9171 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY d45/1o7J0
BUILDING PROJECT I IDENTIFICATION , PERMITNUMBER
ILDIND APPLICATION & PERMIT g 171
(JX IC,•/( C. �I�C..r BUILDING-ELECTRICAL-PLUMBING-MECHANICAL
OWNER'. PLAN CHECK VALIDATION
OTY. ELECTRIC PERMIT FEE
wQ ueh/ PHONE
U
CONTRACTORS OUTLETS-SWITCHES-RECEP 10.00/1.00
4, / v�I'✓/C� uC.NoLIGHTING FIXTURES 10.00/1.00
CONTRACTORS
cSf PPLIANCES-RESIDENTIAL 4.00 55_alki ' esHE PANELS IOO
-
DATE OF APPLICATION
ARCHITECT PANELS (OVER 200 AMP) 20,00 PLAN CHECK FEE P.C.NO.
ENGINEER
Sec.NO SIGNS TRANS, 3.00
ARCH,OR ENO. SPECIAL-CIRCUIT 5,00 PERMIT VALIDATION
ADDRESS
ZIv EMP.METER OR POLE INS. 20.00
APPLICANTS MOTORS SEE FEE SCH. J
A �R1E55 �L - 1
p•t��/"es .J �� SERVICE CHANGE 20.00 '/ffr
Woo LICENSED CONTRACTORS DECLARATION TEMP.POLE 30.00 U
a i t; I hereby affirm that I am licensed under provisions of Chapter 9 ISSUANCE DATE
a (commencing with Section 7000)of Division 3 of the Business and BLDG. ELECT. PLG. MECH.
r M i
aa, Professions Cod n license is in full for r t ❑ ❑ ❑
Z i L W License ass Ian Lic.Number
Dale `' Contractor el
a x BUILDING PERMIT
M a a OWNER-BUILDER DECLARATION
o a U INFORMATION
K
;LL I hereby affirm that 1 am exempt from the Contractor's License MISC.- REFER TO ORD
rn VALUATION
F u o j Law for the following reason.(Sec.7031.5,Business and Professions PERMIT ISSUANCE 10.00
Code.Any city or county which requires a permit to construct,alter,
a al ¢ 0- improve,demolish,or repair any structure,prior to its issuance,also ELEC.CONTR. LIC.NO. ELEC.
w- O LL requires the applicant for such permit to file a signed statement that TOTAL PERMIT TO
$ he is licensed pursuant to the provisions of the Contractor's License
Hi >m Law(chapter 9(commencing with Section 7000)of Division 3 ofthe
a Business and Professions Code)or that he is exempt therefrom and
CITY. PLUMBING PERMIT FEE
a H $ the basis for the alleged exemption.Any violation of Section 7031.5 STORIES TYPE CONSTR.
n ; ,- by any applicant for a permit Subjects the applicant o a civil penalty ALTER-DRAIN -WATER (EA.) 5.00
of not more than five hundred dollars(S500).):
O 1,as owner of the property,or my employees wills 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 does such work FIXTURES-PER TRAP 5.00 SD.FT.FLOOR AREA TOTAL ACREAGE
himself or through his own employees.provided that such improve-
mentsarenot intended oroffered oyees,sae.moved that such
building GAS-EA,SYSTEM-11NC.40UTLETS 6.00
or improvement is sold within one year of completion,the owner- GAS-EA.SYSTEM-OVER 4 (EA.) 2.00 BUILDING USE
builder will have the burden of proving that he did not build or am. RES IND CON PB Omar
13prove for purpose of sale.). INDUSTRIALWASTE INTER3000 El El 1:1 ❑
ass owner of toe properly, exclusively contracting with . .
licensedd 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 anowner of property who builds or improves thereon,and who LAWN SPRINKLERS-OVER 5(EA.) 1.00
contracts for such projects with a contractorts)licensed pursuant mSEWER-SAN ITARV-STORM EA.200ft/10.00
the Contractor's License Law. Di�� TRACT NO. PARCEL NO.
❑ I am exempt under Ser.-,BAP.C.for this WATER HEATER W/VENT 6.00
reason
Owner Date - WATER SYSTEM PAIrl 5.00
iOG ACC.DATE ACG FILE NO.
WORKERS'COMPENSATION DECLARATION WATER TREATING EQUIP. 5.00
1 hereby affirm that I have a certificate of consent to selhinsure,
or a certificate of Workers'Compensation Insurance,or a certified JUN 9. 7 198S ZONING ENG.SITE NO.
copy(he r _ 0 Pa
Policy NAA DD oat anyny/A/ndQnd ./
O ❑ Certified copy is hereby furnished. CI FIRE SPRINK ENERGY T-24
Cliff,
Z ZO PLErlif c py is filed i ti city ins 'e'e 'v'sion. MISC.- REFER TO ORD.
Applicant rr N v 0 N
vi PERMIT ISSUANCE 10.00
CCCERTIFICATE OF EXEMPTION FROM WO KERS' D.Lb FLOOD ZONE A.L.U.C.
LU > COMPENSATION INSURANCE PIS.COPITR./ LIC.NO) PLG.
CL O This Section need not be completed if the permit is for one /� �ry/�Je i7� TOTAL'�Qj Y❑ N� Y N�
Z hundred dollars($100)or less.)
U O 1 certify that in the performance of the work for which this per, DTV. MECHANICAL PERMIT FEE FEE SUMMARY
11 I- mit is issued,1 shall not employ any person in any manner So as to
O W become subject to the Workers'Compensation Laws of California.
d Date ApplicantALTER OR ADD TO MECH. 5.00 BUILDING
} W NOTICE'TO APPLICANT, If,alter making this Certificate of lix-
F ? 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=11F.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 performance of the work for which this permit is issued(Sec. MICROFILM
3097,Civ.C.1. I H EATING UN IT(TO 100,000 B.T.U.) 8.00
Lender's Name H EATI NG UN IT(OV ER 100,000 B.T.U.)9.50
Lender's Address 'ELECTRIC
1 certify that I have read this application and state that the above VENTILATION FAN (SINGLE) 4.00 a dy
information is correct I agree to comply with all city and county PLUMBING
ordinances and state laws relating to building construction, andmy 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, casts and expenses which PERMIT ISSUANCE 10.00 CONST.TAX
may in any way accrue against said City in consequence of the
granti of this permit r ECH.CONT. LIC.NO. MECH.
/ TOTAL TOTAL
Signature of Applicant l/Contractor Uutc
OFFICE COPY
_ I