8640 a.:
APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
o
. BUILDING PROJECT IDENTIFICATI N PERMIT NUMBER
VR_GdN
ADDAESc APPLICATION & PERMIT A 0
1 '
• O BUILDING—ELECTRICAL—PLUMBING—MECHANICAL L�
OWNERS
NAME PLAN CHECK VALIDATION
,• QTY. ELECTRIC PERMIT FEE
NOAMTRAcAt UTLETS-SWITCHES-RECEP 10.00/1.00
n LIC.No 2-Z LIGHTING FIXTURES 10.00/1.00
CONTRACTORS
ADDREss , APPLIANCES-RESIDENTIAL 4.00
14 PHONE �� PANELS 10.00 DATE OF APPLICATION
OR
ARCHITECT PANELS (OVER 200 AMP) 20,08 PLAN CHECK FEE P.C.NO.
ENGINEER
V Llc.No. SIGNS TRANS. 3.00
ARCH.OR NG. PERMIT VALIDATION
ADOR�,..5
fait P ZIP TEMP.METER OR POLE INS. .29,00 /S'
APPLICANT'5
ADDRESS MOTORS SEE FEE SCH. r.�IE(/-p, SERVICECHANGE 20.00
woo LIC &SED CONTRACTORS DECLARATION TEMP.POLE 30.00aZu c, I hereby affirm that I am licensed under provisions of Chapter 9 ISTS
ve er i (commencing with Section 7000)of Division 3 of the Business and BLDG. ELECT. PLG. MECH.
Professions Code dry license is in full forcWndyeffn,t MAI ❑ 1 ❑ ❑
Z o License CI /y v;.Number ` `//L ILYIJI
o m H w Dete Contractor
as BUILDING PERMIT
OWNER-BUILDER DECLARATIONINFORMATION
X ;e n I hereby affirm that 1 am exempt from Ore Contractor's License MISC.— 1 ORD
u o ve Law for the following reason.(Sec.7031.5,Business and Professions 1'9A� VALUATION E/FT.
PERMIT ISSUANCE -�
Code:Any city or county which requiresv permit to construct,alteq
2a ¢Q improve,demolish,or repair any structure,prior to its issuance,also ELEC.CONTR. LIC.NO. ELEC.
o O, requires the applicant for such permit to file a signed statement that TOTAL PERMIT TO
w $ he is licensed pursuant to the provisions of the Contractor's License
Hi
Law(Chapter 9(commencing with Section 7000)of Division 3 ofthe
Q ,a.y
Ii el Business and Professions Code)0r that he is exempt therefrom and QTY. PLUMBING PERMIT FEE
ce 1- the basis for the alleged exemption.Any violation of Section 7031.5 STORIES TYPE CONSTR.
by any applicant for a permit subjects the applicant too civil penalty ALTER-DRAIN -WATER IEA.) 5.00
of not more than five hundred dollars(5500).):
❑ I,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 ProfessionsDRAINS-FLOOR,ROOF,AREA,GOND. 5.00
Code:The Contractor's License Law does not apply to an owner of
properly who build,or improves thereon,and who does such work FIXTURES-PER TRAP 5.00 $O.FT.FLOOR AREA TOTAL ACREAGE
himself or through his own employees,provided that such.improve-
ments are not intended oroffered for sale,If,however,the building GAS-EA.SYSTEM-11 INC.4 OUTLETS 6.00
or improvement is sold within one year of completion,the owner- GAS-EA.SYSTEM-OVER 4 (EA.) 2,00
builder will have the burden ofproving that he did not build or im-
prove for purpose of sale.). RES IND CON PS Other
❑ I,as owner of the property,am exclusively contracting with INDUSTRIAL WASTE INTER. 30.00 0 El 0 0 11
licensed.contractom to construct the project(Sec. 7044,Business LAWN SPRINKLERS-I INC 5 V.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(EA.) 1.00
contracts for such projects with a contractors)licensed pursuant to SEWER-SANITARY-STORM EA.200ftI10.00
the Contractor's License Law. TRACT NO. PARCEL NO.
❑ lam 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.
WORKERS'COMPENSATION DECLARATION WATER TREATING EQUIP, 5.00
1 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 thereof cc. 8 0 Lab. .).
Policy No.CL- .
0 ❑ Certified copy a y(urnished. FIRESPRINK ENERGY T-24
Z Z ❑ Cerlified(.Cop��s Gled with the city inspection division. MISC.- REFER TO ORD.
p Applicant //--�L CO Y 0 NE] Y E) N[:3
= y PERMIT ISSUANCE 10.00
� — CERTIFICATE OF EXEMPTION FROM WORKERS' FLOOD ZONE ..L.U.C.
LD > COMPENSATION INSURANCE: PLG.CONTR. LIC.NO. I.G.P ❑ ❑ � ❑ NO
CL G (This section need not be completed If the permit is for one TOTAL Y N Y
D Z hundred dollars(S 100)or less
U 0 1 certify that in the performance of file work for which this per- QTY. MECHANICAL PERMIT FEE FEE SUMMARY
UL f- mit is issued,I shall not employ any person in any manner so as to
O W become subject to the Workers'Compensation Laws of California. BUILDING
IS. Date Applicant ALTER 08 ADD TO MECH. 5.00
}• to NOTICE TO APPLICANT: If,after making this Certificate of
Ex-emption,you should become subject in the Workers'CompensationAPPLIANCE 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 UNIT(OVER 10p000.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 issacd(Sec. MICROFILM
3097,Civ.C.L HEATING UNIT(TO 100,000 B.T.U.) 8.00
Lender's Name HEATING UNIT(OVER 100,000 B.T.U.)9.50
Lender's Address ELECTRIC
I certify 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 county PLUMBING
ordinances and state laws relating to building construction, unit BOILER-COMP 13 H.P.or 100,000 B.T.U.) 6.00
y hereby authorize representatives of this city to enter upon the BOILER-COMP(Over 100,000 BTU)EEE 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 y way accrue against said 'ty in consequence of the
gran of/IIISpermlt MECH.CONT. LIC.NO. MECH.
ff
? TOTAL TOTAL
S" a u of"Phca onl c or J_Date^
OFFICE COPY