1509 ,APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
)'_dill LD1 NO PROJECT 1 DENTI FICATION PMIT
..".,.a APPLICATION & PERMIT 4 C O n
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BUILDING-ELECTRICAL-PLUMBING-MECHANICAL -
JII
O N 's PLAN CHECK VALIDATION
Nn /J I - - QTY. ELECTRIC PERMIT FEE
(^JC
CONTRACTOR'S
NA � OUTLETS-SWITCHES-RECEP 5.00/1.00
uc.no. T ,5' LIGHTING FIXTURES 5.00/1.00
CONTRACTOR'S �/_ APPLIANCES-RESIDENTIAL 4.00
I C`�
QO GJ PHONE Q PANELS _ 5.00 DATE OF APPLICATION
RCHIT CT CH
PLAN ECK FEE P.C.NO.
OR SIGNS 6.00 - $
ENGINEERryry
LIC.NO, SIGNS TRANS. 3.00 .9&. `-
ARCH,OR ENG. SPECIALCIRCUIT 5.00 PERMIT VALIDATION
SS
ZIP TEMP.METER OR POLE INS. 15.00
APPLICANT'S MOTORS SEE FEE SCH.
ADDRESS _ �7 r� M
�',�//Cp(1'4e✓ Q.p • '�'✓i �I Sl( SERVICE CHANGE 10.00 0�
woo LICENSED CONTRACTORS DECLARATION yw,y''
rc u I hereby affirm that I am licensed under provisions of Chapter 9' 5 DANCE DATE ~��✓
N <H (commencing with Section 7000)of Division 3 of the Business and BLDG. LECT. PLG. MECH.
H N z Professions Code, my license is in full fore - .3 ❑ ❑ ❑
Gi w.o ense las= - Lic.Number
r m j Date--./- Contractor�w
a m /RA BUILDING PERMIT
rc
OWNER-BUILDER DECLARATION
g o a u INFORMATION
X S LL 0< I hereby affirm that I am exempt from the Contractor's License MISC.- REFER TO ORD
m VALUATION
Su0J Law forthefollowingreason.(Sec.]ices a Business and Professions PERMIT ISSUANCE 6.00
2 w j Code: e,dem y or Cor mpair which requires,permit to construct.,Iter,
¢ a improve,demolish:or repair any structure,prior to its issuance,also ELEC.CONTR. - LIC.NO. ELEC ���•
DLL requires istic the dapplicant for the provisions
t0 fills a Contigned Statement that TOTAL PERMIT TO
w $ he is licensed pursuant to the provisions of the Contractor's License
Fzi Law(Chapter 9(commencing with Section 7000)ofDivislon3 oflhe
a Business and Professions Code)or that he isexempl therefrom and QTY. PLUMBING PERMIT FEE fKG
H O the basis for the alleged exemption.Any violation of Section 7031.$ STORIES rTYPE,C'ON'STTRR.
i ;� by any applicant fora permit subjects $5000.licam toacivil penally ALTER-DRAIN VENT-WATER (EA.) 4.00 r✓
of not more than flue hundred dollars(5500)J: -
❑ 1,as owner of the property,or my employees with wages as BACK FLOW PROTECT. DEVICE 2.00 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,CONO. 4.00 ��
Code:The Contractor's License Law does not apply to an owner of
property who builds or improves thereon,and who does.s.mh work FIXTURES-PER TRAP 4.00 SO,FT,FL009 AREA TOTAL ACREAGE
himselforthrough his own employees,provided that such improve- GAS-EA.SYSTEM-1 INC.4 OUTLETS 4.00
me nts are not intended or offered for sale.If.however,the the c building
or improvement is sold within one year of completion, the owner- GAS-EA.SYSTEM-OVER 4 IEA.) 1.00 BUILDING USE
builder will have the burden of proving that he did not build or inr, - - RES IND CON PB Omar
prove for purpose of the INDUSTRIAL WAS T 20.00 ,EK
❑ 1,as owner of the property,um exclusively contracting with ❑ Yu ❑ ❑ ❑
licensed contractors to construct the project(Sec.7044.Business LAWN SPRINKLERS 1 I ASSESSORS PARCEL NO.
and Professions Code:The Contractor's License Law does not apply
to an owner of property who builds or improves Iherenn.and who LAWN SPRINKLER - R 5 IEA.1 1. 0
contracts far such Projects with a contractor(s)licensed pursuant to
the Contracmr's License Law. SEWER-SANITARY-ST M 8.00 - TRACT NO. PARCEL NO.
❑ I am exempt under Sea ,BAP.C.far this WATER HEATER W/V �[ 4.00
reason
Date Owner WATER SYSTEM 4.00 ACC.DATE ACC.FILE N0,
WORK ERS'COMPF,NSAI'ION DECLARATION WATER TREATING EQUIP. 4.00 ,
I hereby affirm that I have a certificate of consent to self-insure. ZONING ENG.SITE NO.
or a certificate of Workers'Compensation Insurance,or a certified
copy ittemof(Sec.3800,Lab.C.).
Policy Na. CanlpaRY
O Cl Certified copy is hereby furnished. FIRESPRINK ENERGY T-24
Z Z Certifiedopy_is led with. ic city inspection division. MISC. REFER TO ORD.
p pvlicantv� NE] v ❑ N
~ m PERMIT ISSUANCE 6.00 FLOOOZONE A.L.U.C.
CERTIFICATE OF EXEh1P7'ION FROM WORKERS
LU COMPENSATION INSURANC17 PLG.CONTR. LIC.NO. PLG,
C• v❑ NE] v❑ N❑
O (This section need not be completed if the permit is for one TOTAL
0 Z hundred callars($100)or lessJ
0 O 1 certify that in the performance of the work for which this per- OTY. MECHANICAL PERMIT FEE FEE SUMMARY
LL 1- mit is issued.I shall not employ any,person in any manner so as to
U become subject to the Workers'Compensation Laws of California. SY1
y Date Applicant ALTER OR ADD TO MECH. 4.00 BUILDING
} W NOTICE TO APPLICANT: If,after making this Certificate f7ET
o '-r
F" ? emption,you should become subject to the Workers'Compensation APPLIANCE _ 4.00 PLAN CHECK / �3
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=C.F.M.) 3.00
CONSTRUCTION LEN DING AGENCY AIR HANDLING UNIT(OVER 10=C.F.M.) 5.00 SEISMIC FEE S�
I hereby affirm that there is a Construction lending agency for EXHAUST_HOOD (WITH DUCT) 2.00
the performance of the work for which this permit is issued(Sec. MICROFILM
3097,Civ.C.). ,y'/(- /� HEATING UNIT(TO 100,000 B.T.U.) 4.00
N
Lender's ame-/�L-�Y HEATI NG UN IT(OV ER 100,000 B.T.U.)7.50
Lender's Address ELECTRIC
I certify that I have read this application and state that the above VENTILATION FAN (SINGLE) 3.00
. information is correct. I agree to Comply with all city and county PLUMBING
ordinances and state laws relating to building construction, um BOILER-COMP(3 H.P.Or100,000B.T.U.) 4.00
hereby authorize representatives of this city to enter upon the BOILER-COMP IOver 100,000 BTU)SEE FEE SCH. MECHANICAL
above-mentioned property for inspection purpoms.
(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 way ace a against Said City in consequence of the PERMIT ISSUANCE 3.00
gran g of t l s Tenn - MECH.CONT. LIC.N0. MECH.
Y DTAL TOTAL 9 79
ignature of Applicant/Contractor D le / �•
OFFICE COPY'