09896APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
BUI LDI NG PROJECT I DENTI FICA-10ON >
PERMIT NUMBER
APPLICATION & PERMIT
BUI LDING - ELECTRICAL- PLUMBING - MECHANICfi [_
09896
BUILDING
noon Ess
76
OWNER'S
NAME
OTY. ELECTRIC PERMIT FEE
PLAN CHECK VALIDATION
1
JffR6WAPNONE
CONTE croR
NAME
UTLETS-SWITCHES -RECEP 10.00/1.00
LIGHTING FIXTURES 10.00/1.00
sec. rvo. .2
CONTRA
ADDRESS oR's
PPLIANCES- RESIDENTIAL 4.00
PANELS 10.00
N 6_1 PHONE
DATE OF APPLICATION
ARCHITECT I
OR
ENGINEER
sec. No.
PANELS (OVER 200 AMP) 20.00
PLAN CHECK FEE P.L. NO.
ISIGNS TRANS. 3.00
ARCH. OR
DDRESS ENG.
SPECIAL CIRCUIT 5,00
PERMIT VA LI DATION
TEMP. METER OR POLE INS. 20.00
. ZIP
�1
/
APPLICANT'SDDRESS
ADDRESS
MOTORS SEE FEE SCH.
SERVICE CHANGE .00
LICENSED CONTRACTORS DECLARATION
TEMP. POLE 30.00
(p 9Q.
I hereby affirm that I am licensed under provisions of Chapter 9
ISSUANCE DATE
(commencing with Section 7000) of Division 3 of the Business and
Professions Code, 6,1y license is in full for a f
License Class �,� Lic. Number
Contractor _�/F� (/�IdI-N
BLDG.
❑
I ELECT. I
PLG. MECH.
❑ ❑
City of Cunerti o
BUILDINGINFORMATION
OWNER-BUILDER DECLARATION
1 hereby infirm that I am exempt from the Contractor's License
Law for the following reason. (Sec. 7031.5, Business and Professions
Code: Any city or county which requires permit to construct, alter,
improve, demolish, or repair any structure, prior to its issuance, also
requires the applicant R r such permit to file a signed statement that
he is licensed pursuant to the provisions DI the Comractor a License��
Law (Chapter 9Commencing with Section 7000) of Division 3 of the
Business and Professions Code) or that he is exempt therefrom and
the basis for the alleged exemption. Any violation of Section 7031.5
INFORMATION
MISC.- REFER TO ORD
VALUATION
S/FT.
PERMIT ISSUANCE 10.00 ei'G`
ELEC. CONTE. LIC. NO.
ELEC.
TOTAL 3
PERMIT TO
[[[ Le2
QTY. PLUMBING PERMIT FEE
1
STORIES
TYPE CONSTR.
ALTER -DRAIN & VENT -WATER (EA.) 5.00
by any applicant for a permit subjects the upplicam tea civil penalty
of not more than five hundred dollars ($500).):
❑ I, as owner of the property, or my employees with wages as
their sole compensation, will do the work. and the structure is not
intended or offered for sale (Sec. 7044. Business and Professions
BACK FLOW PROTECT. DEVICE 4.00
OCC.GROUP
RES. UNITS
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
sa FT. FLOOR AREA
TOTAL ACREAGE
himself or through his own employees, provided that such improve -
merits arenot intended oroffered for sale. If, however, tic building
GAS-EA.SYSTEM-111NC.40UTLETS 6.00
or improvement is sold within one year of completion, the owner-
builder will have the burden of proving that he did not build or im'
prove for purpose ofsxle.).
I, as owner of the property, am exclusively contracting with
licensed contractors to construct the project (Sec. 7044, Business
GAS - EASYSTEM -OVER 4 (EA.) 2.00
.
BUILDING USE
RES IND CON PB Ome,
El 13 1:1 El El
INDUSTRIAL WASTE I LATER. 30.00
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 (if property who builds or improves thereon, and who
LAWN SPRINKLERS - OVER 5 (EA.) 1.00
contracts for such projects with a contractor(s) licensed pursuant to
the Contractor's License Law.
SEWER -SANITARY -STORM EA. 200ft/10.00
TRACT NO.
PARCEL NO.
WATER HEATER W/VENT 6.00
❑ lam exempt under Sec. ,B.&P.C. for this
reason
Owner Dale
WATER SYSTEM 5.00
ACC. DATE
ACC. FILE NO.
WORK ERS'COMPENSATION DECLARATION
WATER TREATING EQUIP. 5.00
I hereby Infirm 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. Pony_ 6
FIRESPRINK
v ❑ N ❑
ENERGY T-24
Y ❑ N❑
❑ Certified copy eby (umisli'
iS Certified cop led with the inspection clivi ion.
Applicant
MISC.- REFER TO ORD.
CERTIF.OF E".. PTION FROM WORKERS'
PERMIT ISSUANCE 10.00
FLOODZONE
A.LU.C.
PLG. CONTE. LIC. NO.
PLG.
TOTAL
COMPENSATION INSURANCE
This section real not he completed if the permit is for )Be
Y ❑ N ❑
Y ❑ N❑
QTY. MECHANICAL PERMIT FEE
FEE SUMMARY
hundred dollars IS 100) or lcss.l
1 certify that in the performance of the work for which this per-
mit is issued, I shall not employ any person in any manner so as to
become subject to the Workers' Compensation Laws of California.
Date Applicant
NOTICE. TO APPLICANT: If, after making this Certificate of Fit-
emption, you should become subject to the Workers' Compensation
provisions of the Labor Code, you must forthwith comply with
such provisions or this permit shall be deemed revoked.
BUILDING
ALTER OR ADD TO MECH. 5.00
APPLIANCE 5.00
PLAN CHECK
FEE
AIR HANDLING UNIT (TO 10JWC.F.M.) 4:00
AIR HANDLING UNIT(OVER 10=C.F.1406.00
SEISMIC FEE
CONSTRUCTION LENDING AGENCY
EXHAUST HOOD (WITH DUCT) 5.00
MICROFILM
I hereby affirm that there is a construction lending agency for
the performance of the work for which this permit is issued (Sec.
3097. Civ.C. ).
Lender's Name
HEATING UNIT (TO 100,000 B.T.U.) 8.00
HEATING UNIT (OVER 100,000 B.T.U.)9,50
ELECTRIC
()
Lender's Address
VENTILATION FAN (SINGLE) 4.00
PLUMBING
I Certify that 1 have read this application and state that the above
nl'or Immo is correct. 1 agree to comply with all city and county
ordinances and state laws relating to building construction, and
BOILER-COMPI3 H. P. Dr 100,0008.T.U.) 6.00
BOILER -COMP (Over 100,000 BTU) SEE FEE SCH.
MECHANICAL
hereby authorize representatives of this city to enter upon the
above-mentioned property for inspection
MISC.- REFER TO ORD.
ORDCONST.
TAX
(We) agree to sI ,indemnify and ke City of
*rss
Cupertino against I' tittles, judgments, es which
mayinanyycru,againstsaiCc, of the
PERMIT ISSUANCE 10.00
ECH. CONT. LIG NO.
MOTAL
TOTAL
granting oft mit
Signatu a of Affplicantiggractor V Dale
OFFICE COPY