09865 APPLICAI4T'Q11LI (Nlf ATYYN'ViTHIN RED LINES - USE BALL POINT PEN ONLY
BUILDING PROJECT IDENTIFICATION PERMIT NUMBER
ADDRESS AAPPLICATION & PERMIT •• 0
WI G
DIN -
9865
BUILDING-ELECTRICAL-PLUMBING-MECHANICAL
OWNER'S _ & PLAN CHECK VALIDATION
NAME I - QTS!. ELECTRIC'PERMIT*✓+' 4EE.1 ,
CONTRACTORS
(2-/0 -A3UTLETS-SWITCHES-RECEP 10.00/1.00 /5.3,-
N E
(.1C. ac.No, 1, ,3 / LIGHTING FIXTURES 10.00/1.00
TRA
CONCTons
O
CONTRACTOR
PPLIANCES-RESIDENTIAL 4.00
C
/Y) - J, PHONit PANELS AM,4 10.00 10, DATE OF APPLICATION
ARRCHITECT PANELS (OVER 200 AMP) A -20.003.Q, PLAN CHECK FEE P.C.NO.
O
ENGINEER
LIC.NO. SIGNS TRANS.
ADDRESS ENG' SPECIAL CIRCUIT - 5.00 PERMIT VALIDATION
ZIP TEMP.METER OR POLE INS. 20.00 '
ADOR ESS Ts MOTORS - FEESCH.
SERVICE CHANGE 20.00
F09' TE 1�-•
oo LICENSED CONTRACTORS DECLARATION MP.POLE r 30.00 �/.1'
X,u w I hereby affirm that 1 am licensed under provisions of Chapter 9 _ 1$/SUAANICE DATE
(Commencing with Section 7000)of Division 3 of the Business and p p BLDG. ELECT. PLG. MECH.
D i Professions Code n ' y license is is full fore it CI 0 �p
o z,n o [)are las Lic.Numhc f. - ❑ ❑ ❑
rn t w Dote Contr to
wOWNER-BUILDER DECLARATION A,P BUILDING;PERMITvjy,f.v
' O' MISC.- REFER TO ORD 3GNFORMATI ONIM-.,,*,�
X ; y I hereby affirm that 1 am exempt from the Contractor`s License VALUATION
u 0 j Law for the following reason.(Sec.7031.5,Business and Professions x E/FT.
H - PERMIT ISSUANCE �(^ ( 10.00 /Q, -
y Code:Any city or county which requires permit to construct,alter,
s a <o improve,demolish,or repair any structure,prior to its issuance,also ELEC.CO TR. LInC.'Nn0. ELEC.
C¢ requires the applicant for such permit to file a signed statement that di S�EV�I PERMIT TO
u w m a- he is licensed pursuant to the provisions of the Contractor's License
H z
as
Law(Chapter 9(commencing with Section 7000)of Division 3 ofthe
Iz o Business and Professions Code)0r that he is exempt therefrom and QTY. �} PLUMBING PERMITF,E
H the basis for the alleged exemption.Any viOlation ufSection 7031.5 { t ' " ' " - y, STORIES TYPE CONSTR.
i ; by any applicant for a permit subjects the applicant to a civil penalty
of not more than five hundred dollars($500)J: ALTER-DRAIN&VENT-WATER (EA.) 5.00
❑ Las owner the property,or my employees with wages as BACK FLOW PROTECT. DEVICE 4.00 OCC.GROUP RES.UNITS
their sole compensation,will 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
,;S* ' property who builds or improves thereon,and who does such work FIXTURES-PER TRAP 5.00 SO,FT.FLOOR AREA TOTAL ACREAGE
Jhimself or through his own employees,provided that such improve
^ ments are not intended or offered for sale.I L however,the building GAS-EA.SYSTEM-11 NC.4 OUTLETS 6,00
((( or improvement is sold within one year of completion,the owner
builder will have the burden of proving that he did not build or im- GAS-EA.SYSTEM-OVER 4 (EA.) 2.00
�
- BUILDING USE
e .*• prove for purpose ofsale.). INDUSTRIAL WASTE INTER. 30.00 - RES IND CON PB Omar
❑ 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 Contractor's License Law docs not apply
to an owner of property who builds or improves thereon,and who LAWN SPRINKLERS,OVER 5(EA.) 1.00
contracts lot such projects with a contructods)licensed pursuant to
the Contractor's License Law. SEWER:SANITARY-STORM EA.20011t/1 0.00 TRACT NO. PARCEL NO.
❑ loin exempt under Sec. ,B.&OC.fur this
aeon WATER HEATER W/VENT 6.00
Owner Date WATER SYSTEM 5.00 ACC.DATE ACC.FILE NO.
WORKERS'COMPENSATION DECLARATION WATER TREATING EQUIP. 5.00
I hereby affirm that I have a certificate of consent to self-insure,
or a certificate of Workers'Compensal ion Insertijyy{I ZONING ENG.SITE NO.
copy thereof(Sec.3800,Lab.C.)'.)"•L (��j//pp '
Policy No. Comp'y
0 ❑ Certified copy is hereby furnished.
FIRE SPRINK ENERGY T-24
Z 2 Certifieppg�• t� th-F ms iondiy�s�'oy.
F 0 Applicant• i(X +i.C_+_TL�/.fLi - e�S�sy MISC.- REFER TO ORD. Y NQ y No
O: - CERTIFICATE OF EXEMPTION FROM WORKERS' . PERMIT ISSUANCE - 10.00 FLOODZONE A.L.U.C.
LU COMPENSATION INSURANCE PLG.CONTR. LIC,NO. PLG.
CIL o' Th section 'need not be completed if the permit is for one TOTAL Y❑ N Y❑ IN
0 2 hundred dollars IS 100)or less.) . -
CJ 0 1 certify that in the performance of the work for which this per. OTV " MECHANICALsP.ERMIU i xFEE ,L , FLEE SUMMARY
LL F mit is issued,1 shall not employ any,person in any manner so as to C
O W become subject to the Workers'Compensation Laws of California. . -
d Dare Applicant ALTER OR ADD TO MECH. 5.00 BUILDING
} W NOTICE TO APPLICANT: If,after making this Certificate of lix -
F.Z 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 00
provisions or this permit she]]be deemed revoked. AIR HANDLING UNIT(TO 10, 0C.F.M-) 4.00 -
CONSTRUCTION LENDING AGENCY AIR HANDLING UNIT(OVER 10=11FM.) 6.00 SEISMIC FEE
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 permit is issued(Sec. MICROFILM
3097,Civ.C.). �.���� HEATING UNIT(TO 100,000 B.T.U.) 8.00
Nam ame
Lender's Address HEATING UNIT(OV ER 100,000 B.T.U.)9.50 ELECTRIC
/r: �k fy that I have read this application and state that the above VENTILATION FAN (SINGLE) 4.00
information is correct. I agree to comply with all city and coon ly PLUMBING ,
ordinances and state laws relating l0 building construction, and BOILER-COMP(3 H.P.DP 100,000 B.T.U.) 6.00
hebove reby enti o ed representatives for ins of this city to enter upon the BOILER-COMP IOver 100,000 BTU)SEE FEE SCH. MECHANICAL
I^ hereby autioro property forinspofth i 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 CONSTJ.TAX
may In any Way accrue against said City In Consequence Of the
granting of this permit. MECH.CONT. LIC.NO. MECH,
TOTAL TOTAL
51 'pure of Applicant/Contractor Date
OFFICE COPY