9042 TION`APPLICANT TO FILL IN INFORMAWITH N RED LINES - USE BALL POINT PEN ONLY
:. •
� A
BU I LDING PROJECT IDENTIFICATION PERMIT NUMBER
BUILDING JJ
APWI A ON PERMIBUILDING _
9042
ADDRESS
BUILDING-ELECTRICAL-PLUMBING-MECHANICAL
Ow
NAME PLAN CHECK VALIDATION
^/ TV. ELECTRIC PERMIT FEE
HONI /�
CONTRACTORS
OUTLETS-SWITCHES-RECEP 10.00/1.00
LI�.Ny"L �•,3 LIGHTING FIXTURES 10.00/1.00
APPLIANCES-RESIDENTIAL 4.00
UbPHONr.:A6>' r�J PANELS 10.00 DATE OF APPLICATION
ARCHITECT PLAN CHECK FEE P.C.NO.
E
OR � PANELS (OVER 200 AMP) 20.00 NGINEER
uc.No. ISIGNS TRANS. 3.00
ADDRESS ENG SPECIAL CIRCUIT 5,00 PERMIT VALIDATION
zIP TEMP.METER OR POLE INS. 20.00
APPLICANT'$
ADDRESS MOTORS SEE FEE SCH.
SERVICE CHANGE 20.00 ����////
w o o LICENSED CONTRACTORS DECLARATION TEMP.POLE 30.00 S J'�•G
a v 1 hereby at that I am licensed under provisions of Chapter 9 A/
Q vwAi ISSUA CE DATE
(commencing with Section ]000)of Division 3 of the Business and BLDG. ELECT. PLG. MECH.
0 w z License
c,and m li a sc' In full fort ❑ ❑
2 o,A - License SSV L�Number
o w�a, Date�-I�.+�IContnc[ar _
a a, re a OWNER-BUILDER DECLAR BUILDING PERMIT
' O' U MISC.- REFER TO ORD INFORMATION
w ; w 1 hereby affirm that I am exempt from the Contractor's License
u O a Law for the following reason.(Sec.]031.5,Businessandl'rofessions VALUATION $/FT.
H - PERMIT ISSUANCE 10.00
Code:Any city or county which requirespermit toconstruct,also
0 improve,Jcmolish,or repair any structure,prior to its issuance,also ELEC.CONTR. LIC.NO. ELEC.
ca
DLL requires the applicant for such permit to file a signed statement that TOTAL
w m he is licensed pursuant to the provisions of the Contractor's License PERMIT T
F z a
Law(Chapter 9(commencing with Section 7000)of Division 3 ofthe [�i A
z D Business and Professions Code)or that he is exempt therefrom and DTV. PLUMBING PERMIT FEE / Ld
2 F m the basis for the alleged exemption.Any violation O($edion 7031.5 STORIES TYPE CONSTR.
La; by any applicant for a permit subjects the applicant to a civil penalty
of not more than five hundred dollars(S500).): ALTER-DRAIN&VENT-WATER (EA.) 5.00
❑ I,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,CON D. 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
himselfor through his own employees,provided that such improve-
menu an not intended moffered fee Sale.If,however,the building GAS-EA.SVSTEM-11NC.40UTLETS 6,00
or improvement is sold within one year of completion,the owner- GAS-EA.SYSTEM-OVER 4(EA.) 2.00
builder will h
ave the burden of proving that he did not build or im- BUILDING USE
prove for purpose ofsale.). INDUSTRIAL WASTE 30.00 RES IND CON PB Omer
❑ 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 ASSESSORSPARCEL NO.
and Professionslons Code ThContractor's ontractor's License Law Joos not apply
to anowner of property who builds or improves thereon,and who LAWN SPRIN KL R -•10 1.00
contracts for such projects with a contrador(s)licensed pursuant to
the Contractor's License Law. SEWER-SANITARY-STORM EA.200ft/10.00 TRACT NO. PARCEL NO.
re❑til am exempt under Sec. ,B.&RC.for this WATER HEATER T - >{�nO 6.00
Owner Date WATER SYSTEM ' 5.00
woRRERs'COntPENsnTION DECLARATION WATER TREATING EQUIP. 5.00 ACC.DATE ACC.FILE NO.
I hereby affirm that I have a certificate of consent to self-insure.
or a certificate of WorkeLab.C.)(.C.) gju It
n .mme•,o_ r a yeltifled ZONING ENG.SITE N0.
co ter o�1 �fC/�.Q/
Pa (2l�7anyAlle
❑ Certifi A copy hs hereby turd ed. '
Z Z rt 't( 'v1n. FIRE SPRINK ENERGY T 24
H O pplicun _ ISC.- REFER TO ORD, Y N 0 v N�
� N Cl' F n I � - K, PERMIT ISSUANCE 10.00 p' FLOOD20NE A.L.U.c.
L COMPENSATION INSURANCE PLG.CONTR. LIC.NO. pLc.
0 ('Phis section need not be completed if the permit is for ane TOTAL �. Y E] NE] Y F ry�
U O hundred dollar,IS 100 nosh,sJ
I certify that in the performance ol'the work for which this per- DTV. MECHANICAL PERMIT FEE SUMMARY
LL U mit is issued,I shall not employ any person in any manner so as to FEE
O W became subject to the Workers'Compensation Laws of California.
2 Date.Applicant ALTER OR ADD TO MECH. 5 00 BUILDING
} Va Date i TO APPLICANT: It aHcr making this Certificate of Ex-
F ? emotion,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=11C.F.M.) 4.00 FEE
CONSTRUCTION LENDING AGENCY AIRHANDLINGUNIT(OVER IO,000GRM.16A0 SEISMIC FEE
I hereby afforn 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.
3097,Civ.C.). HEATING UNIT(TO 100,000B.T.U.) 8.00 MICROFILM
Lender's Namz zD
Lender's Address ° HEATI NG UN IT(OV ER 100,000 B.T.U.)9.50 ELECTRIC
I certify that 1 have read this application and state that the above VENTILATION FAN (SINGLE) 4.00
ordinances is state. I agree to comply with all city and county PLUMBING M
ordinances and state laws relating to building ,construction, and BOILER-COMP(3 H.P.or 100,0008.T.U.) 6.00
hereby authorim representatives of this city «m enter upon the BOILER-
abovcmentionedpropertyforinspectionpurposes. COMPIOver 100p008TU1 SEE FEE SCH. MECHANICAL
I (We) agree to save, indemnify and keep harmless the City of MISC.- REFER TO ORD.
Cupertino against liabilities,judgments, costs and expenses which
may in any way accrue against said City in consequence of the PERMIT ISSUANCE 10.00 CONST.TAX
gra 'ng of this penult' MECH.CONT. LIC.NO. MECH.
TOTAL
azure ol'Applicanl/Co ra TOTAL or Date /V\
OFFICE COPY �)