8538 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
BUILDING PROJECT IDENTIFICATION PERMIT NUMBER
TULDHxG APPLICATION & PERMIT
A.pRESS
Rp33
RAE L BUILDING -ELECTRICAL-PLUMBING-MECHANICAL 8538
x OWNERS y PLAN CH ECK VALIDATION
NAME
QTY. ELECTRIC PERMIT'.i:1%
' • :FEE,., pA4110
v ONE 7 5-211
NOAM1ERAcrons UTLETS-SWITCHES-RECEP 10.0011.00
LIC.No. LIGHTING FIXTURES 10.00/1.00 MAY 2 - 1985
CONTRACTOR S PPLIANCES-RESIDENTIAL 4.00
ADDRESS
//..� ,Z, PHONE Z. 9 PANELS 10.00 I�Ilf41t!'q;lam
ORRCNI ECT PANELS (OVER 200 AMP) 20.00 PLAN CHECKECK FEEFEE P.C.NO.
ENGINEER
LIC.No. ISIGNS TRANS. 3,00
ADDRESS ENG' SPECIAL CIRCUIT 5.00 PERMIT VALIDATION
ZIP TEMP,METER OR POLE INS. 20.00
ASMOTORS SEE FEE SCH.
ADDREDDRESSS
SERVICE CHANGE 20.00
mo LICENSED CONTRACTORS DECLARATION TEMP.POLE 3400
a iI hereby affirm that 1 am licensed under provisions of Chapter 9 ISSUANCE DATE
w ¢ % (commencing with Section 7000)of Division 3 of the Business and SLOG. ELECT. PLG. M C .
2 Professions Code, my license is in full farce a t. ❑ ❑ ❑
Z0 !0 License as Lic.Numneryje3�!
O Zn, w Date Comm mr
< m dow " ;BUIL-DING PERMITx�.'t n
¢ ¢ OWNER-BUILDER DECLARATION
¢ w INFORMATION'•;
I hereby affirm that I am exempt from the Contrctor's License MISC.- REFER TO ORD -
LL00¢ Lawforthefollowingreason.(Sec.7031.5,Business and Professions PERMIT ISSUANCE 10.00 vRwATION E/FT.
Code:Anycity orcounty which requiresa permit to construct.m � ELEC.CONTR. LIC.NO.
Q ¢ improve,demolish,or repair any structure,prior to its issuance,also ELEC.
a wCLL requires the applicant for such permit to file a signed statement that TOTAL
$ he is licensed pursuant to the provision,of the Contractor's License ERMIT TO
H z i
Law(Chapter 9(commencing with Section 7000)of Division 3 ofthe ^ s"';
Business and Professions Code)Or that he is exempt therefrom and QTY: PLUMBING'PERMIT'' . . FEE.T'
IF H the basis for the alleged exemption.Any violation of Section 7031.5 _ ;f. STORIES TYPE CONSTR.
w. by any applicant for a permit subjects he applicant to a civil penalty ALTER-DRAIN -WATER (EA.) 5.00
of not in..than five hundred dollars($500).):
❑ 1.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:The Contractors 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 Sa FT.FLOOR AREA TOTAL ACREAGE
• himself Or through his own employees,provided that such improve-
menta are not intended or offered 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-EA.SYSTEM-OVER 4(EA.) 2.00
builder will have the burden of proving that he did not build or im- BUILDING USE
prove for purpose ofsale.). INDUSTRIAL WASTE INTER3000 IND CON PB Om.
. .
,
❑ I,as owner of the property,am exclusively contracting with ❑ Cl ED ❑
licensed contractors to construct the project(Sec. 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 of property who builds or improves thereon,and who LAWN SPRINKLERS-OVER 5(EA.) 1.00
contracts actor's h projects with a contractors)licensed pursuant to SEWER-SANITARY-STORM EA.200ft/10.00
the Contractor's for
Os'S License Law. TRACT N0. PARCEL NO.
«a❑ I am exempt under Sec.-,BAP.C.for this WATER HEATER W/VENT 6.00
non
Owner Date WATER SYSTEM 5,00 ACC.DATE ACL.FILE NO.
WORKERS'COMPENSATION DECLARATION WATER TREATING EQUIP, 5.00
I hereby affirm that 1 have a certificate of consent to self-insure, ZONING ENG.SITE N0.
or a certificate of Workers'Compensation Insurance,or a certified
copy thereof(Sec.3800.Lab.C.I
Policy No. Companyp>f.
Q ❑ Certified copy is hereby,turn is ed FIRE SPRINK ENERGY T24
Z Z ❑ Certified c I^•Oled 'th the "Sy nspection division. MISC.- REFER TO ORD.
yApplicant V N V N
- CERTIFICATE OF PTION FROM WORKERS' PERMIT ISSUANCE 10.00 FLOOD ZONE A.L.U.C.
ANC
UJ 2! COMPESAION a (This section need not beTcomple ed if heEpermit is for one PLG.CONTR. LIC.NO. TOTAL Y N Y N�
CL
Z hundred dollars IS 100)Or less.) •'
U O I certify that in the performance of the work for which this per QTV. MECHANICAL.PERMIT a FEE 4' FEE SUMMARY
LL 1- mit is issued,I shall not employ any person in any manner so as to _ -"' -
O become subject to the Workers'Compensation Laws of California. - -
y Date Applicant ALTER OR ADD TO MECH. 5.00 BUILDING
>- tz3 NOTICE TO APPLICANT: If,after making this Certificate of Ex-
? emotion,you should become subject to the Worker'Compensation APPLIANCE 5.00 PLAN CHECK
provisions of the Labor Code, you must forthwith comply with FEE
U such provisionsor this permit shall be deemed revoked. AIR HANDLING UNIT(TO 10=C.F.M) 4.00
CONSTRUCTION LENDING AGENCY AIR HANDLING UNIT(OVFA 10=CEM.) 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 1Q0,000 B.T.U.) 8.00
Lender's Name HEATING UNIT(OV ER 100,000 B.T.U.)Lender's Address ELECTRIC
I certify that I have read his application and state hat he 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-COMB 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 BTU)SEE FEE SCH. MECHANICAL
above-mentioned property for inspection purposes.
(We) agree to Save, indemnify and keep harittess 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 co ^equence of the
granting of is permit. MECH.CONT. LIC.NO. MECH.
TOTAL , TOTAL' /
Signature of Applicant/C for Date Q
OFFICE COPY