09545APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
BUILDING PROJECT IDENTIFICATION
&PERMIT
BUILDING - ELECTRICAL- PLUMBING - MECHANICAL
PERMIT NUMBER
on� Q r
BUILDINGAPPLICATION
ADDRESS
O NER'S
NAME I �SOTY.
PHONE57W-/y81
ELECTRIC PERMIT FEE
PLANCHECK VALIDATION
NOAMERACTos
OUTLETS -SWITCHES -RECEP 10.00/1.00
LIGHTING FIXTURES 10.00/1.00
-* 1 Isr+o.,7
AS
TRACT -
dooREss
PPLIANCES- RESIDENTIAL 4.00
//14pa 14=J PHONE
DATE OF APPLICATION
PANELS 10.00
Oqc Ecr
ENGINEER
uc. ND.
PANELS (OVER 200 AMP) 20.00
PLAN CHECK FEE P.C. NO.
SIGNS TRANS. 3.00
ADDRRESS eNc.
SPECIAL CIRCUIT 5.00
P OATION
EMP. METER OR POLE INS. 20.00
ZIP
AUG 2 3 1995
A
ADDRESS
ss
MOTORS SEE FEE SCH.
SERVICE CHANGE 20.00
y� ,y
Cl{a) O{ I CUpel `IOO
LICENSED CON "T RACTORS DECLARATION
TEMP. POLE 30.00
I hereby affirm that 1 am licensed under provisions of Chapter 9
(commencing with Section 7000) of Division 3 of the Business and
Professions Code unA my license is in full Tome and eff et.
License Class Lic. Nu I cr
ISSUANCE DATE
BLDG. ELECT. MECH.
O ❑ ❑
Date_�,� i Contractor
BUILDING,PERMIT
INFORMATION
OWNER -BUILDER DECLARATION
1 am exempt lions the Contractor's License
I hereby collo following Professions
ess to
Law for theity orconywhih c. requires a permit
Code: Any city or county which requirese permit m construct, alter,
MISC.- REFER TO ORD
PERMIT ISSUANCE 10.00
VALUATION
ELE0. CONTR. LIF NO.
ELEC.
TOTAL
improve, helapplic, Or repair any Permit that
10fi pa Si n its alConC0. talsohat
requires else applicant for such pemil to fila a signal Contractor's
he is licensed to the provisions of tire ConveLire the
PER IT TO
QTY. PLUMBING PERMIT FEE
9(copursuant
of -Division 3 of the
Law (Chapter 9 (commencing with Section is exempt
Business and Professions Code) or that he is exempt therefrom and
STORI
TYP CONSTR.
the basis for the alleged exmn prion. Any violation of Section 7031.5
by any ca,h,
permit subjects S5000.he licwltmacivil pamlty
ofnotofeth thnt an for ive
of not more than fiee hundred dollars (5500).):
ALTER-DRAIN-WATER(EA.)5.00
❑ I, as owner of,the property, or my employees with wages ABACK
their sole compensation, will do the work, and the structure is not
FLOW PROTECT. DEVICE 4.00
OCC. GROUP
.UNITS
DRAINS -FLOOR, ROOF, AREA,COND. 5.00
intended or offered for sale (Sea 7044, Business and Professions
Code: The Contractor's License Law does not apply to an owner of
property who builds or improves thereon, and who does such work
himself or through his own employees, provided that such improve-
ments are not intended or offered for sair. If, however. The building
FIXTURES - PER TRAP 5.00 C
SQ FT. FLOOR AREA
TOTALACREAGE
'
GAS -EA. SYSTEM -1 INC. 40UTLETS 6.00 G
or improvement is sold within one year of completion, the owner-
builder will have the burden of proving that he did not build or int-
prove for purpose of sale.).
❑ 1, as owner of the property, am exclusively contracting with
GAS EASYSTEM OVER 4 (EA.) 2. 00
- . -
BUILDING USE I
RE IND eoN PB' Omer
�; El
INDUSTRIAL WASTE INTER. 30.00
LAWN SPRINKLERS - 1 INC 5 V.6. 6.00
licensed contract.,, to construct the project (Sec. 7044, lousiness
and Professions Code. The Contractor's License Law does not apply
AssEssORSPARCEL NO.
to an owner of property who builds or improves thereon. and who
LAWN SPRINKLERS - OVER 5 (EA.) 1.00
contracts for such projects with a contractors) licensed pursuant to
the Comment,', License Law,
TRACT NO. PARCEL NO.
SEWER -SANITARY -STORM EA. 200ft/10.00 D
❑ lam exempt under Sec.-, B.&P,C. for this
WATER HEATER W/VENT 6.00
a on
Owner Date
WATER SYSTEM 5.00 O
ACC. DATE
ACC. FILE NO.
WATER TREATING EQUIP. 5.00
WORK Ii RS'COMPENSATION DECI-ARATION
I hereby affirm that I have a certificate of consent to olf-i......
or a certificate of Workers' Compensation Insurance. or a certified
ZONING
ENG. SITE NO.
copy thereof (Sea 3800, Lub.C.).
Policy No. Company
❑ Certified copy is hereby furnished.
j}ECertified py i5 filed with the city inspection division.
Appl cant�j.I(C(�rr
FIRE SPRINK
Y[3 No
ENERGY T44
Y0 NE]
MISC.- REFER TO ORD.
CERTIFICATE OP EXEMPTION FROM WORKERS'
PERMIT ISSUANCE 10.00 to(fO
FLOOD ZONE
A.L.U.C.
COAIPENSATION INSURANCE
IT his section need not be completed if the permit is for one
Y El NEI
Y 0 N0
PLG. CONTR. LIC. NO.
PLG. /.n
TOTAL 00
hundred dollars IS 100) or less.)
I certify that in the performance oIthe work I'or which this per-
s
mit is sued, I shall not employ any person in any Runner so as to
QTY. MECHANICAL PERMIT FEE
FEE SUMMARY
BUILDING
becomesubject To The Workers' Compensation Laws of California.
Date Applicant
ALTER OR ADD TO MECH. 5.00
NOTIC17 10 APPLICANT: It, after making this Certificate of Ex-
APPLIANCE 5.00
PLAN CHECK
FEE
emption, you 0muld become subject to the Workers' Compensation
provisions of the Labor Code you must forthwith comply with
such provisions or this permit shall be deemed revoked.
AIR HANDLING UNIT (TO 10=C,F.M.) 4.00
AIR HANDLING UNIT(OVER IO,000C.EM.) 6.00
SEISMIC FEE
CONSTRUCT ION LENDING AGENCY
I hereby affirm that there is a construction lending agency for
EXHAUST HOOD (WITH DUCT) 5.00
The performance .f the work for which (his permit is issued (Sec.
3097,Civ.CJ,
MICROFILM
HEATING UNIT (TO 100,000 B.T.U.) 8.00
Lender's Name
N
Lender's Name
HEATING UNIT (OVER 100,000 B.T.U.)
ELECTRIC
VENTILATION FAN (SINGLE) 4.00
I certify that I have read this application and state that the above
information is correct. 1 agree to comply with all city and county
ordinances and stale laws relating to building construction, and
PLUMBING
�' Q�%
BOILER-COMP(3 H.P. or 100,000 B.T.U.) 6.00
BOILER -COMP (Over 100,000 BTU) SEE FEE SCH..
MECHANICAL
hereby authorize representatives of this city to enter upon the
above-mentioned property for inspection purposes.
(We) agree to Save, indemnify and keep harmless the City of
Cupertino against liabilities, judgments, costs and expenses which
may in al way accrue against said City in consequence of the
gra°`�'11 his permR
MISC. - REFER TO ORD.
PERMIT ISSUANCE 10.00
CONST. TAX
MECH. CONT. UC. NO.
MECH.
/0 A Kai. �lr� Ike
TOTAL
TOTAL
Signalfire o (Spun t n ru for Dale
INSPECTOR COPY