09544APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
BUILDING PROJECTlDENTIFICATION
APPLICATION & PERMIT
BUILDING—ELECTRICAL—PLUMBING—MECHANICAL
PERMIT NUMBER
09544s
BUILDING
aDooqE
INNIP. I
NaME/y` I
PHONE ) a
CITY. ELECTRIC PERMIT FEE
PLAN CHECK VALIDATION
NAMERACT Rs
UTLETS-SWITCHES -RECEP 10.00/1.00
No. 20
Me
LIGHTING FIXTURES 10.00/1.00
. NT AC o'sI
aoNRE55
PPLIANCES- RESIDENTIAL 4.00
PANELS 10.00
F / PHONE -C
DATE OF APPLICATION
ARRCH TE
D
ENGINEER
LIC. NO
PANELS (OVER 200 AMP) 20,00
PLAN CHECK FEE P.C. NO.
PAM
SIGNS TRANS. 3.00
ADDRESS ENa
SPECIAL CIRCUIT 5.00
PERMIT VALIDATION
ZIP
F
AUG 2 3 1985
IN
EMP. METER OR POLE S. 20.00
ADORES
aoDRESS
MOTORS SEE FEE SCH.
SERVICE CHANGE 20.00
City of Cupertino
LICENSED CONTRACTORS DECLARATION
TEMP. POLE 30.00
I hereby affirm that I am licensed under provisions of Chapter 9
(commencing with Section 7000) of Division 3 of the Business and
Professions Code, and m license is in full force and ef(e
License Class r Lia Number- F/�
Date Contractor
ISSUANCE DATE
BLOQ
❑
ELECT.
❑
PLG. MECH.
❑
1
-
OWNER -BUILDER DECLARATION
I hereby affirm that I am exempt from the Contractor's License
Law for the fallowing reason. (Sec. 7031.5, Business and ProfessionsPERMIT
Code! Any city or county which requires a permit to construct, alter,
BUILDING PERMIT
INFORMATION
MISC. — REFER TO ORD
ISSUANCE 10.00
VALUATION
$/FT.
ELEC. CONTR. LIC. NO,
ELEC.
TOTAL
improve, JCahiloh, or re Pair any structure, prior to its issuance, also
requires the applicant for such permit to file a signed statement that
he is licensed pursuant to the provisions of the Contracmr's License
P R Ir 0
Law (Chapter 9 (commencing with Section 7000) of Division 3 of the
❑usiner. and N ficszluns Code) or that he is exempt therefrom and
the basis for the allege) exemption. Any violation of Section 703 LS
by any applicant fora permit subjects the applicant toacivil penalty
of not more than five hundred dollars ($500).1'.
CITY. PLUMBING PERMIT FEE
/
STORI
TVPP ONSTR.
ALTER -DRAIN -WATER IEA.) 5.00
❑ I, as owner of the property, or my employees with wages as
their sole compensation, will do the work, and the structure is not
BACK FLOW PROTECT. DEVICE 4.00
OCC. GROUP
RES. UNITS
DRAINS -FLOOR, ROOF, AREA,COND. 5.00
intended or offered for sale (Sec. 7044, Business and Professions
Code: The Contractor's License Law does not apply to all owner of
property who builds or improves thereon. and who does such work
himself or through his own employees. provided that such improve-
mumsorenotintended or offered for sales lL howeveq the but ldingGAS-EA.SVSTEM-11NC.40UTLETS
FIXTURES - PER TRAP 5.00"(�
6.00 Ob
SO. FT. FLOOR AREA
TOTAL ACREAGE
or improvement is sold within one year of completion, the owner-
builder will have the burden of proving that h e did not build or int-
- . -..
GAS EASYSTEM OVER 4 (EA.) 200
BUILDING USE
prove for purpose ofsaleJ.
❑ 1, as owner of the property, am exclusively contracting with
IND CON PB Omer
0 0 El
INDUSTRIAL WASTE INTER3000
. .
LAWN SPRINKLERS- 1 INC 5 V.B. 6.00
licensed contractors to construct the projectISec. 7044, Business
and Professions Code: The Contractor's LicencC Law does not apply
to an owner oIproperty who builds or improves thereon, and who
ASSESSORS PARCEL NO.
LAWN SPRINKLERS - OVER 5 (EA.) 1.00
contracts for such projects with a contractors) licensed pursuant to
the Contractor's License Law.
TRACT NO. PARCEL NO.
SEWER -SANITARY -STORM EA. 200tt/10.00 00
❑ lam exempt under Sec. .B.&P.C. (or this
rea4lm
WATER HEATER W/VENT 6.00 CYJ
Owt'cr Date
If WATER SYSTEM 5.00 C�-Ut
ACC. DATE
ACC. FILE NO.
WATER TREATING EQUIP. 5.00
WORK ERS'COMPENSATION DECLARATION
1 hcrcby affirm Hill 1 have a certificate of consent to celf-ir,um.
or a certificate of Workers Compensation Insurance, or a certified
ZONING
ENG. SITE NO.
copy thereof(Sec. 3800, Lab.Cy
Policy No. Company
FIRESPRINK
y N�
ENERGYT24
v NE]Anp
Cl Certilmdcopyisherebyfumished.
Certified copy is filed with the city inspection division.
campy..: em,r 3
MISC. - REFER TO ORD.
CER 'I'I FICA'1'17 OF EXEMPTION FROM WORKP-RS•
PERMIT ISSUANCE 10,00 OO
FLOOD ZONE
A. L. J.C.
COMPENSA"PION INSURANCE
1"['his section need not be completed if the permit is for one
y ❑ N�
y N�
PLG,CONTR. ❑D. NO.PLG,
ry1
TOTAL VV
hundred dollms IS 100) or less.)
I certify that in the performance of the work for which this per-
mit is issued, I shall not employ any person in any manner so as to
CITY. MECHANICAL PERMIT FEE
FEE SUMMARY
BUILDING
become subjccl to the Workers' Compensation Laws of California.
Date Applicant
ALTER OR ADD TO MECH. 5.00
NOTICE: TO APPLICANT: If, after making this Certificate of fix-
APPLIANCE 5.00
AIR HANDLING UNIT (TO 10000 GF.M.) 4.00
PLAN CHECK
FEE
emption, you should become subject to lira Workers' Compensation
provisions of 0m Labor Code, you must forthwith comply with
such provisions or this permit shall be deemed revoked,
AIR HANDLING UNIT (OVER 10MC.EM.) 6.00
SEISMIC FEE
CONS'fRUC'1'ION LENDING AGENCY
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 Beirut is issued (Sec.
3097, Civ.C.L
MICROFILM
HEATING UNIT (TO 100,000 B.T.U.) 8.00
Lender's Name
Lender's Address
HEATING UNIT (OVER 100,000 B.T.U.)9.50
ELECTRIC
VENTILATION FAN (SINGLE) 4.00
I certify that I have read this application and state Iltxt the above
ill'ognmion is rorrect. I agree to comply with all city and county
ordinances and stale laws relating to building construction, and
PLUMBING
UD
g01LER-OOMP(3 H.P. or 100,0008.7. U.) 8.00
gOI LER-COMP IOver'100,000 BTU) SEE FEE SCH.
MECHANICAL
hereby authorize representatives of this city to enter upon the
above-Inuntiuned 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 any way accrue against said City in nsequence of the
co
MISC. - REFER TO ORD.
PERMIT ISSUANCE 10.00
-
CONST. TAX
grantor of tiro ermi1.MECH.
CONT LIC. NO.
MECH.
TOTAL
TOTAL
Stg ' m rel Cnn ran[ r Ua[c
INSPECTOR COPY