09643 APPLICANT TO FILL IN INFORMATION W RED LINES - USE BALL POINT PEN ONLY
BUILDING PROJECT I DEN
TI FTI
ICAON PERMIT NUMBER
RDILniNG APPLICATION & PERMIT 09643
AooREsf -yy ING- ELECTRICAL-PLUMBING-MECHANICAL
OwNER'a PLAN CHECK VALIDATION
TNAME QTY. ELECTRIC PERMIT FEE
• / P.ONE
CONTRACTORS JST UTLETS-SWITCHES-RECEP 10.00/1.00
10!01D�OAAD LIC.NO 10A LIGHTING FIXTURES 10.00/1.00
CONTRACTOR'S
ADDRESSDDRESSgPPLIANCES-RESIDENTIAL 4.00
L, PHONE Q0 1 PANELS 10.00 DATE OF APPLICATION
ARCHITECT PANELS (OVER 200 AMP) 20.00 PLAN CHECK FEE D.C.NO.
OR
ENGINEER
LIC.No. SIGNS TRANS. 3.00
AARCH OR DDRESS ENG, SPECIAL CIRCUIT $.QQ PERMIT VALIDATION
ZIP TEMP.METER OR POLE INS. 20.00 PPAIL)APPLICANTS
ADDRESS MOTORS SEE FEE SCH. AUG 2
SERVICE CHANGE 20.00 1985
w o O LICENSED CONTRACTORS DECLARATION TEMP.POLE 30.00 /z{sf p{ ��p r{
¢ is u I hereby affirm that I an licensed under provisions of Chapter 9 y�b'3UXUM0EIIno
HG w (commencing with Section 7000)of Division 3 of the Business and BLOC. ELECT. PLG. MECH.
H
n , Professions Codedn)ply license is in full for • ,d f y ❑ ❑ ❑
z: o m - License Class V Lia Number
Q Zr w Uatc �aCnntractor .�Q..
BUILDING PERMIT
¢ ¢w a OWNER-BUILDER DECLARATION - INFORMATION
DA " MISC.- REFER TO ORD
a N I hereby affirm that I am exempt from the Contractor's License VALUATION $/FT.
F .. o a Law for the following reason.(Sec.7031.5,Business and Professions PERMIT ISSUANCE 10.00
Code:Any city oreounly which requires a permit to construct,alter,
or ¢Q 2O improve,demolish.or repair any structure,prior to its issuance,also ELEC.CONTR. LIQ NO. ELEC.
- O 001 1
u requires the applicant for such permit to file a signed statement tlul TOTA
v w$ lie is licensed pursuant to the provisions of the Contractors License PERMIT TO
H z i Law(Chapter 9(commencing with Section 7000)of Division 3 of the
- a Business and Professions Code)or that he is exempt therefrom and OTY. PLUMBING PERMIT FEE
¢ = $ the basis for the alleged exemption.Any violation of Section 7031.5 STORIES TYPE CONSTR.
n ; by any applicant for a permit subjects the applicant on civil penalty ALTER-DRAIN -WATER (EA.) $,00
of not more than five hundred dollars($500),):
C 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,COND. 5.00
Code:The Contractor's License Law does not apply to an owner nl
properly who builds or improves thereon,and who does such work FIXTURES-PER TRAP 5.00 SO.FT.FLOOR AREA TOTAL ACREAGE
•
himselforthrough his ownemployees,for
provided that such improve- GAS-EA.SYSTEM-1 INC.4 OUTLETS 6.00
meals are not finis sold or offered for sale.IL however,the budding
or improvement is sold within one year of completion, the owner- GAS-EA.SYSTEM-OVER 4(EA.) 2.00 BUILDING USE
builder will have the burden of proving Thal he did not build or int- IND CON PB Omer
Prove Ivor purpose of tale.). INDUSTRIAL WASTE INTER. 30.00
❑ I,as owner of the property,am exclusively contracting with ❑ ❑ ❑ ❑
licensed cootracmrs to construct the project(Sce. 7044,Business LAWN SPRINKLERS-1 INC 5 V.B. 6.00 gSSE SSORS PARCEL NO.
and Professions Code:The Contractor's License Law does not apply
to an owner of properly who builds or improves thereon.and who LAWN SPRINKLERS-OVER 5(EA.) 1.00
contracts for such pmje cls with a contractorfs)licensed pursuant to
the Contractor's License Law. SEWER-SANITARY-STORM EA.200ft/10.00 VRACT NO. PARCEL NO.
❑ h am exempt under Sec.-.BAP.C.for this WATER HEATER W/VENT 6.00
reason
Owner Date WATER SYSTEM 5.00
PCC.GATE ACC.FILE NO.
WORKERS'COMPENSA'FION DECLARA'T'ION WATER TREATING EQUIP. 5.00
1 hereby affirm that I have a certificate ofconecnt to self-insure.
or a certificate of Workers'Compvuation Insurance.or a certified ZONING ENG.SITE NO.
copy I hereof lSec.3:300,LanyJff C/S�J✓3
Policy N rt Company
❑ Certified copy is hereby furnish cd. FIRE SPRINK ENERGY T-24
Z 2 ❑ Certif ypyjs RI with t • city inspection division. MISC.- REFER TO ORD. ❑ ❑ ❑ ❑
O APPlicani- -7 P r; V N V N
CC rn CERTIPICATE OF EXEMPTION FROM WORKERS' PERMIT ISSUANCE 10.00 FLOOD ZONE A.L.U.C.
W > COMPENSATION INSURANCE PLG.CONTR. LIC.NO. PLG.
CL (This section need not be completed if the permit is for one TOTAL Y[_ NF] Y❑ N❑
CL Z
hundred dollars IS 100)or less.)
U O 1 certify that in the performance of the work for which this per- OTY. MECHANICAL PERMIT FEE FEE SUMMARY
LL F mit is issued.I shall not employ any person in any Conner so as to
U become subject to the Workers'Compensation Laws of California.
n Dare Applicant ALTER OR ADD TO MECH. 5.00 BUILDING
} to NOTICE TO APPLICANT: If,after making this Certificate of Ex-
f- 2 emption,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)X IOC.F.M.) 4.00
CONSTRUC'f1ON LENDING AGENCY AIR HANDLING UNIT(OVER 10DWC.F.M.) 6.00 SEISMIC FEE
1 hereby affirm that there is a construction lending agency for EXHAUST HOOD(WITH DUCT) 5.00
the 3097,Cis.C.). e of the work lirr which this permit is issued(Sec. MICROFILM
HEATING UNIT(TO 100,000 B.T.U.) 8.00
Lender's Name HEATING UNIT(OVER 100,000 B.T.U.)9.50
Lender's Address ELECTRIC
I certify that 1 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-COMP(3 H.P.or 100,000 B.T.U.) 6.00
hereby authorize representatives of this city to enter upon the BOILER-COMP (Over 100,000 BTU)SEE FEE SCH. MECHANICAL
above-mentioned properly for inspection purposes.
(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 awned said City in consequence of the PERMIT ISSUANCE 10.00
gra ling f permit. MECH.CONT. LIC.NO. MECH.
40,111 �� TOTAL TOTAL
Signat�ureX/of�pplicant/Contractor Date 711.
OFFICE COPY