATION
NAME CITY. ELECTRIC PERMIT FEE
PHONE I
'AME OUTLETS UTLETS-SWITCHES-RECEP 10.00/1.00
q T .Lm.NO _0, .?n / LIGHTING FIXTURES 10.00/1.00
C "TRAC
ADDRESS OR's APPLIANCES-RESIDENTIAL 4.00
pHON iT t PANELS 10.00 DATE OF APPLICATION
R HITECT a� PLAN CHECK FEE P.C.NO,
OR PANELS (OVER 200 AMP) 20.00
ENGINEER
LIC.No. SIGNS TRANS. 3.00
ADDRRESS ENG. SPECIAL CIRCUIT 5.00 PERMIT VALIDATION
ZIP TEMP.METER OR POLE INS. 20.00 PAID
APPLICANTS MOTORS SEE FEE SCH.
ADDRESS Ess
p,I .w r SERVICE CHANGE 20.00 SEP 041985
wo o LICENSED CONTRACTORS DECLARATION TEMP.POLE 30.00
¢ o o i hereby affirm Ihat 1 ant licensed under provisions of Ch.pier'1 �It�B q(;"
wz s Icontcaencing with Section 7000)of Division 3 of the Business and
s, BLDG. ELECT. PLG.
r y i Professions Code,and my license is in full force and effect
Z,
o m - License ClClas^ Ic.Number I-;i= -
O r Date /o-..?Y•.t � 6r.0 rlmctor /�/.1/+n L
¢ se s 3-5 9 9-8 a BUILDING PERMIT
¢ ¢ ¢ OWNER-BUILDER DECLARATION
o d u INFORMATION
w 3 LL 1 hereby afluca that I am exempt trout the Contractor's Liccase MISC.- REFER TO ORD VALUATION LL o j Law for the following reason(Sec]031.5,Business and Professions PERMIT ISSUANCE 10.00 $/FT.
Code:Any city or county which requires a permit to constmet,alter.
¢ Q 2O improve,demolish,or repair any structure,prior to its issuance,also ELEC.CONTE. LIC.NO, ELEC.
O ¢ requlms the applicant for such permit to file a signed d,trinent that TOTAL P IT TO
wmhe is licensed pursuant to the provisions of the Contractor's License - ,
HZQ Law(Chapter 9(commencing with Section 7000)of Division 3 ofthc
4 o Business and Professions Code)or that he is exempt therefrom ands OTV. PLUMBING PERMIT FEE
¢ F0 the basis for the alleged exemption.Any violation of Section 7031.5 STORIE TYPE CONSTR,
ate _ by any applicant for a permit subjects the applicant to a civil penalty ALTER-DRAIN -WATER (EA.)of . .
not more then five hundred dollars(5500).): d
❑ 1,as owner of the property,or my employees with wages as BACK FLOW PROTECT. DEVICE 4A0 OCCGROUPRES.UNITS
their sole coca sensation,,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 bullas Or improve,Ihercon,and who heCS Such work FIXTURES-PER TRAP 5.00 SO,IT,FLOOR AREA TOTAL ACREAGE
himself or though his own employees,provided Ihat such improve-
mentsarenet intended oroffered for sale.If,however,the building GAS-EA.SYSTEM-1 INC.4 OUTLETS 6.00
or improvement is sold within one year of completion, the owner- GAS EASYSTEM OVER 4(EA.) 200
builder will have the burden of proving that h - . - . .
o did not build or im- BUILDING USE
prove for purpose of sale J' INDUSTRIAL WASTE INTER. 3000 IND CON PB Omer
❑ I,as owner of the property,a exclusively contracting with . ❑ ❑ ❑ ❑
licensed contractors to construct tie project(Sec. 7044,BusinessLAWN SPRINKLERS-1 INC 5 V.B. 6.00 ASSESSORS PARCEL N0.
and Professions Code:The Contractors License Law docs trot 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 contractors)licensed pu¢umlt to
toe Contrator's Ger Law. SEWER-SANITARY-STORM EA.200ft/10.00 TRACT NO. PARCEL NO.
❑ 1 rncexccapt under Sc,.-,L&P.C.for thus WATER HEATER W/VENT 6.00
reason
Owner Date WATER SYSTEM 5.00 ACC.DATE ACC.FILE No.
WORK 17RS'COMPF:NSATION DECLARAT ION WATER TREATING EQUIP. 5.00
I herehy affirm that I have a ectificat,of consent to self-insure. ZONING ENG.SITE NO.
or a certificate of Workers'Compensation Insurance,or a certified
copy thereof(Sec 3500,Lah.C.I
Policy o. BornpemY Yom• 1/ �_ „• ,
O Cc rifled copy P.hcrcbylurms o FIRE SEE INK EN ERGY T-24
Z 2 Certified copy is fled with tic city Inspection division.
H 0 Applicant MISC.- REFER TO ORD. Y ❑ N❑ Y ❑ N❑
it y CER IWICATF OF EXEMPTION FROM WORKERS' PERMIT ISSUANCE 10.00 FLOOOZONE A.La C.
W > COMPENSATION INSURANCE PLG.CONTE. LIC.NO. PLG.
CL 0( This Section need not be completed if the permit is for one TOTAL Y❑ N❑ Y[:] N❑
hundred dollars(S 100)or less.l
U O I 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
0 become Subject to the Workers'Compensation Laws of California.
WDate Applicant ALTER OR ADD TO MECH. 5.00 BUILDING
} to NOTICE TO APPLICAN"f'. If,afit,making this Certificate of Ex-
Z emotion,you should become subject to the Workers'Compenwlion 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 10jWC.F.M.) 4.00
CONS1RUCTION LENDING AGENCY AIR HANDLING UNIT(OVER 10=C.F.M.).6.00 SEISMIC FEE
1 hereby affirm that there is a construction lending agency for EXHAUST HOOD(WITH DUCT) 5.00 nn
the performance of the work for which this permit is issued(Sec. MICROFILM
3097.C'iv.C.). / / HEATING UNIT(TO 100,000 B.T.U.) 8.00
Lender's Name-
Under,Addhe
ame Under'sAddreo.; ss. 0 HEATING UNIT(OVER 100,000 B.T.U.)9.50 ELECTRIC
I certify that 1 ho14inus a ppli a Ion a d`stt +7t the aboveI
ENTILATION FAN (SINGLE) 4.00 A•ni7
inl'crolation is correct 1 agree to comply with all city and county PLUMBING
ordinances and state laws refiling to building construction, andILER-COMPI3H.P.or100,000B.T.UI 6.00hereby authorim representatives of Ihis city es enter upon theOILER-COMP(Over 100,000 BTU)SEE FEE SCH. MECHANICAL
above-mentioned property for inspection purpoms(We) agree to Save, indemnify and keep harmless lee City ofISC.- REFER TO ORD.
Cupertino against liabilities,judgments, costs ;cod expenses which PERMIT ISSUANCE 10.00 CONST.TAX
may in any way acerae against said City in consequence of the 9.00
granting.(thispennit MECH.CONT. LIG NO. MECH.
J TOTAL TOTAL
"Mgna e o Applicant/Contrac ar a Date >. 00.
INSPECTOR COPY
1