9280 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
BU LDI NG PROJECT I DENTI FICATI ON PERMIT NUMBER
AD - APPLICATION & PERMIT 0
ADDRESS
OREss106/.L^
BUILDING-ELECTRICAL-PLUMBING-MECHANICAL
OMNER'S PLAN CHECK VALIDATION
NAME D " ?_ 'L q/ OTV ELECTRIC PERMIT FEE
'HONECONTRACTORS KA UTLETS-SWITCHES-RECEP 10.00/1.00
2-�/ LOC.No./����� LIGHTING FIXTURES 10.00/1.00
C�ONTPACTOR'S 9Slt�9 PPLIANCES-RESIDENTIAL 4.00 '
3 vHONJE 71e PANELS 10.00 DATE OF APPLICATION
O
ARCHITECT PANELS 200 AMP) 20.00 PLAN CHECK FEE
OR P.C.NO.
NGINEER
uc.No. SIGNS TRANS. 3.00 9
.DURESS ENG ' SPECIAL CIRCUIT_ 5.00 PERMIT VA
ZIP TEMP.METER OR POLE INS. 20.00 DEC 2 1985
ADDRESS MOTORS y SEE FEE SCH.
SERVICE CHANGE - 20.00 Clfy. of CU�,{�
o o LICENSED CONTRACTORS DECLARATION TEMP.POLE 30.00 V-caullO.
<u w I hereby af6nn that I am licensed under provisions of Chapter 9 ISSUANCE DATE
N < N (commencing with Section 7000)of Division 3 of the Business and. BLDG. ELECT. PLG. MACH.
I'fofc,oms Code and ntlicense.is in full for t '.`f.�{ ❑ ❑
o 0 H o License Class 04 &2' y Lac.Number LtJ _ ❑
Date Contractor
P r E BUIL ING PERMIT
¢ ¢ i a OWNF-R-BUILDI?R DECLARATION' IN ORMATION
wh I hereby affirm that I am exempt from the Contractor's License MISC.- REFER TO ORD
u o a Law for the following reason.(Sec.7031.5.Businessand Protein.. PERMIT ISSUANCE 10.00 VALUATION SIFT,
- � Code:Any city or county which requiresa permit toconstruct,alter,
¢ ¢ ¢ FO improve,demolish,or repair any structure,prior to its issuance,also EL N��j�}�_�/ LIC.NO, ELEC.
D u requires the applicant for such permit to rile a signed statement that gV ydiY� TOTAL i
X
m he is licensed pursuant to the provisions of the Contractor's License
ri >
Law(Chapter 9(commencing with Section 7000)of Division 3 of the
a Business and Professions Code)or that he is exempt therefrom and CITY. PLUMBING PERMIT FEE
¢ = $ the basis for the alleged exemption.Any violation of Section 7031.5 STORMS TYPE CONSTR.
i3 � by any applicant for a permit subjects theappl%Iplicant to a civil penalty ALTER-DRAIN&VENT-WATER (EA.) 5.00
of not more than five hundred dollars(SSL):
0 I,as owner of the property,or my employees with wages as BACK F LOW PROTECT. DEVICE 4.00 OCC.GROUP RES.uwTs
their sole compensation,will du the work,and the structure is not
'vended 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 improve thereon,and who does such work FIXTURES-PER TRAP 5.00 80.FT,FLOOR AREA TOTALACREAGE
himself or through his own employees,provided that such improve-
mentsara not intended or offered for sale.If,hewcvcr,the bit ifiling GAS-EA.SYSTEM-111NC.40UTLETS 6.00
or improvement is sold within one year of completion,the owner- - GAS-EASYSTEM-OVER 4 IEA) 200 BUILDING USE
builder will have the burden of proving that he did not build or inn- . . .
RE IND CON PB Otner
prove for purpose of sale.). INDUSTRIAL WASTE INTER. 30.00
❑ 1,as owner of the property,am exclusively contracting with ❑ ❑ ❑ ❑
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 Cummuctor's License law dues not apply
to an owner of property who builds Or improves thriven.and who LAWN SPRINKLERS-OVER 5(EA.) 1.00
contracts for such projects with A eontraetoNs)licensed pursuant to.
the Contractor's License Law. SEWER-SANITARY-STORM EA.200ft/10.00 TRACT No. PARCEL No.
❑ l um exempt 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.
WORK ERS'COMPENSATION DECLARATION WATER TREATING EQUIP. 5.00
I hereby affrm that I have a certificate of consent to self-imue. ZONING
of a certificate of Workers'Compensation Insuranec or a certif•J ENG.SITE NO.
copy thereof(Sec 3800,Lab.
C.l. 1TJl�G�_�__I
Policy No. Company
O ❑ Certified copy is hereby furnished. FIRE SPRINK ENERGY RF4
Z 2 a9'Certitic c th inspecpon division. MISC.- REFER TO ORD. ❑ ❑ ❑ ❑
p Applicant �..:a V N Y N
� N CERTIFICATE 01'EXEMPTION FROM WORKERS' PERMIT ISSUANCE 10.00 FLOOD ZONE A.L.u.C.
W COMPENSATION INSURANCE PLG.CONTR. LIC.NO. PLG. Y❑ N❑ Y ❑ N❑
EL _ (This section need not he completed if the pennii-is for one TOTAL
hundred dolles(S 100)or less.) . 1
U O I certify that in the performance of the work for which this per- OTV MECHANICAL PERMIT FEE FEE SUMMARY
IL I- mit is issued,I shall not employ any person in any manner so as to
O become subject to the Workers Compensation taws of California.
y Date ApplicantALTER OR ADD TO MECH. 5.00 BUILDING
} W NOTICE TO APPLICANT: If,after..eking this Certificate of Ex-
2 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 10,000C.F.M) 4.00
CONSTRUCTION LENDING AGENCY AIR HANDLING UNff(OVER I0,000C.EM.) 6.00 SEISMIC FEE -
I hereby affirm that there is a construction lending agency for EXHAUST HOOD (WITH DUCT) 5.00
the performance o!the work for which this permit Is issued(Sec. MICROFILM
HEATING UNIT(TO 100,000 B.T.U.) 8.00.
3097.
Lender's Name HEATING UN IT(OVER 100,000 B.T.U.)9.50 ELECTRIC
Lender's Address
I certify that I have read this application And stat,that the chose VENTILATION FAN (SINGLE) 4.00
information is correct. 1 agree to comply with all city and countySII FR C«�(3 H.P.Or 100,000 B.T.U.) 6.00 PLUMBING
ordinances and state laws relating to building construction, and
hereby authorize repressmatives of this city to enter upon the BOILER-COMP (Over 100,000 BTU)SEE FEE SCH. MECHANICAL
above-mentioned property for inspection purposes.
(We) agme, to save, indemnify and feel) harmless the City'of Misc.- REFER TO ORD.
Cupertino against liabilities,judgm costs and expenses which CONST.TAX
may in any wa accrue agail Aid City in coase Rem, f the PERMIT ISSUlts CE 10.00
granbngoft m MECH.CONT. LIC.NO. MECH.
a�i p� ��. TOTAL TOTAL
to Appl' ant/Contractor to y�"
OFFICE COPY