8935 ^It PPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
17UILDING PROJECT IDENTI FICA Y gppL'ICATION & PE
PERMIT NUMBER
aU1L G
AOa
BUILDING-ELECTRICAL-PLUMBING-MECHANICAL 8935
OWNER'b `
NAVE ( PLAN CHECK VALIDATION
�p- QTY. ELECTRIC PERMIT FEE
CONTRACTORS L6 �Fi[
1E CC _ / b fl' UTLETS-SWITCHES-RECEP 10.00/1.00
� /A C.NO. '/' LIGHTING FIXTURES 10.00/1.00
ooeess oRs
a {/(�aL 277 PPLIANCES-RESIDENTIAL r 4,00
6 r d/@ h/Olt(HONE (14. �� PANELS 10.00 GATE OF APPLICATION
ARC ITECT
CR
PANELS (OVER 200 AMP) 20.00 PLAN CHECK FEE
ENGINEER
ARCH.OR ENG. sec.NO. SIGNS TRANS. 3.00
ADDRESS SPECIAL CIRCUIT 5.00 PERMIT VALIDATION
ZIP rrEMP.METER OR POLE INS. 20.00
ADDRESNT'b
ADDRESS MOTORS SEE FEE SCH. ✓/'n�
SERVICE CHANGE
v Mai
'09 LICENSED CONTRACTORS DECLARATION TEMP.POLE 30.00
a I hereby affirm that 1 am licensed antler provisions of Chapter 9 ISSUANCE DATE
N<N (commencing with Section 7000)of Division 3 of the Business and BLDG. ELECT. PLG. MECH.
'_'3 Pboressions Codes a y icense is in full fort and fr et
toyLicense Class l (e Lie.Number -7/0
9 0. Detc�f �,Cantructor �L wy ❑ ❑ ❑
Lr ir w a TOWNER-BUILDER DECLARATION BUILDING PERMIT
3 n N 1 hereby affirm that I am exempt from the Contractor's License MISC.- REFER TO ORD
INFORMATION
woe Law"Any following reason
7031.5,Business and Professions VALUATION
t - � ERMIT ISSUANCE 10.00 S/FT.
F w> f CoCode:Any city or county which requirese permit to construct,alter,
a a 0 O Improve,demolish,or repair any structure,prior[o its issuance,also ELEC:CONTR. LIC.NO. ELEC.
y e u requires the applicant for such permit to file a signed slatemenl that TOTAL PERMIT TO
w m w he is licensed pursuant to the provisions of the Confrnclor's License
> 2 > Law(Chapter 9(cc-on cut with Section 7000)o(Division3of the OL��
< Business and Professions Code)or that Ise is exempt therefrom and DTV. PLUMBING PERMIT FEE /
1-m the basis for the alleged exemPlion.Any violation of Section 703 ad
STORIES TYPE CONSTR.
by any applicant for a permitsubjects the applicant toecivil penalty ALTER-DRAIN -WATER (EA.) 5.00
of not more than five hundred dollars(3500).):
❑ 1,as owner of the property,or my employees with wages as BACK FLOW PROTECT. DEVICE 4.00
It sole compensation,will Jo the work,and the structure is no( OCC.GROUP RES.UNITS
intended or offered for sale(8ec. 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 SO,FT.FLOOR AREA TOTAL ACREAGE
himself or through his own employees,provided that such improve-
nrame are not intended or offered for sale.I L however,the buildingGAS-EA.SYSTEM-1INC.4 OUTLETS 6.00 C
or improvement is sold within one year or 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 sale.). INDUSTRIAL WASTE INTER. 30.00 RES IND CON PB ower
❑ I,as owner of the property,am exclusively contracting with - El 13
licensed contractors to construct the project(See. 7044,Business LAWN SPRINKLERS-1 INC 5 V.B. 600
0 El
and Professions Code.The Contractor's License Law does not apply . ASSESSORS PARCEL NO.
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
the Contractor's License Law. SEWER-SANITARY-ST .200tt/10.00 i
TRACT NO. PARCEL NO.
❑ 1 am exempt under Sec. ,B,&P.C.for this
reason WATER HEATER W/ 8.00
Owner Date WATER SYSTEM OC'= 5.00
ACC.DATE ACC.FILE NO.
WORKERS-COMPENSATION DECLARATION WATER TREATI 5.00
I hereby affirm that I have a certificate ofconsent to self-insure,
or a certificate of Workers'Compensation Insurance,or a certified cuperino ZONING ENG.SITE NO.
copy thereof(Sec.3800,Lab.C.). 1
Policy No, Company
0 ❑ Certified copy is hereby furnished.
ZZ ❑ Certified copy is Ned with the city Inspection division. FIRE SPRINK ENERGY T-24
_ Applicant MISC.- REFER TO ORD, v N� v NE]
CERTIFICATE CERTIFICATE OF EXEMPTION FROM WORKERS' PERMIT ISSUANCE 10.0()1/0- FLOOD ZONE A.L.U.C.
L COMPENSATION INSURANCE PLG.CONTR. LIC.NO. PLG.
CL o (This section need not be completed if the permit is for one - TOTAL Y❑ NE] I Y [:] NC]
:DZ hundred dollars IS 100)or less.)
U O I certify that in the performance of the work for which this per- DTV MECHANICAL PERMIT FEE FEE SUMMARY
LL U mit is issued,I shgll npl employ any person in any manner so as to
0 W becomery5fsu�b7ry� / I orkers' pe f allfornia,
a Datl!T�. pplicant � ALTER OR ADD TO MECH. 5.00 BUILDING
} W NOTICE TO APPLICANT: If,alter making this Certifica c f Ex-
H ? emption,you should become subject to the Workers'Compensation APPLIANCE 5.00 PLAN CHECK
provisions of the Labor Code, you must forthwith comply with
U such provisions or this permit shall be deemed revoked. AIR HANDLING UNIT(TO 10=r,F.M.) 4.00 FEE
CONSTRUCTION LENDING AGENCY. AIR HANDLING UNIT(OVER 10p00C.F.M.) 6.00 SEISMIC FEE
1 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.). HEATING UNIT(TO 100,000 B.T.U.) 8.00
Lender's Name
Lenders Address HEATI NG UN IT(OV ER 100,000 B.T.U.)9.50 ELECTRIC
I certify that I have real]this application and state Ihat the above VENTILATION FAN (SINGLE) 4.00
information isstateL ir agree to comply with all city and county PLUMBING
ordinances and state lows 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 [he BOILER-COMP (Over 100,000 BTU)SEE FEE SCH.
above-mentioned property for inspection purposes. MECHANICAL
(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 accrue against said City in consequence of the PERMIT ISSUANCE 10.00
gra if of this pertni MECH.CONT. LIC:NO. MECH.
TOTAL . TOTAL
Signature of pphcanl/COolr Date ,
OFFICE COPY