9396 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
BU I LDING PROJECT I DENTIFI CATION PERMIT NUMBER
ADSG APPLICATION & PERMIT 9396
ADDRESS EES
BUILDING-ELECTRICAL-PLUMBING-MECHANICAL
OWNER r PLAN CHECK VALIDATION
"AME OTY. ELECTRIC PERMIT FEE
DNE
mSme s UTLETS-SWITCHES-RECEP 10.00/1.00
L' LIc.ND.. LIGHTING FIXTURES 10.00/1.00
r, TRACTOR'S
ADDRESS PPLIANCES-RESIDENTIAL 4.00
DRESSE55 a
�p�/JPHONE~ PANELS 10.00 GATE OF APPLICATION
DRrcHIrecT Q QuPf PANELS (OVER 200 AMP) 20.00 PLAN CHECK FEE P.C.No.
NGINEER
LIC.No SIGNS TRANS. 3.00
ADDRESS END
PWAL70 SPECIAL CIRCUIT 5,00 PERM _WMW ION
1JAJ A ` ZIP TEMP. METER OR POLE INS. 20.00 q nn Qtle
APPLICANT
2 rs MOTORS SEE FEE SCH. JUL $ 1965
SERVICE CHANGE 20.00
w o o- LICENSED CONTRACTORS DECLARATION TEMP.POLE 30.00 City of Cupertino
a i I hereby affirm that I am licensed under provisions of Chapter 9 ISSUANCE DATE
m rt w (commencing with Section 7000)of Division 3 of the Business and BLD ELECT. PLG. MECH.
F D z Professions Code,and no,license is in full force and effect. ❑ ❑ ❑
z O to ea License Clas - Lie Numbs
g m r w Date Contractor
Y f BUILDING PERMIT
¢ re sc OWNER-BUILDfiR DECLARAT ON
a a D INFORMATION
is ; m I hereby affirm that 1 am exempt from the Contractor's License MISC.- REFER TO ORD
u o j Law for the following reason.(Sec.7031.5,Bruinessand Professions VALUATION $/FT.
_ PERMIT ISSUANCE 10.00
Code:Any city or county which requires apermiuo construct,alter,
¢ ¢ ¢ O Improve,demolish,or repair any structure,prior to Its Issuance,also ELEC.CONTE. LIC.NO.LL ELEC.requires the applicant for such permit to file a Signed statement that TOTAL PERMIT TO
n w m w he is licensed pursuant to the provisions of the Contractor's License
La Law(Chapter 9(commencing with Section 7000)of Division 3 ofthe
4 o Business and Professions Code)or that he is exempt therefrom and OTY. PLUMBING PERMIT FEE
¢ H the basis for line alleged exemption.Any violation of Section 703 L5 STORIES TYPE CONSTR.
by any applicant for a permit subjects the applicant Ina civil penalty ALTER-DRAIN (EA.) 5.00 'II 1r
of not more than five hundred dollms($500).): T �7I 1
❑ I,as owner of the properly,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 (See. 7044, Business and Professions DRAINS-FLOOR,ROOF,AREA,COND. 5.00
Code:The Contractor's License Law,docs not apply to an owner of
property who builds or improves thereon,and who does such work FIXTURES-PER TRAP 5.00 sa FT.FLOOR AREA TOTAL ACREAGE
• himself or through his own employees,provided that such improve-
Rents me not intended or offered for sale.If,however,the building GAS-EA.SVSTEM-l1NC.40UTLETS 6.00
or improvement is sold within one year of completion,the owner- GAS-EA.SYSTEM-OVER 4 (EA.) 2.00
builder will have the burden of proving that he did oot'huild or inn- BUILDING USE
prove for purpose cfsale.). c -\ INDUSTRIAL WASTE INTER. 30.00 EEs INO a PB Omer
D I,as owner of the properly,am exclusively contracting with ❑ ❑ 1:1 1:1licensed contractors to construct the project(Sec. 7044, Business LAWN SPRINKLERS- 1 INC 5 V.B. 6.00 ASSESSO RCE:NO.
and Professions Cade:The Contractor's License Law docs Ful apply
to an owner of properly who builds or improves thereon.and who LAWN SPR INKLERS-OVER 5 (EA.) 1.00
contracts lift such projects with a contructons)licensed Pursuant SEWER-SANITARY-STORM EA.200ft/10.00
Rfe Contractors License Law. TRACT NO. PARCEL NO.
❑ I am exempt under Sec.-,IT&P.0 fur this WATER HEATER W/VENT 6.00
reason
Owner Uute WATER SYSTEM 5.00 ACC.DATE ACC.FILE NO.
WORK ERS'COMPENSA'IION DECLARATION WATER TREATING EQUIP. 5.00
/ 1 hereby affirm thal I have a certificate of consent hi"If-insure, _
or a cetlihcale of Workers'Compensation Insurance,or a ccrlificd ZONING ENG.SITE NO.
copy Ihcreof(Scc.3800,Lah.C.l. O
Policy No. Company-
0
ompany 0 0 Certified is hereby fu fished.
FIRE SPRINK ENERGY T 24
Z_ Z +-For'tied y is, Ie h < 'nspwlion division. MISC.- REFER TO ORD. Y ❑ N❑ Y ❑ N❑
p hcmv
cc:~ rn PERMIT ISSUANCE 10.00
�( ' C' TIPIC .Oh .(I!MI'1'ION PROM WORKIiRS' FLOOD ZONE A.L.u.C.
LL C .1PENSATION INSURANCE PLG.CONTE. uC.No. PLG.
� Z I This section need not be completed it(he pennit is for one TOTAL Y❑ N❑ Y ❑ N❑
hundred dollars IS 100)or less,)
U O 1 certify(hal in the performance of the work for which this per OTY MECHANICAL PERMIT FEE FEE SUMMARY
LL U mil is issued,I shall not employ any person in any manner so as to
0 of become subject to the Workers:Compensation Laws of Calihi rnia. y�
Date Applicant ALTER OR AOD TO MECH. 5.00 BUILDING ]V
} tin NOTICE TO APPLICANT: If,after making this Certificate of F
2 emption,you should become subject to the Workeri Compensation APPLIANCE 5.00 PLAN CHECK
provisions of lire Labor Code, you must forthwith comply will FEE
U such provisions or(his permit shall be deemed revoked. AIR HANDLING UNIT(TO 10,000CF.M.) 4.00
CONSTRUCTION LENDING AGENCY AIR HANDLING UNITIOVER 10=C.EM.) 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 ismed(See. MICROFILM
3097,Civ.CJ. HEATING UNIT(TO 100,000 B.T.U.) 8.00
Lender's Name , HEATI NG UN IT 100,000 B.T.U.)9.50
Lender's Address ELECTRIC
I certify that lhave read this application and stale that the above VENTILATION FAN (SINGLE) 4.00
• information is correct. I agree to Co),nply 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 remewmatives of this city to enter upon the BOILER-COMP(Over IOD,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 aridFexpeases which
may in any way accrue, PERMIT ISSUANCE 10.00 CONST.TAX
again said City in Consequence of the
granting of this permit MECH.CONT. LIC.NO, MECH.
TOTAL TOTAL
42 App ntj,Contractor-
V INSPECTOR COPY
1