09643 (2) APPLICANT TO FILL IN INFORMATION WI N RED LINES - USE BALL POINT PEN ONLY
BU LD1 NG PROJECT I DENTI FICATI ON PERMIT NUMBER
BUILDADDRING , APPLICATION & PERMIT
O?2 B LDING - ELECTRICAL-PLUMBING-MECHANICAL 09643
Owfi
I • NAME OTV. ELECTRIC PERMIT FEE PLAN CHECK VALIDATION
PHONE
CONTRACTORS UTLETS-SWITCHES-RECEP 10.00/1.00 �(
C/ LI C.NO. LIGHTING FIXTURES 10.00/1.00
ADDRESS T R's APPLIANCES-RESIDENTIAL 4.00 j
,l PRONE AFr_ PANELS10.00
ORRCHIrec PANELS (OVER 200 AMP) .DATE OF APPLICATION
20.00 PLAN CHECK FEE P.C.NO.
ENGINEER
LIC.NoSIGNS TRANS. 3.00
ARCH.
DD ESS ENG. SPECIAL CIRCUIT 5.00 PERMIT VAGt9gElgp�'
ZIP EMP.METER OR POLE INS. 20.00 oe
Y"gM�IJ
ADDRESS MOTORS SEE FEE SCH. AUG 2 9 '198[
ADDRESS
J
SERVICE CHANGE 20.00
'02 LICENSED CONTRACTORS DECLARATION TEMP.POLE 30.00 City of Cupertino
< u u I hereby uffinn that 1 all,licensed under provisions of Chirpier 9 ISSUANCE DATE
w c w (commencing with Suction 7000)of Division 3 of the Business and BLDG. ELECT. PLG. MECH.
H y z Profusions Code,,��I7 my license is in full force and effect )
z o,A - License Class G/!J Lie.Number iNR�+ El 1:1El
O y F w Date Contractor�rL ik r C
Y E
BUILDING PERMIT
¢ ¢ a OWNER-BUILDER DECLARATION
a a INFORMATION
w5 H I hereby affirm that I am exempt from the Contractor's License MISC.- REFER TO ORD
.. o a Law for the following reason.(Sec.7031.5.Business and Professions VALUATION $/FT.
❑ � 0J Code:Any city or county which requires a permit construct,alter,
PERMIT ISSUANCE 10.00 n �'
¢ ¢ p improve,demolish,or repair any structure,prior to its issuance,also ELEC.DONTR, LIC.NO. ELEC. q/1
in
u wDLL requires the applicant for such permit to file a signed statement that TOTAL [N PER MIT TO
m m he is licensed pursuant to the provisions of the Contractor's License
Hz >
Law(Chapter 9(commencing with Section 7000)of Division 3 ofthe
4 o Business and Professions Code)0r that hm
u is exempt therefrom and OTY. PLUMBING PERMIT FEE
¢ H the basis forillealleged exemption.Any violation of Seclion703L5 STORIES TYPE CONSTR.
n ; � by any applicant for a permit subjects file applicam toacivil penalty ALTER-DRAIN -WATER (EA.) 5.00
of not mora than five hundred dollurs($500))',
❑ 1,:¢owner of the property,or on,anploycee with wages as BACK FLOW PROTECT. DEVICE 4.00 OCC.CROUP RES.UNITS
their sole compensation,will do the work,and Ile structure Is not
intended or offered for sale (Sec. 7044, Business and Professions DRAINS-FLOOR,ROOF,AR EA,CON D. 5.00
Code:'file Contractor's License Law does not applyle an owner 01'
properly who builds or improves thereon,and who does such work FIXTURES-PER TRAP 5.00 $0.FT.FLOOR AREA TOTAL ACREAGE
himself re through his own employees,provided that such improve-
nrentsarcnor intended hhis.roffercdfor sale.If,ed that suhein"o., GAS-EA.SV$TEM-l1NC.40UTLETS 6.00
t or improvement is sold within one year of completion, - . - . .00 the owner- GAS EASYSTEM OVER 4 (EA) 2
builder will have the burden of proving that he did ne obuild or im- BUILDING USE
prove for purpose ofsale). INDUSTRIAL WASTE INTER3000 R INO CON PS other
❑ I,as owner of the property,um exclusively contracting with . .
❑ Q ❑ ❑
licensed contractors to construct itm project(Seo. 7044,Business LAWN SPRINKLERS- 1 INC 5 V.B. 6.00 ASSESSORS PARCEL NO.
and Professions Code:The Contractor's License Law does not apply
to an owner oIproperly who builds or improves thereon,and who LAWN SPRINKLERS-OVER 5(EA.) 1.00
contracts for such projects with a conlnmtorLs)licensed pursuant to SEWER-SANITARY-STORM EA.200ft/10.00
the Conlmctors License Law. RACT NO. PARCEL NO.
❑ I con exempt under Sec. ,IL&KC.for this WATER HEATER W/VENT 6.00
reason
Owner Date WATER SYSTEM ' 5.00 ACC.DATE ACC.FILE NO.
WORK ERS'COMPI�NSATION DECLARATION WATER TREATING EQUIP, 5.00
I hereby affirm that I have a certificate ofconsent to self-insure. ZONING
or a certificate of Workers'Compensation Insurance,or a certified ENG.SITE NO.
copy thercof(Sec.3800,Lab.C),,
Policy No. Company
0 ❑ Certified copy is herebyhuintshed' FIRE SPRINK ENERGY L24
Z Z ❑ Certified cap' -s filed with the city inspection division. MISC.- REFER TO ORD.
O Applicant Y❑ NE] Y ❑ N❑
� y CI?R'I'IFICATE OF EXEMPTION FROM WORKERS' PERMIT ISSUANCE 10.00 FLOOD ZONE A.L.U.C.-
W > COMPENSATION INSURANCE PLG.CONTR. LIC.NO. , PLG.
CL ❑ 1'I his section need not be completed if file pencil is for oro. TOTAL Y❑ N❑ Y ❑ N❑
:D Z hundred dollars($100)or less)
U O 1 cerlily that in the performance of the work for which this per- QTY. MECHANICAL PERMIT FEE FEE SUMMARY
1L 1- mil is issued,I shall not employ any person in any manner so as to
O W become subject to the Workers'Compensation Laws of California.
0- Date Applicant ALTER OR ADD TO MECH. 5.00 BUILDING
} to NOTICE '10 APPLICANT: If,after making this Certificate of Es-
F 2 emption,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 10MC.F.M.) 4.00
CONSTRUCTION LENDING AGENCY AIR HANDLING UNIT(OVER IQOOOCF.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,Civ.0 L HEATING UNIT(TO 100,000 B.T.U.) 8.00
Lender's NamAddy HEATING UNIT(OV ER 100,000 B.T.U.) /
Lender's Address ELECTRIC
I C
I cenity that 1 have read this u,pf,alion and slate that the above VENTILATION FAN (SINGLE) 4.00
in Rlnnulion is correct. I agree to comply with all city and county PLUMBING
ordinances and sfate 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 aver upon the
above-mentioned property for Inspection purposes. BOILER-COMP (Over 100,000 BTU)SEE FEE SCH. MECHANICAL
(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
may in any way accrue against said City in consequence of the
granting of this permit. MECH,CONT, LIC,NO. MECH.
�I_ TOTAL TOTAL
Signature of kpplcant aril...tar G�/T/'Dale
INSPECTOR COPY -
I