C9147 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
BU LDI NG PROJECT I DENTI FICATI ON PERMIT NUMBER
BUILDINGAPPLICATION & PERMIT �� ��
ADOR E55
BUILDING -ELECTRICAL-PLUMBING-MECHANICAL
OWNER'S AN CHECK VALIDATION
OX NAME It 411""/022 QTY. ELECTRIC PERMIT FEE
g E
ONTR R'S W(�n K yI ?s�71 OUTLETS-SWITCHES-RECEP '10.00/1.00
NAME
LIC.NO. LIGHTING FIXTURES 10.00/1.00
COADDRESNTRASS ORs PPLIANCES-RESIDENTIAL 4.00
PRONE PANELS 10,00 • DATE OF APPLICATION
ARCHITECT PANELS 200 AMP) 20,00 PLAN CHECK FEE P.C.NO.
DR P ID
ENGINEER
LIC.' c.No. SIGNS TRANS. 3.00
ARC R.OR ENG. SPECIAL CIRCUIT 5.00 PERMIT VALIDATION
ADDRESSZIP TEMP.METER OR POLE INS. 20.00 JUN 21 1985 '
AEMOTORS SEE FEE SCH.
ADDRDDRESSSS
SERVICE CHANGE 20.00 City of Cupertino
o Z.
LICENSED CONTRACTORS DECLARATION TEMP.POLE 30.00
U I hereby at in that I am licensed under provisions of Chapter 9 ISSUANCE DATE
m <N (commencing with Section 7000)of Division 3 of Ute Business and BLOC. ELECT. PLG. MECH.
y z Professions Code,and my license is in Cull force and street. -
z 0 m Lieeme Class Lic.Number. y
o z" w IJutc Contractor 0
a y f BUILDING PERMIT
rc w a OWNER-BUILDER DFCLARA'I'ION - INFORMATION
oo " MISC.- REFER TO ORD
w 3 LL I- 1 hereby affirm that I am exempt CrOm the Contractor's GCensC VALUATION
u0< Law for the following reason.(Sec.7031.5,Business and Professions PERMIT ISSUANCE 1000 S/FT.
Code:Any city or corny which requires permit tornnstrart'.1 er,
2 improve,demolish,or repair any structure,prior to its issuance,also ELEC.CONTR. C.NO. ELEC. Q O O
S m, requires the applicant for such permit to file a signed statement that TOTAL PERMIT TO _
o. w he is licensed pursuant to the provisions ol'the Contractor's License
H z i Law(Chapter 9(commencing with Section 7000)of Division 3 ofthe / A ('f
< Business and Professions Code)or that he is exempt therefrom and / V
r m the basis for tlm alleged exemption.Any violation of Section 703 LQTY. PLUMBING PERMIT FEES v S O IE TYPE LaNSTR:
ate _ by any applicant for a perm it subjects th applicant to a civil penalty ALTER-DRAIN -WATER (EA.) 5.00
at not more than five hundred dollars(S 5001.E
❑ I,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,COND. 5.00
Code', 'file Contract.,',,License Law does not apply to an owner of
property who builds or improves thereon,and who does such work F IXTURES-PER TRAP 5.00 SO,FT.FLOOR AREA TOTAL ACREAGE
.,,at,lf or act
rote his own employees,provided that such im building
mentsam nhroug his or offered ees,provided 11WI s,ch building GAS-EA.SYSTEM-11NC.40UTLETS 6.00
or improvement is sold within one year of completion,the owner- GAS-EASYSTEM-OVER 4 (EA.) 200 BUILDING USE
build,,will have the burden of proving that he did not build or im . . .
- S IND CON PB Orher
prow for purpose of side.). INDUSTRIAL WASTE INTER. 3000 El ❑ El 1:1❑ as owner of the property, exclusively contracting with .
licensedd contractors ntraors to construct the
project(Sec. 7044,Business - LAWN SPRINKLERS- 1 INC 5 V.B. 6.00 ASSESSORS PARCEL NO.
and Professions grope The Con builds,s License Law does not apply
to contracts
owner of property who builds tr improves thereon,and who LAWN SPRINKLERS-OVER 5 (EA.) 1.00
conContraorsu Licenects LwithacontractaRs)licensed pursuant to SEWER-SANITARY-STORM EA.200ft/10.00
file Contractor's License Law. TRACT NO. PARCEL NO.
❑ I am exempt under Sec. .B.&P.C.far this WATER HEATER W/VENT 6.00
reason
Owner • • Date WATER SYSTEM 5.00 ACC.DATE ACC.FILE NO.
-V vzqp$7 ftizovo-P"
WORKERS'COMPENSA' toN D .LARA'f IDN WATER TREATING EQUIP. 5.00
hereby atfinn that 1 have o certil ic.d Of consent to sell-insure,
or a certiticate W Workers'Compensation Insurance,or a certified ZONING ENG.SITE NO.
copy thcmof(Sec.3800,Lab.C.).
Policy No. Company •-.
O ❑ Certified copy is hereby furnished. FIRE SPRINK ENERGY T2A
z Z ❑ Certified copy is filed with the city inspection division.
� 0 Applicant MISC.- REFER TO ORD. Y � N❑ y,O-. NE]
CC rn CERTIPICATF OF EXEMPTION FROM WORKERS; PERMIT ISSUANCE 10.00 FLOOOZONE A.L.U.C.
LU7 COAIPF-NSATIONINSURANCE. PLG.CONTR. LIC.NO. PLG, y� NEl VE] N
CL Z( This section need not be completed if the permit is for one TOTAL
hundred dollars IS 100)or less.)
U 0 I certify that in the performance of the work for which this per CITY. MECHANICAL PERMIT FEE FEE SUMMARY
LL H IIIA is issued,I shall not employ any person in any manner so as to
U become subject to the Workers'Compensation Laws of California. BUILDING
n Date-Applicant ALTER OR ADD TO MECH. 5.00
I } N NO'I'ICIi '10 APPLICANT: It,atter making this Certificate of fix-
? cmption,YOU Should become subject to the Workers'Compensation APPLIANCE 5.00 PLAN CHECK
pruvisions'of the Labor Code, you must lorthwith comply with FEE
U such provisions or this permit shall be deemed revoked. AIR HANDLING UNIT(TO 10,000QF.M.) 4.00
CONSTRUCTION LENDING AGENCY AIR HANDLING UNIT(OVER 10p00GEM.) 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,C.), HEATING UNIT(TO 100,000 B.T.U.) 8.00
Lender's Name
Lender's AddreHEATING UNIT(OVER 100,000 B.T.U.)9.50 ELECTRIC
ss
1 certify that 1 have read this application and state that the above VENTILATION FAN (SINGLE) 4.00
• 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 100,000 B.T.U.) 6.00
hereby authorize representatives of this city to enter Upon the BOILER-COMP(Over 100,000 RTU)SEE FEE SCH. MECHANICAL
ubuve-mentioned property for inspection purposes.
(We) agree to save, indemnify and keep harndess the City of MISC.- REFER TO ORD.
Cupertino against liabilities,judgments costs Lou 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.
AA r TOTAL TOTAL
ignu u of A phcant rs to Date
INSPECTOR COPY '
- I