09641 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN-ONLY
SUI LD1 NG PROJECT IDENTIFICATION - - PERMIT NUMBER
.,( nDILDING APPLICATION & PERMIT
l` ADDRESS I -
C 'F- wa BUILDING- ELECTRICAL-PLUMBING-MECHANICAL 09641
OWNER'$ I PLAN CHECK VALIDATION
/ NAME 'QTYt ELECTRIC PERMIT FEE -
`L M P_QS U PHONE
CONTRACTORS
NAME ` OUTLETS-SWITCHES-RECEP 10.00/1.00
SO O "fS LIC,NO. LIGHTING FIXTURES 10.00/1.00
CONTRACTORS -
ADORESzI PPLIANCES-RESIDENTIAL 4.00
�)IS \ PHONE 5 QZ PANELS 10.00 DATE OF APPLICATION
ARCHITECT PLAN CHECK FEE P.C.NO. .
OH PANELS (OVER 200 AMP) 20.00
ENGINEER n'S O �yr LI ii
h...) `�A er S uc.No. SIGNS TRANS. 3.00
ARCH.OR ENG. PERMIT VALIDATION
ADDRESS pp SPECIALCIRCUIT - 5A0
en y 8111 zIP EMP.METER OR POLE INS. 20,00
AOOREss
APPLICANT T's - MOTORS SCH.
,
SERVICE CHANGE 20.00
w o Or LICENSED CONTRACTORS DECLARATION TEMP.POLE AUG 2 9 19890
u u I hereby affirm that I am licensed under provisions of Ch.pler'I I65U_AN/E DATE
N a w (commencing with Section 7000)of Division 3 of the Business ami BLDG. ELECT. PLG. MECH.
o Professions Code n @@ license is in full floc sLe ffe ❑ ❑ ❑ ❑
Oi= �/ License .lass - Vy Lia Number 2`I
A!: "f� Dole e{-$S Contruclor
Q y E J
ce S, w a OWNER-BUILDER DECLARATION BUILDING PERMIT
w ; u INFORMATION
u w I hereby atl'inn that I am exempt from the Contractor's License MISC.- REFER TO ORD 1
r .. O4 Lawfor tlse following reason.(Sec.7031.5,Business and Professions PERMIT ISSUANCE 10.00 vAWAT10N $/FT._
as a Code:Any city Or county which requires a permit to Construct,alter,
`a M C 0O improve,demolish,(it repair uoy structum,prior to its issuance,also ELEC.CONTR. LIC-NO. ELEO. %I
u requires the applicant for such permit m file a signed statenu.•nt HurtTOTAL
PERMIT TO
e w m a he is licensed pursuant n the provisions of the Contractor's License / 3
H- => Lawless andr9(commcnCde)cing or that he
is 00)exemfDtheian3 and
the
Business and professions Code)or IAn hi is exempt therefrom and QTY. PLUMBING PERMIT 'FEE ON
I[H$ the basis for the allege)exemption.Any viohatica of See nol rn L5 STORIES TYPE CONSTR.
if any umeflo fore handbill
S500o.lie hicantmacivilpewlty ALTER-DRAIN -WATER (EA.) 5.00
' of not more than five hundred dollars(85007.):
❑ I,as owner of the property,or my employees with wages as BACK FLOW PROTECT. DEV ICE 4.00
their sole compensation,will do the work,and the etnmtrue is oat OCC.GROUP REg.UNITS
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 builds m in,roves thmem,:Illll who(toes sash work FIXTURES-PER TRAP 5,00 SO,FT,FLOOR AREA TOTAL ACREAGE
himself re through his own employees,provided that such improve. I
omerits r
not intended or within
rone year
if, the the owner. GAS-EA.SYSTEM-11NC.40UTLETS 6.00
or improvement is e b within one year of completion, the owner- i
builder will have the burden of proving that lie did not build or in,- GAS-EA.SYSTEM:OVER 4 (EA.) 2.00 ' BUILDING USE
for RES IND CON PB 011ier
prove 1,aso nee of sale.). INDUSTRIAL WASTE INTER. 30.00
❑ d as owner of the property,he reject(Se contracting with
licensed contractors: constructthe project(Sec.7044,Business LAWN SPRINKLERS-1 INC5 V.B.'. '6.00 ASSESSORS PARCEL NO.
and Professions Cody.The who
bildsContractor's License Lusv does not apply
- m nn owner of property who builds or improves thereon,and who LAWN SPRINKLERS-OVER 5(EA.) 1.00
contracts for such projects with a coulnmlOGS)licensed purSum t In
tireCommctor'sLicense Law. SEWER-SANITARY-STORM EA.200ft/10.00 TRACT NO. PARCEL NO. I
❑ I am exempt under Sec..,B.&P.C.for this -r WATER'HEATER W/VENT 6.00
reason
Owner Date WATERSYSTEM5.00 , •ACC.DATE - ACC.FILE Ni
WORKI?RS'COMPI?NSA'I'ION DECLARATION ,WATER TREATING EQUIP. 5.00 '
I hereby affirm that I have a re cafe ofconsenl nsur•
or a certificate of Workers'Compc,"G 111,1no 0 u c ZONING 'ENG.SITE NO.'
copy lheryoC Iseec.�800 L' C.1.
Policy No>r%rC' 1'AII61�•
O '5 Certifiedcopy is hereby fur.ished. FIRE SPRINK ' ENERGY T-24
z^�/ ❑ Certified is file ill tl cilY inspection division. ..
H U/ Applicant MISC.- REFER TO ORD. v N v NE]
C
CCERTIFICAT H OF EXEMPTION.PROMPORKERS' PERMIT ISSUANCE 10.00 FLOODZONE A.L.U.C.
LU > COMPENSATION INSURANCE PLG.CONTR. LIC.NO. PLG.
1 Q (This section need not be completed if the permit is for one _ TOTAL Y 0 N 0 Y F] NE]
::) Z hundred dollars IS 100)nT less.) -
U O I certify that in the performance of the work for which this per- QTY. MECHANICAL PERMIT FEE FEE SUMMARY.
LL 1- mit is issued, I shall not employ any person in any manner so as to
O W become subject to the Workers:Compensation Laws of Calibur .iu.
y Date Applicant ALTER OR ADD TO MECH. 5.001 BUILDING
} W NOTICE TO APPLICANT: If,after making this Certificate of fix-
2 emption,you should become subject to the Workers'Compensutiml 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 10,000C.F.M.) 4.00
CONSTRUCTION LENDING AGENCY AIR HANDLING UNIT(OVER 10=C.F.M.) 6.00 SEISMIC FEE
I hereby affirm that there is 4 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 HEATING UN IT 100,000 B.T.U.)9.50 Q JL a
Lender's Address ELECTRIC
I certify that I have read this application and state that the above VENTILATION FAN (SINGLE) 4.00 ..
i nfornution d correct. I agree to comply with all city and county BOILER-COMP(3 H.P.or lOO,000B.T.U.) 6,00 PLUMBING
\ oNinences and state laws relating IO building construction, and
/ hereby authorize representatives of this city to enter upon Ili° BOILER-COMP IOver 100,000 BTU)SEE FEE SCH. MECHANICAL
above-mentioned property for inspection purposes.
(We) agree to Save, indemnify and keep harmless the City of IS
- REFER TO ORD.
Cupertino against liabilities,judgments, costs and expenses which CONST.TAX
may in any wuy accoe against said City In consequence Of tile 'PERMIT ISSUANCE 10.00-
grantingofthispefnlit MECH.CONT. - LIC.NO. - MECH.
-X ZGt' TOTAL TOTAL
Signature of Applicant/Contruclor r Date
OFFICE COPY