09891 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT.PEN ONLY
BUI LDI NG PROJECT I DENTI FICATION PERMIT NUMBER
a111LDING ?SJL NILC�4ay0 _ Y PA APPLICATION & PERMIT
goOR Ess 09891
NP TNO ' BUILDING —ELECTRICAL—PLUMBING—MECHANICAL
OWNER'S
NAME - PLAN CHECK VALIDATION
0 QTELECTRIC PERMIT FEE
r A P PHONE -9 t Y.
CONTPpCTOP'S
NAME; 'OUTLETS-SWITCHES-RECEP 10.00/1.00 '-
' LID.NO, LIGHTING FIXTURES 10,00/1.00 C`
nooeess TORS PPLIANCES-RESIDENTIAL 4.00
PHONE PANELS 10.00 DATE OF APPLICATION
ENGINEER
OR _ • PANELS (OVER 200 AMP) 20.00 PLAN CHECK FEE P.C.NO.
-LIC.NO. SIGNS TRANS. 3.00
ARCH.OR ENG.
ADDRESS SPECIALCIRCUIT 5.60 PERMIT VALIDATION
ZIP TEMP.METER OR POLE INS. 20.00
ADDRESS Ts MOTORS
EE SCH. /A'` L-OZJ/—•`^—
SERVICE CHANGE . 20,00
'02 LICENSED CONTRACTORS DECLARATION TEMP.POLE Is 1980,00 Q
�� s��
¢2< o I heiehy(commencing with
that I am licensed under provisions of Chapter 9 , ISS ANCE D TE
y PrsioswithSection 700e is
fill force
of theect, as and BLDG. ELECT. PLG. MECH.
H y z Professions Code;and my license is in full force and effect. . �.�
0 z
!-A o License Class T_Le.Number - ❑ �I El 1:1m H j
Date Contractor G� p/ L^F-
¢ M w ¢ OWNER-BUILDER DECLARATION / p BUILDING PERMIT
°
A,
p w I hereby affirm that I am exempt from the Contractor's License M ISG.— INFORMATION
a- REFER TO O
Hu O¢ Law for the following reason.(Sec. uires a,Businessand Professions _ VALUATION $/FT.
PERMIT ISSUANCE 10.00
ar M 4 0 Code: e,dem y demolish,
countypair any structure,
requires prior t o construct,uanc ,fter,also Q
¢ rt ¢ D improve,demolish,or repair any structure,prior to its issuance,also ELEC.CONTR. LIC.NO.
ELEC.
C
u. requires the applicant for such permit to file a signed statement that TOTAL 3 - PERMIT TO
o. w m m he is licensed pursuant to he provisions of the Contractor's License
HiQ Law(Chapter 9(commencing with Section 7000)of Division 3 ofthe -
4 D Business and Professions Code)or that he is exempt therefrom and CITY. PLUMBING PERMIT FEE � 'i
¢ H m the basis for the alleged exemption.Any violation of Section 7031.5
i b STORIES TYPE CONSTR.
; � by applicant for penalty ALTER-DRAIN VENT-WATER
oC'nyt more than Cive hundred dollars(8500).): (EA.) 5.00
y� 1,as owner of the property,or my employees with wages as BACK FLOW PROTECT.DEVICE 4.00
their sole compensation,will do the work,and the Structure is not OCC.GROUP RES.UNITS-
intended or offered for sale(Sec. 7044;Business and Professions DRAINS-FLOOR,ROOF,AREA,COND. 5.00
w
Code:The Contractor's License Law does not apply to an oner of
property who builds or improves thereon,and who docs such work FIXTURES-PER TRAP 5.00 56 FT.FLOOR AREA TOTAL ACREAGE
himself or through his own employees;provided that such improve-
mentsarenmintendedorofferedforsole.If,however,the building GAS-EA.SYSTEM-11 NC.4 OUTLETS 6.00 '
or improvement is sold within one year of completion,the owner- GAS-EA.SYSTEM-OVER 4 IEA.) 2,00
builder will have the burden of proving'that he did not build or im- BUILDING USE
prove for purpose of sale.l.- INDUSTRIAL WASTE INTER. 30.00 • RES'. IND CON PB Drhe,
O d as owner of the property,ainhe exclusively contracting with 0 0 ❑ 0 0
licensed contractors to construct the project(Sec.7044,Business LAWN SPR INKLERS-1 INC 5 V.B. 6.00 ASSESSORS PARCEL NO.
and Professions Code:The who
Contractor's License Law does not apply
to tr owner of property who builds tr improves thereon,and who LAWN SPRINKLERS-OVER 5(EA.) 1.00
contracts for such projects with a colitractor(s)licensed pursuant to
the Contractor's License Law. L' SEWER-SANITARY-STORM EA.200ft/10.00 TRACT NO, PARCEL No.
rca❑1 lamexemptunder Sec. TOY7 .BAP.C.for this WATER HEATER W/VENT ' 6.00
owner - Uae/ WATER SYSTEM 5.00 I
ACC.DATE- ACC.FILE NO.
WORKERS'COMPENSATION DECLARATION WATER TREATING EQUIP, 5.00
I hereby affirm that I have a certificate of consent to self-insure, -
or a certificate of Workers'Compensation Insurance,or a certified ZONING ENG.SITE NO.
copy thereof(Sec.3800,Lab.C.).
Policy No. Company
O ❑ Certified copy is hereby furnished.
Z Z ❑' Certified copy is filed with the city inspection division. FIRE SPRINK ENERGY T-24
Applicant MISC.- REFER TO ORD. y' N❑ Y0 N[:]
� T CERTIFICATE OF EXEMPTION FROM WORKERSPERMIT ISSUANCE IOc, FLOOD ZONE q.L.u.c.
CLo> COMPESION(This section need not be comple ed Rif heSUANCtpermit is for one PLG.CONTR. LIC.NO. TOTAL Y[' N V N
CL
:3 Z hundred dollars IS 100)ml )
rIessJ
U O 1 certify that in the performance of the work for which this per. CITY MECHANICAL PERMIT FEE FEE SUMMARY
LL U, mit is issued,I shall not employ any person in any manner so as to
become subject to the Workers'Compensation Laws of California.
Ua Date Applicant ALTER OR ADD TO MECH. 5.00
BUILDING
} IL NOTICE TO APPLICANT: If,after making this Certificate of Ex-
F ? emption,you should become subject to the Workers'Compensation App LIANCE 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 AIRHANDLINGUNIT(OVER 10,00DC.RM.) 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,Civ.CJ. . HEATING UNIT(T0 100,000 B.T.U.) 6.00
Lender's Name
Lender's Address HEATING UNIT(OVER 100,000 B.T.U.)9.50 ELECTRIC —:t
I certify that I have read this application and state that Ile 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-COMP(3H.P.or100,0008.T.U.) 6.00
hereby authorize representatives of his city to
enter upon the BOILER-COMP (Over 100,000 BTU)SEE FE E 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 -
grant f his aif MECH.CONT. LIC.NO. MECH,
C
TOTAL TOTAL
S' ature of Eli ontractor at
OFFICE COPY