8497 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
. BUILDING PROJECT IDENTIFICATION PERMIT NUMBER
BUILDING APPLICATION & PERMIT
ADOREss ®/9 5 o V�
b �• BUILDING-ELE(�TRICAL-PLUMBING-MECHANICAL 8 97
Owhe.'B - * PLAN C ALIDA
"IR LX r1 Iy�p /� CITY. .I ELECTRIC PERMIT FEE
PXONE �-y
NAME ACTOR OUTLETS-SWITCHES-RECEP t&.W/1.00
LIC.NO. LIGHTING FIXTURES iD-00/1.00
CONTRACTOR'S �1'1 1 u/l •'I A//�j,-('"l-1
ADDRESS APPLIANCES-RESIDENTIAL 4.00
PHONE PANELS 10.00 DATE OF APPLICATION
OR
PANELS (OVER 200 AMP) 20.00 PLA CHECK FEE P.C.NO.
ENGINEER
LIC.No. SIGNS TRANS. 3.00
AD,
ENG. SPECIALCIRCUIT 5.00 PERMIT VALIDATION
RCRESS
ZIP EMP.METER OR POLE I20.00
APPLICANT'S MOTORS NS E FEE SCH.
ADDRESS
SERVICE CHANGE 0
Foo LICENSED CONTRACTORS DECLARATION TEMP.POLE 30.00
au u 1 hereby affirm that 1 am licensed under provisions of Chapter 9 K ISSUANCE DATE
N z w (commencing with Section 7000)of Division 3 of the Business and
n G. ELECT. PLG. MECH.
D Z Professions Code,and my license is in full force and effect. Q - El
i e License Class Lic,Number
P- u F j Dam Contractor
m rc< OWNER-BUILDER DECLARATION BUILDING PERMIT
rc w u INFORMATION
X. 3 u I- 1 hereby affirm that 1 am exempt from the Contractor's License MISC.- REFER TO ORD
F ILow - VALUATION S/FT.
J Law for the following reason.(Sec.7031.5,Businessand Professions PERMIT ISSUANCE 9 .00
f w�Z Code:Any city or county wh ich requires a permit to construct.alter,
Q �¢O improve,demolish,or repaireny.structure,prior its issuance,also ELEC.CONTR. LIC.NO. ELEC.
m LL requires the applicant for such permit to file a signed statement that TOTAL PERMII TO
X he is licensed pursuant to the provisions of the Contractor's License L L�G7• f �6,,, �/
rii Law(Chapter 9(comm.ncingwith Sec(ion7000).fDivision3 ofthe a
a Business and Professions Code)or that he is exempt therefrom and CITY. PLUMBING PERMIT FEE
Is r the basis for the alleged exemption.Any violation of Section 703 L5 STORIES TYPE CONSTR.
by any applicant for a permit subjects the applicant to a civil penalty ALTER-DRAIN -WATER (EA.) 6.6o
of not more than five hundred dollars(5500).):
❑ 1,as owner of the property,or my employees 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,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�Q �� SO.FT.FLOOR AREA TOTAL ACREAGE
himself or through his own employees,provided that such improve-
mentsare not intended oroffered for sale.Il',however,the building ste GAS-EA.SVSTEM-11NC.40UTLETS 600
or improvement is Sold within one year of completion,the owner- GAS-EA.SYSTEM-OVER 4(EA.) 2.00
builder will have the burden of proving that he did not build or im- BUILDING USE
prove for purpose of sale.). RES IND CON PB Other
❑ I,as owner at the property,am exclusively contracting with INDUSTRIAL WASTE INTE 30.00 ❑ ❑ ❑ ❑ ❑
licensed contractors to construct the project(Sec.7044,Business LAWN SPRINKLERS- .B. 6.00 ASSESSORS PARCEL NO.
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 t%%%3 1.00
contracts for such projects with a conlracror(s)licensed pursuant to SEWER-SANITAR Oft/10.00
the Contractof s License Law. TRACT NO. PARCEL NO.
❑ 1 am exempt under Sec. ._,B.&P.C.for(his WATER HEATER ENT \(� .00
ua,,
Owner Date WATER SYSTEM O 5.00 ACC.DATE ACC.FILE NO.
iKERS'COMPENSATION DECI-ARATI N WATER TREATING EQUIP. S5.00
I hereby affirm that 1 have a certificate of consent to self-insure, ZONING ENG.SITE N0.
or a certificate of Workers'Compensation Insurance,or a certified
copy thereof(See.3500,Lab.CJ,
Policy No. Company
O ❑ Certified copy is hereby furnished. FIRE SPRINK ENERGY T 24
_Z Z ❑ Certified copy is filed with the city inspection division. MISC.- REFER TO ORD.
O Applicant Y❑ N❑ Y ❑ N❑
~ va PERMIT ISSUANCE 40:60 FLOOD ZONE A.L.U.C.
� - CERTIFICATE01:EXEMPTION FROM WORKERS'
aQ COMPENSATION INSURANCE PLG.CONTR. LIC.NO. TOTAL �� Y❑ N❑ Y❑ N❑
(This section need not be completed if the permit is for one
D Z hundred dollars(SI00)or less.)
U O 1 certify that in the performance of the work for which this per, CITY - MECHANIC RMIT FEE FEE SUMMARY
LL F mit is issued,I shall not employ any person in any manner so as to
U become subject to the Workers'Compensation Laws of Califomia.
0 y Dare _Applicant ALTER OR ADD MECN. 5.00 BUILDING
>_ N NOTICE TO APPLICANT: If,after making this Certificate of Ex.
Z emption,you should become subject to the Workers Compensation APPLIANCE 5.40 � PLAN CHECK
provisions of the Labor Code, you must forthwith comply with IR NDFEE
L,1 such provisions or this permit shall be deemed revoked. AHALING (TO 10 4.00
CONSTRUCTION LENDING AGENCY AIRHANDLING UNIT C.F.M.) 6.00 SEISMIC FEE
I hereby affirm that there is a construction lending agency for EXHAUST HOOD( H DUCT) 5.00
the performance of the work for which this permit is issued(Sec. MICROFILM
3097,Civ.C.). I HEATING UNIT(TO 100,000 B.T.U.) 8.00
Lender's Name HEATING UNIT IOV ER 100,000 B.T.U.)9.50 ELECTRIC �•r�
Lender's Address
I certify that I have read this application and state that the above VENTILATION FAN (SINGLE) 4.00 /)16
information is correct. I agree to comply with all city and county PLUMBING
ordinances and state laws relating to building construction, and 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 too 7U EE SCH. MECHANICAL 9
above-mentioned property for inspection purposes.
(We) agree to save, indemnify and keep harmless the City of MISC:- Nd F 0 ORD.
Cupertino against liabilities,judgments, costs and expenses which CONST.TAX
may in any way accrue against said City in consequence of the PERMIT ISSUANCE 10.00 3
grant this permit MECH.CONT. LIC.NO. MECH. q
21� TOTAL TOTAL Gf
Sig o App¢ant/Contractor Dat '
OFFICE COPY