09608 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
BUILDING PROJECT IDENTIFICATION PERMIT NUMBER
G,LG APPLICATION & PERMIT
ADDRESS ��60„�f'✓,'.
NAME a
BUILDING-ELECTRICAL-PLUMBING-MECHANICAL NAME DTV. ELECTRIC PERMIT FEE PLAN CHECK VALIDATION
0J - Ce PHONE _ p
Nome AcrDR's UTLETS-SWITCHES-RECEP 10.00/1.00
„�. TIC.No. - ,4" LIGHTING FIXTURES 10.00/1.00
ADDRESS
oR's PPLIANCES-RESIDENTIAL 4.00
REss
HONE PANELS 1 10.00 DATE OF APPLICATION
q y45'yK FEE P.C.NO.
DR 6 PANELS (OVER 200 AMP) 20.00 PLAN CHEC
ENGINEER
uc.NO, SIGNS TRANS. 3.00
ARCH.
OR ENG' SPECIAL CIRCUIT S.QQ PERMIT VALIDATION
Zip TEMP.METER OR POLE INS. 20.00 PAID
Ali MOTORS SEE FEE SCH.
ADDRESS
p -2
IS, // , __ -_- SERVICE CHANGE 20.00 SEP 041595
o o LICENSED CONTRACTORS DECLARATION TEMP, POLE 30.00 (�
a u U I hereby affirm that I am licensed under provisions of Chapter 9 tibNAAtDwino
G,
w (commencing with Section 7000)of Division 3 of the Business and D m BLDG. ELECT. PLG. MEC .
F w z Professions Code,and my license is in full force and effect. ❑ a ❑
Z O y - License ClasaCw?,g.,,;!zLic.Number G f
O a Y z 0W Date zo. 9,,Pp_
.-Contmnor e u .B 3 - 9- •8 r
¢ ¢ ¢ OW ER-BUILDEBUILDING PERMIT
R DECLARATION -
a a ut u INFORMATION
w ; w I hereby affirm that 1 um exempt from the Contractor's License MISC.- REFER TO ORD
F LL O ot Law for the following reason.(See 7031,5,Businenand Professions pERMIT ISSUANCE 10.00 VALUATION S/FT.
Code:Any city or county which requiresa penal to construct,alter,
¢ tap improve,demolish,or repair any'structure,prior to its issuance.also ELEC.CONTR. LIC.NO. ELEC.
ut
- o u requires the applicant for such permit to file a signed statement that TOTAL PE IT TO
d w m w he is licensed pursuant to the provisions of the Contractor's License
Fz >
Law(Chapter 9(commencing with Section 7000)of Division 3 of the
a Husiness and Professions Code)or that he is exempt therefrom andDTV. PLUMBING PERMIT FEE
¢ =$ the basis for the alleged exemption.Any violation of Section 7031.$ STORIES TYPE CONSTR.
a ; by any applicant for a permit subjects the applicant ma civil penalty ALTER-DRAIN -WATER (EA.) 5.00
of not more than five hundred dollars(5500).1:
❑ I,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 Contractor's License Law does not apply to an owner of
property who builds or improves thereon,and who docs such work FIXTURES-PER TRAP 5.00 s2 FT.FLOOR AREA rorALACREAGE
himself re through his own employees,provided that such improve-
orimprovemenntcndedwithinoffered
one or year
If,however, theo nee- GAS-EA.SYSTEM-1INC.4OUTLETS 6.00
or improvement will h nt is sold within one year oft he d completion the owner- GAS-EA.SYSTEM-OVER 4 (EA.) 2.00
builder will have the burden of proving that he Jid not build or im- BUILDING USE
prove 1for,as owner
of soled. R IND CON PB Omer
❑ I,as owner of the property,am exclusively contracting with INDUSTRIAL WASTE INTER. 30.00 ❑
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 for such projects with a contractons)licensed pursuant to SEWER-SANITARY-STORM EA.200ft/10.00
the Contractor',Lieanse Law. TRACT NO. PARCEL NO.
❑ tam exempt under See. ,B.&I'.C.for this WATER HEATER W/VENT 6.00
ason
Owner Date WATER SYSTEM 5.00
ACC.DATE ACC.FILE N0,
WORK ERS'COMPENSAI'IONDECLARATION WATER TREATING EQUIP. 5.00
1 hereby affirm that I have a certificate of consent to self-insure.
or a certificate of Workers'Compensation Insurance,or u certified ZONING ENG.SITE NO.
copy thereof(See.3800,Lab.C.I n -
['.he,No. a "ompany X3''1.
0 ❑ Certified copy is hereby furnished. FIRE SPRINK ENERGY T"24
F ZO ❑ Certified copy is filed with the city inspection division. MISC.- REFER TO ORD, v N v N
Applicant m ❑ ❑
CC = CERTIFICATE OIF EXEMPTION PROM WORKERS' PERMIT ISSUANCE 10.00, FLOOD ZONE A.L.u.C.
LU > COMPENSATION INSURANCE PLG.CONTR. LIC.NO.
mPLG. V� N� Y � N
0 �
(This melidn need not he completed it the permil is for one TOTAL
hundred dollars IS 100)or Is,,.)
U 0 1 certify that in the performance of the work for which this per- DTV. MECHANICAL PERMIT FEE FEE SUMMARY
LL H mit is issued,I shall not employ any person in any manner so as to
U become subject to the Workers'Compensation Laws of California.
U d Date Applicant ALTER OR ADD TO MECH. 5.00 BUILDING
} US NOTICE TO APPLICANT: If,alter making this Certificate of Fs-
F 2 caption,you should become subject to the Workeri Compensation APPLIANCE 5.00 PLAN CHECK
provisions of the Labor Code, you must forthwith comply with FEE
U such provisions or this permit shall he deemed revoked. AIR HANDLING UNIT(TO 10AOOC.F.M.) 4.00
CONSTRUCTION LENDING AGENCY AIR HANDLING UNIT(OVER 10000C.F.M.) 6.00 SEISMIC FEE
I hereby affirm that there is a construction lending agency for EXHAUST HOOD(WITH DUCT) 5.00 4 rM
the performance of the work for which this permit is issued(Sec. MICROFILM
3097,Civ.C.). HEATING UNIT(TO 100,000 B.T.U.) 8.00dp
Lender's Nome HEATING UNIT(OVER 100,000 B.T.U.)
Lender's address '/�a ELECTRIC
I certify that l hav&&this SPplie on cons tfaR t i the above VENTILATION FAN (SINGLE) 4.00 .q.6,2
. information is correct. I agree to comply with all city and county PLUMBING
ordinances and state laws relating in building construction, and BOILER-COMP(3 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 harmless 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 conaequcoce of the
granting of this permit. MECH.CONT_ LIC.NO. MECH.
TOTAL
3� Od TOTAL
ngna enLApplicanl/Contmnor ` ate
INSPECTOR COPY