9420 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
BUI LDING PROJECT I DENTI FICATION PERMIT NUMBER
BUILDING APPLICATION & PERMIT A n 0
ADDRESS�j " CE G
/e CN �C BUILDING -ELECTRICAL-PLUMBING-MECHANICAL
HANER'S I PLAN CHECK VALIDATION
/
A5� - CITY. ELECTRIC PERMIT FEE
i' �r 1. RarvE
CONTRACTOR'S
OUTLETS-SWITCHES RECEP 10.00!1.00
yl/ " LIC NO. LIGHTING FIXTURES 10.00/1.00
CONTRACTOR'S PPLIANCES-RESIDENTIAL 4.00
A�DID/R�E[$$/ //��/I�f �
/�] /'f/��II�[.({/a .PRONE PANELS 10.00 DATE OF APPLICATION
6 f314
OR
ARCHITECT
PANELS (OVER 200 AMP) 20.00 PLAN CHECK FEEP.C.NO.
ENGINEER
LIC.No. SIGNS TRANS. 3.00
AARCH,OR DDRESS ENG. SPECIAL CIRCUIT 5.0D PERMIT VALIDATION
ZIP TEMP. METER OR POLE INS. 20.00 }�.�J'
APPLICANT'S PACT� -
ADORBss MOTORS SEE FEE SCH. '
SERVICE CHANGE 20.00 AUG - 51985
'
F 0 o S LICENSED CONTRACTORS DECLARATION TEMP.POLE 30.00
a u U I hereby affirm that I am licensed under provisions of Chapter 9 t gno
N a"' HM
(commencing with Section 7000)of Division 3 of the Business and - BLDG.P-11LG. MECH.
F n i Professions Code .my license is in full forge fate / '
o i m D Licens CISs
Lie.Nundsc 9 - 11
F L F w Date Contractor
a sa E
¢ ¢ a OWNF:R-BUILDER DECLARATION 8DING PERMIT
A a v - INFORMATION
X ;0 y I hereby collo that I sm exempt from the Contractor's License MISC.- REFER TO ORD
r u o J Ialw for the following reason.(Sec.7031.5,Business and ProfessionsPERMIT ISSUANCE VALUATION $/FT.
w� Cade:Any city orcounty which 10.00
requiresa permit to construct,alter, -
¢ ¢¢ improve,demolish,or repair any slructone,prior to its issawncc,also ELEC.CONTH. LIC.N0. ,. ELEC. '
F m , reglllres the applicant for such perinll t0 file a signed statement that TD � PERMIT TO
a. he is licensed pursuant to the provisions of the Contractor's License . i, j
F Z i Law fChapter9(wmmencing with Section 70007 of Division the •(If/IJ/"�/�J/v/i`]
a Business and Professions Code)or that he is exempt therefrom and CITY. PLUMBING PERMIT FEE
al
f Z D
¢ 1- $ the basis for the alleged exemption.Any violation of5ection 7031.$ 1 STORIES TYPE CONSTR.
n ; •- by any applicant for a permit subjects the applicant to a civil penalty ALTER-DRAIN (EA.) 5.00
of net more than Ove hundred dollars(S500).):
❑ I,as owner of the property,or my employees with wages as BACK FLOW PROTECT. DEV ICE 4.00 OCC.GROUP RES.UNITS
their sole compensation,will do the work,and the structure is not
intended or offered for sale(Sec. 70.19, Business and Professions DRAINS-FLOOR,ROOF,AREA,COND. 5.00
Code:The Contractor's License law docs 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 TOTALACREAGE
himself or through his own employees,provided that such improve. -
meatsarenotintendedorofferedfo,sale.If,howeveD tilehuilding GAS-EA.SYSTEM-11NC.40UTLETS 6.00
or improvement is sold within one year of completion,the owner-' GAS EASYSTEM OVER IEA1 200 BUILDING USE'.
builder will have the burden of proving that h - . - . .
e did not build or inn- :IND CON PB other
prove 1,as ofor wner
the p INDUSTRIAL WASTE INTER. 30.00 - ❑ Cl ❑. ❑
- ❑ d as owner of the property,ant exclusively.7044,Bu with
licensed contractors to construct the Project(Sec does not
_ LAWN SPRINKLERS-1 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 forsuch projects with a contractorls)licensed pursuant to SEWER EA.200ft/10.00
the Contractor's License Law. TRACT N0, 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'COMPENSA'I'ION,DECLARATION WATER TREATING EQUIP. - 5.00
I hereby affirm-that I have a carlificatuof consent losel C-insure,. I -
or it ZONING certificate of Workers'Compensation Insurance,or a certified ENG.SITE NO,
copy thereof(Sec.3�X�Cdfwith
li O Cer'turnished. - FIRE SPRINK ENERGY T 2a
Z p ON.pp meert copthe city inspection division. MISC. REFER TO ORD. y N v N
❑ ❑ ❑ ❑
MT ERTIFICATEOF EXEMPTION PROM WORKERS' PERMIT ISSUANCE 10.00 FLOOD ZONE A.L.U.O.
W > COAIPF.NSATION INSURANCE PLG.CONTR. LIC.NO. PLG:
d O (This section need not be completed if the permit is for one TOTAL Y❑ N❑ Y❑ N❑
Z) Z. hundred dollars IS 100)or less.)
U O 1 certify that in the peflOtm ace of the work for which this per- OTY. MECHANICAL PERMIT FEE FEE SUMMARY
U. F mil is issued,I shall not employ any person In any manner so as to
O become subject to the Workers:CompePation Laws of California.
O y Date-Applicant- � ALTER OR ADD TO MECH.' 5.00 BUILDING
} Do NOTICE TO APPLICANT', If,after making-this Certificate Of E.
F. 2 cnlption,you should become subject to the Workers'Compensation APPLIANCE - 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 10,000CF.M.) 4.00
CONSTRUCTION LENDING AGENCY AIR HANDLING UNITIOVER 10=C.F.M.16.00 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.C.). _ - HEATING UNIT(TO 100,000 B.T.U.) 6.00
Lender's Name HEATING UNIT(OVER 100,000 B.T.U.)9.50 '
Lender's Address - ELECTRIC
I certify that l have read this application and state that the above VENTILATIONFAN (SINGLE) 4.00 - • • -
information n correct..[la agree to comply with all city and county PLUMBING
ordinances and state laws relating m building construction,,dandcounty
BOILER-OOMPI3 H.P.or 100,0008.T.U.I '6.00
hereby authorize representatives of this city to enter upon lila
above-mentioned property for inspection purposes. BOILER-COMP Over 100,000 BTU)SEE FEE SCH. MECHANICAL
(We) agree to ave; indemnify and keep harmless the City of MISC.- REFER TO ORD.
Cupertino eg'i habiliti figments, costs and expenses which CONST.TAX
may in any y ace g list id City in consequence of the PERMIT ISSUANCE 10.00 -
ting f S perm) J MECH.CONT. LIC.NO. - MECH.
TOTAL TOTAL
,nature of Applicant/Contractor Uatc
OFFICE COPY