09829 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES -W. BALL POINT'PEN ONLY
BUI LDI NG PROJECT IDENTIFICATION - - PERMIT NUMBER
BUILDING APPLICATION & PERMIT
AD0 E
(a$S BUILDING-ELECTRICAL-PLUMBING-MECHANICAL 09829
OwNER'S /,, PLAN CHECK VALIDATION
ff�'O��D 10 CITY. ELECTRIC PERMIT FEE
1� PHONE
NAMERAc7oas UTLETS-SWITCHES-RECEP 10.00/1.00
LIC.NO, LIGHTING FIXTURES 10.00/1.00
nooneis Tons APPLIANCES-RESIDENTIAL 4.00
PHONE PANELS 10.00 DATE OF APPLICATION '
ARCHITECT ry PLAN CHECFEE P.C.NO.
ON K
ENGINEER PANELS (OVER 200 AMP) 20.00
/�TSI�(j
sec.No. SIGNS TRANS. 3.00 -
Aooeess LNG. PERMIT CIRCUIT 5.00 PERMIT VALIDATION
ZIP EMP. METER PrAfa INS. 20.00 Q
ADDREavrS MOTORS SEE FEE SCH.
SERVICE 20.00
0¢ i
F 0 O LICENSED CONTRACTORS DECLARATION TEMP.P P. "9&00
a U 1 hereby airmen that I am licensed under provisions of Chapter 9
so< m (commencing with Section 7000)of Division 3 of the Business and ISSUANCE DATE
.
F w z Professions Code,and my license is full force and effect BLDGELECT. PLG. MECH.
❑ ❑ ❑
a i T W License Class Lic.Number
,A F Date Contractor
¢ Y J
ne ¢re¢ OWNER-BUILDER DECLARATION BUILDING PERMIT
°' ° MISC.- REFER TO ORD INFORMATION
w ; N 1 hereby affirm that I am exempt from the Contractor's License
u o j Law for the following reason.(Sec.7031.5.Busineesand Professions VALUATION S/FT.
- PERMIT ISSUANCE 10.00
0 Codc:Any city or county which structure,permit toconsuancat also
.U
¢ ¢ ¢° improve,demolish,or repair any structure,prior m its issuance,also ELEC.CONTR. LIC.NO. ELEG
w °¢ requires the applicant for such permit to file a signed statement that TOTAL30
m m he is licensed pursuant to the provisions of the Contractor's License PERMIT TO
rz< LBW(Chapter 9(commencing with Section 7000)Of Division 3 ofthe
ssTF/`9P. UCS
i 4 ° Business and Profeions Code)or that he is therefrom and QTY. PLUMBING PERMIT FEE
ce I- the basis for the alleged exemption.Any violation of Section 7031.5 STORIES. TYPE CONSTR.
i3 _ by any applicant for a permit subjects the applicant to a civil penalty ALTER-DRAIN -WATER IEA.) 5.00
of not mom than five hundred dollars($500).)'
❑ 1,as owner of the property,or my employees with wage,as BACK F LOW PROTECTDEV ICE 400
their sole compensation,will do the work.and the structure e,not . .
OCC.GROUP RES.UNITS
intended or of7e ed lilt sale (Sea 7044, Business and Profession, DRAINS-FLOOR,ROOF,AREA,COND. 5.00
Code:'I'Im Contractor's License Law does not apply to an owner of
property who builds or in,roves thereon,and who does such work FIXTURES-PER TRAP 5.00 SO.FT.FLOOR AREA TOTAL ACREAGE
himself arc
not into his awn employers provided eve such improve-
. mots are nhroug intended or employees,
l mvEdcd that
building GAS-EA.SVSTEM-11NC.40UTLETS 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
prove for purpose of[lie p INDUSTRIAL WASTE INTER. 30.00 0 11 IND El Q GO., -
❑ I,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 Codc:The Contractor's License Law does not apply
to an owner of property who builds or improves Harmon.and who LAWN SPRINKLERS-OVER 5 (EA.) 1.00
contracts for such pro ects with a con Dartot(a)licensed pursuant to
the Contract s I n Law. SEWER-SANITARY-STORM EA.200h/10.00 TRACT NO. PARCEL NO.
rc,❑sonl am em u r5g� ,B.&P.C.lot this WATER HEATER W/VENT 6.00
ownemd� ��C3D-a"R/' •;° WATER SYSTEM 5.00 ACC.DATE ACG FILE NO.
-
WORK I.RS'COMPENSATION DECLARATION WATER TREATING EQUIP. 5.00
1 hereby affirm that 1 have a certificate ofconsent to self-insure,
or a certificate of Workers Compensation Insumm e.or a certified ZONING ENG.SITE NO.
copy themof(Sec.3800,Lvb.C.).
Policy No.-Company-
0
o. CompanyO ❑ Certifiedcopyishercbyfurnished. RE SPRINK ENERGYTig
Z 2 ❑ Certified copy is fled with the city inspection division.
F O Applicant MISC.- REFER TO ORD. .Y L] N Y ❑ N�
CC Ln Cl:RTI FICA117 OF EX 17MPTION FROM WORKERS' PERMIT ISSUANCE 10.00 FLOODZCNE A.I_u.C.
LU > COMPFNSA'I'I ON INSURANCE, PLG.CONTR. LIC.NO. PLG
CL Q (Thi, section need not he completed if the Permit is for one TOTAL Y❑ N❑ V [:] N❑
Z hundred dollars IS 100)or ITI
U O I certify that in the perfoRe unce of the work for which this per- DTV. MECHANICAL PERMIT FEE FEE SUMMARY
LL F mit is issued, I shall not employ any person in any manner so as to
O () become subject to the Workers'Compensation Laws of California.
¢. Date Applicant ALTER OR ADD TO MECH. 5,00 BUILDING
} W NOTICE TO APPLICANT If,after oinking this Ccrtircate of Rz-
F ? emption,you should become subject to the Workers'Compensation APPLIANCE com5.00 PLAN CHECK
U
provisions of the Labor Code, you must forthwith ply with FEE such provisions or this permit shall be deemed revoked. AIR HANDLING UNIT(TO 10=12-F.M.) 4.00
CONSTRUCTION LENDING AGENCY AIR HANDLING UNIT(OVER 10MC.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
3097,0,C.). H EATI NG UNIT(TO 100,000 B.T.U.) 8.00
Lender's Name
Lender's Address HEATING UNIT(OVER 100,000 B.T:U.)9.50 ' ELECTRIC 30 �
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, and BOILER-COW(3 H.P.or 100,000 B.T.U.) 6.00
hereby authorize representatives of this city es enter upon the BOILER-COMP (Over 100,000 BTU)SEE FEE SCH. MECHANICAL
hereby entioned properly forinspofth i purposes.
(we) agree to sive, indemnify and keep hamiless the City of MISC.- REFER TO ORD.
Cupertino// mn liabilities,judgments costs and expenses which PERMIT ISSUANCE CONST.TAX
may inony way accrue vgains['mW sty in consequence of the 10.00
grants I- nli, ' // n MECH.CONT. LIC.NO. MECH. -
a Itl fl D� TOTAL TOTAL
Su naturc�t Apphcvnt Contractor Date
• OFFICE COPY