9265 (2) APPLICANT TO FILL IN INFORMATIONWITHIN RED LINES - USE BALL POINT PEN ONLY
BUILDING PROJECT IDENTIFICATION' PERMIT NUMBER
BUILDING APPLICATION & PERMIT
ADDRESS
DING -ELECTRICAL-PLUMBING -MECHANICAL 9265
OWNER' PLAN CHECK VALIDATION
NAME CITY. ELECTRIC PERMIT FEE
C oro UTLETS-SWITCHES-RECEP 10.00/1.00
N �f
I.IC No �' LIGHT(NG FIXTURES 10.00/1.00
CONT ACTOR's [� �f APPLIANCES-RESIDENTIAL
4.00
ADPREES L liN��/�G)•//Q
j C PHONE 1 :2 • PANELS 10.00 DATE OF APPLICATION
ARCHITECT PANELS (OVER 200 AMP) 20,00 PLAN CHECK FEE P.C.N0.
OR
ENGINEER
LIC.No, SIGNS TRANS. 3.00
ARCH.OR ENG. SPECIAL CIRCUIT 5.00 PF%0DATION
r ZIP EMP.METER OR POLE INS. 20.00 II�L
APPLICANT'B -- JUL 121985
ADDRESS MOTORS SEE FEE SCH.
SERVICE CHANGE 20.00
woo LICENSED CONTRACTORS DECLARATION TEMP.POLE 30.00 City Of Cupertino
a o I hereby afirn that I um licensed under provisions of Chapter') ISSUANCE DATE
m rt u (commencing with Section 7000)of Division 3 of the Business and BLDG. ELECT. PLG. MECH.
H m i 1'm1'cloons Codc,und•ji, I ,,,is in full fmc a aft rot.
z O m - License Clan_"ey - Lic.Nmnbe < 1El
9 H °w Uute Commctor /
a f BUILDING`PERMIT
an w a OWNER-BUILDER DECLARATION INFORINATION
A o A `a MISC.- REFER TOO )
w LL w- I hereby affirm that I am exempt from the Contractor's License VALUATION $/FT.
re u o¢ Law for the following reason.(Sec.7031.5,Busimessand Professions PERMIT ISSUANCE 10.00
Code:Any city or county which requiresapermit to construct.alter,
TE
Q 2 improve,demolish,or repair any structure,prior to its issuance,also ELEC.CONTE. LIC,NO. ELEC.
- m crequires the applicant for such permit to File a signed statement that TOTAL PERMIT TO
a w m LL m he is licensed to m the provisions of the Contractor's License
F Z Q
Law(Chapter 9(coin Booting sell fitSection 7000)of Divroon3 oftbe
Business and Professions Code)or that he is exempt therefrom and OTY. PLUMBING PERMIT FEE
r c the basis for the alleged exemption.Any violation of Section 7031,5 J:!S-0R1ESf TYPE CONSTR.
as by any applicant for a pemtit subjects the applicant too civil penalty ALTER-DRAIN -WATER (EA.) 5.00
of nom
t om than live hundred dollars(55001.1'.
El 1,
as owner Of the property,or my employees with wages as BACK FLOW PROTECT.DEVICE 4.00 oCC.GRoup RES.UNITS
sole cum pensation,will do the work,and the structure is not
intended or offered for sale (Set. 7044, Business and Professions DRAIN$-FLOOR,ROOF,AREA,COND. 5.00
Code: The Contractor's License Low docs not apply to an owner of
property who builds or improves thereon,and who does such work F IXTUR ES-PER TRAP 5.00 50,FT,FLOOR AREA TOTALACREAGE
himself a through his own employees,for side.
If.ed that such improve-
runt,himseOd
are not intended or offered for sale.IC howeveq the building GAS-EA.SYSTEM-1 INCA OUTLETS 6.00
or improvement is sold within one yearof completion,the owner- GAS-EA.SYSTEM-OVER 4 (EA) 2.00 BUILDING USE
builder will have the burden Of proving forcer did not build or im- E IND CON PB Omer
prove for purpose of sale.). INDUSTRIAL WASTE INTER. 30.00
❑ I,as owner of the properly,am exclusively'contracting will, ❑ ❑ ❑ ❑
licensed contractors to construct the project(Sec. 7044,Business LAWN SPRINKLERS- 1 INC 5 V.B. 6.00 ASSESSORSPARCELNO.
and Professions Code:The Contractor's License Law does not apply
to on owner'of property who builds or improves thereon.and who LAWN SPR IN KLERS-OVER 5 (EA.) 1.00
contracts for such projects with a contractors)licensed pursuant to SEWER-SANITARY-STORM EA.200ft/10.00
the Contractor,License Law. TRACT NO. PARCEL NO.
❑ lam exempt bhrer Sea ,B.&P.C.tie this WATER HEATER W/VENT 6.00
rca.von
Owner Date WATER SYSTEM 5.00 ACC.DATE ACG FILE NO.
WORKERS•COMPENSATION DECLARATION WATER TREATING EQUIP. 5.00
1 hereby affirm that I have a ce acme of consent to self-insure
or a ferlificate of Workers'Compensation InSUmRCp or a ceri(ied ZONING ENG.SITE N0.
copy thereof(Sec.3800,Lab.C.L
policy No. Com any
❑ Ce li pyi IN nishcd. FIRESPRINK ENERGY T 24
Z Z r er y�p Is with theiry inspection division. MISC.- REFER TO ORD.
Ap mnnl Y❑ N❑ Y❑ N❑
acct' C5 FICATE 017 EXEMPTION FROM WORKERS' PERMIT ISSUANCE 10.00 FLOOD ZONE A.L.U.C.
LU > COMPF-NSATION INSURANCE ExIbIw PLG.CONTR. LIC.NO. PLG. -
d O (Phis section need not be completed if the permit is fc,JIuae TOTAL Y❑ N❑ Y❑ N
'Z) Z. humJred dollars IS 100)or les.) -
U 0 1 comfy that in the performance of the work for which this per- CITY. MECHANICAL PERMIT FEE FEE SUMMARY
EL 1- out is issued,I shall not employ any person in any manner so as to
_ 0 become subject to the Workers'Compensation Laws of Californio. I•k
LU Dalc - Applicant ALTER OR ADD TO MECH. 5.00 BUILDING
} N NOTIC17 TO APPLICANT: If,after making()is Certificate of 15x-
(_ Z emption,you should become subject In the Workers'Compensation APPLIANCE 5.00 PLAN CHECK
provisions of the Labor Code, you must forthwith comply with FEE
CJ such provisions or this permit shall be deemed revoked. . AIR HANDLING UNIT(TO 10MC.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 a construction lending agency for EXHAUST HOOD (WITH DUCT) 5.00 _
the perfornonce of the work for which this pernit is issued(Sec. MICROFILM
3097,Civ.CJ. HEATING UNIT(TO 100,000 B.T.U.) 8.00
Lender's Name
NHEATING UNIT(OVER 100,000 B.T.U.)9.50 Loader's Names ELECTRIC
k I certify thud l have read this application and'late thaithe above VENTILATION FAN (SINGLE) 4.00
ordinances n mlot, 1 agree to comply with c oily and county PLUMBING
ordinances and state laws relating to comply
will, construction; andmy BOILER-COMP(3 H.P.or 100,000 B.T.U.) 6.00
hereby authorize representatives of this city to enter upon theWOO above-mentioned properly for inspection purposes. BOILER-COMP (Over 100,000 BTU(SEE FEE SCH. MECHANICAL
(We) agree to save, indemnify and keep harmless the City of MISC.- REFER TO ORD.
Cupertino against liabilities,judgments, costs and expenses which CONST.TAX
may in any w accm against said City in consequene of the PERMIT ISSUANCE 10.00
gm0 ' o(t erm -------'M
ECH.CONT. LIC.NO, MECH.
TOTAL TOTAL
Signatur of 6Pn C nfractor Ua
INSPECTOR COPY .�.".