9299 (3) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
BUI LDI NG PROJECT I DENTI FICATI ON PERMIT NUMBER
BUILDING APPLICATION & PERMIT
A DREss ^yn/
51'1 BUILDING -ELECTRICAL-PLUMBING-MECHANICAL VL1��
WS _ PLAN CHECK VALIDATION
NAME QTY. ELECTRIC PERMIT FEE
ONE
CT
NAME OUTLETS-SWITCHES-RECEP 10.00/1.00
NAME
III No. LIGHTING FIXTURES 10.00/1.00
rON
A APPLIANCES-RESIDENTIAL 4.00
AooREss
PHONE PANELS 10.00 DATE OF APPLICATION
ARC.IRICI • PANELS (OVER 200 AMP) 20,00 PLAN CHECK FEE P.0.NO.
OR
ENGINEER
uc.NO SIGNS TRANS. 3.00
ARCH,OR ENG. , PERMIT VALIDATION
-t ADDRESS SPECIALCIRCUIT 5.00
ZIPEMP.METER OR POLE INS. 20.00
APPLICANT-S A
MOTORS SEE FEE SCH. 1D
ADDRESS PAID
SERVICE CHANGE 20.00
w o Er Z.
LICENSEDCON'PRAC'IORS DECLARATION TEMP,POLE 30.00 JUL 16 1985
\Q o U 1 hereby allinn that I am licensed under,proviounis of Chapter 9 ISSUANCE DATE l`
z w (con,ro,o6ng with Section 7000)of Di ....3 of the Business aad BLOC. L T MECH. `
D i ,I'm Nssions Code,A nd my license is in full bor, �n�d effect. p Q
oz ow o License Class_._Lic.Number 7-7"lF i�
trZ
0 se F j Date �•� £ Contractors.
¢ m f BUILING PERMIT
¢ e, w ¢ OWNER-BUILDER DECLARATION IN ING PERMIT
oo " MISC.- REFER TO ORD
F
; 01< I hereby collo that I am exempt from tire Contractor's License VALUATION 5/FT.
F .. v,¢ Law for the followlogreason.(Sea 7iresa permit
to
Professions PERMIT ISSUANCE 10.00
Code:Any city or county which requires a permit to construct alter,
ac >-
2O improve,demolish,or repair any structure,prior to its issuance,also ELEC.CONTR. LIC,NQ ELEC,
a at E I]¢ requires the applicant for such permit to file a signed statement that TOTAL PERMIT TO
n As o he is lieensed pursuant to the provisions or the Contractor's License
� z >
Law(Chapter 9(commencing with Section 70001 ofDivision 3 ofthe
< Business and Professions Code)or that he is exempt therefrom and QTY. PLUMBING PERMIT FEE
¢Ho the basis for the alleged exemption.Any violation of Section 7031.$ STORIES TYPE CONSTR.
dam _ by airy applicont fora permit Subjects the applicant toacivilpenalty gLTER-DRAIN&VENT-WATER (EA.) 5.00
at not nmrc than tivelmndred d(illars(5500).):
❑ 1,as owner of the property,or my Cmployees 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,AR EA,COND. 5.00
Code'I'1¢Contractor's License Law does not apply to an owner of
property who builds or improves thereon,and who does such work FIXTURES-PER TRAP 5.00 SO,FT.FLOOR AREA TOTAL ACREAGE
• himselfre throughhis ownemployees.pro
vided ev suchimprove-
mmseftonotinthhiso, employeesulelted that suhebudding GAS-EA.SYSTEM-11NC.4OUTLETS 6.00
or improvement is sold within one year of completion,the owner- GAS-EA.SYSTEM-OVER 4 (EA.) 2.00
builder will have the burden o'proving that he did not build or owner-
BUILDING USE
prove for purpose of sale.). INDUSTRIAL WASTE INTER. 30.00 RE IND CON PB Omer
0 I,as owner of the property,am exclusively Contracting with ❑ ❑ ❑ ❑
licensed contractors to construct the project(Sea.7044,Business LAWN SPRINKLERS-1 INC 5 V.B. 6.00 ASSESSORS PARC ELNO.
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 forsuch projects with a contmctons)licensed pursuant to
the Contractor's License Law. SEWER-SANITARY-STORM EA.200ft/10.00 TRACT NO. PARCEL No.
❑ I':un uxmnpt under Sec ,B.&P.C.for this WATER HEATER W/VENT 6.00
reason
Owner Date WATER SYSTEM 5.00 ACC.DATE ACC.FILE NO.
WORKS RS'CONIPE NSATION DECLARATION WATER TREATING EQUIP, 5.00
I hereby affirm that I have aacriifcateof consent to self-insure. ZONING
or a certificate of Workers'Compensation Insurance,or a certified ENG.SITE N0.
copy thereof(Sec.3800,Lab.CJ.
Policy No. Company
Q ❑ Certified copy is hereby furnished. FIRE SPRINK ENERGY T 24
z Z $ Cer'ieit Copy is filed�wit) the city inspection division: MISC.- REFER TO ORD. ❑ ❑ ❑ ❑
O n BrI / V N V N
CC W CERTIFICATE OF EXEMPTION K ON WORKERS' PERMIT ISSUANCE 10.00 FLOOD ZONE A.LU.C.
LLI > COMPENSATION INSURANCE PLG.CONTR. LIC.NO, PLG.
EL Z CPU, section need not be completed if the permit is for on, TOTAL V❑ N❑ v ❑ N❑
hundmd dollars(4100)or less.)
V O 1 certify that in the performance of the work I'or which this per- CITY. MECHANICAL PERMIT FEE FEE SUMMARY
LL F unit is issued,I shall not employ any person in any mann,,so as to
Ow become subject to the Workers'Compensat ion Laws of California. BUILDING
OL Date Applicant ALTER OR ADD TO MECH. 5.00
} to NOTICE 'f0 APPLICANT: If,after making this Certificate of Ex-
emption,you should become subject to the Workers'Compensation 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 10SMCF.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
3097 uCiv. MICROFILM
CA
of the work for which this permit is issued(Sec. HEATING UNIT(TO 100,000 B.T.U.) 8.00
Lender's Name
Lender's NAddreame HEATING UNIT(OV ER 100,000 B.T.U.)9.50 ELECTRIC
I artily tlwt I have read this application and Stam that the above VENTILATION FAN (SINGLE) 4.00
• inl'oriation is correct. I agree to comply with all city and county PLUMBING
ordinances and state laws relating to building Construction, and BOILER-COMP(3H.P.or100,000B.T.U.I6.00
hereby authorize representatives of this city to enter upon the
above-mentioned property 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 PERMIT ISSUANCE 10.00 CONST.TAX
may in any way accrue against said City in consequence of the
g anling O(this Permit MECH.CONT. LIC.NO. MECH.
1e 54 TOTAL TOTAL
n n ontre Ute
INSPECTOR COPY