09827 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
BUILDING PROJECT IDENTIFICATION PERMIT NUMBER
BUILDING APPLICATION & PERMIT.
ADDRESS BUILDING rnd
0982
I OWNERS PLAN CHECK VALIDATION
NAME OTY. ELECTRIC PERMIT FEE
Ae,w (,t PNONE
\ CNAMEONTRACTORS r UTLETS-SWITCHES-RECEP 10.00/1.00 TO
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POS A:kL%6!t1J Ki,. LIC.NO. DI} LIGHTING FIXTURES 10.00/1.00
aooae`ss ioRsQ APPLIANCES-RESIDENTIAL 4.00
/I 5-�c'k�a� PHONE -Y741 PANELS 10.00 DATE OF APPLICATION
ORRCRIiEci PANELS (OVER 200 AMP) 20.00 PLAN CHECK FEE P.C.NO,
ENGINEER
LIC.NO, SIGNS TRANS. 3.00
ADDRESS ENG. SPECIAL CIRCUIT 5.00
PERMIT VALIDATION
ZIP ITEMP.METER OR POLE INS. 20.00
ADURESr
Ns MOTORS SEE FEE SCH. /J
SERVICE CHANGE 20.00
w o o LICENSED CONTRACTORS DECLARATION TEMP.POLE 30.00 /y'
<U w 1 hereby affirm that I am licensed under provisions of Chapter 9 6 ISSUANCE DATE
h Z aa (commencing with Section 7000)of Division 3 of the Business and / BLDG. ELECT. PLG. MECH.
H 7 Z Professions Co a and my license is in full for c 7� f( c. ❑ ❑ ❑
2 0'x - License Class- ContraNumber-�1L y�
o m F� Date_' Contractor � (�
¢ M s < r BU D NG PERMIT
¢ Ic ¢ OWNERBUILDER DECLARATION
M
a u 1 FORMATION
X g N 1 hereby affirm that I am exempt from the Contractor's License MISC.- EFER TO ORD
u o ¢ Law for the following reason.(Sec.7031.5,Business and Professions VALUATION $/FT.
r - PERMIT ISSUANCE 10.0016
wt0 Code:Any city orcounty which requires a permit o construct,alter,
re S, ¢Q improve,demolish,Dr repair any structure,prior to its issuance,also ELEC.CONTR. LIC.NO. ELEC.
e. /J��
0 LL requires the applicant for such permit to file a signed statement that TOTAL/1 PER IT TO
E:
m he is licensed pursuant to the provisions of the Contractor's License
I- Z >
Law(Chapter 9(commencingwith Section 7000)of Division 3 ofthe
i i o Business and Professions Code)or that he is exempt therefrom and QTY. PLUMBING PERMIT FEE I�h Iii
W
H $ the basis for the alleged exemption.Any violation of Section 7031.5 D S TYPE CONSTR.
d3 - by any applicant for a permit subjects the applicant on civil penalty ALTER-DRAIN -WATER (EA.) 5.00
of not more than five hundred dollars(S500).1:
❑ I,as owner of the property,or my employees with wages as BACK FLOW PROTECT.DEVICE 4.00 DCC.GROUP RES.UNITS
their sole compensation,will do the work,and the structure is not
intended or offered for sale (Sec. 7044, Business and Professions DRAINS-FLOOR,ROOF,AREA,GOND. 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
• himself or through his own employees,provided that such improve.
ments are not intended or offered for sale.IG however,the building GAS-EA.SYSTEM-11NC.40UTLETS 6.00
or improvement is sold within one year of completion, - . -OVER 4 IEA. .00 the owner- GAS EASYSTEM ) 2
builder will have the burden of proving that he did not build or am, BUILDING USE
prove for purpose of sale.). INDUSTRIAL WASTE INTER. 30.00 RE5 IND GN PB Omer
C] 1,as owner of the property,am exclusively contracting with11 1:1
licensed contractors to construct the project(Sec.7044,Business LAWN SPO INKLER$-1 INC 5 V.B. 6.00 ASSES50 5 ARCEL NO.
El El
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 projects with a contactor(s)licensed pursuant to SEWER-SANITARY-STORM EA.200ft/10.00
the Contractor's License Law. TRACT NO. PARCEL NO.
❑ lam exempt under Sac,.,B.&P.C.for this WATER HEATER W/VENT 6.00
reason
Owner Data WATER SYSTEM 5.00 ACC.DATE ACC.FILE N0,
WORKERS'COMPENSATION DECLARATION WATER TREATINGEQUIP. 5.00
1 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(See.3800,Lab.C.).
Policy No. Company
❑ Certified copy is hereby furnished. FIRE SPRINK ENERGY TP4
Z Certified - py is aed ith the cit Insp trio. division.
F O Applicant-P, ;L �'.ay .- MISC.- REFER TO ORD. Y � NE] Y ❑ N[]
� N C.R'TIFICATEOFEXE 'TION'TION FROM RS' PERMIT ISSUANCE 10.00 FLOOD ZONE A.L.U.C.
0- >
(This section need not beTION complle cd Rf heLpermil is for one PLG.CONTR. LIC.NO. TLOG.TALY N Y Nr]ao
Z hundred dollars US 100)or less.)
U O 1 certify that in the performance of the work for which this per- QTY MECHANICAL PERMIT FEE FEE SUMMARY
LL U mil is issued,I shall not employ any person in any manner so as to
Q
become subject to the Workers'Compensation Laws of California.
LU Date Applicant ALTER OR ADD TO MECH. 500 BUILDING
>_ N NOTICE TO APPLICANT: If,after making this Certificate of Ex- .
emplion,you should become subject to the Workers'Compensation APPLIANCE 5.00 PLAN CHECK
provisions of the Labor Code, you must forthwith comply with FEE
C.1 such provisions or this permit shall be deemed revoked. AIR HANDLING UNIT(TO 10,000C.F.M.) 4.00
CONSTRUCTION LENDING AGENCY AIR HANDLING UNIT(OVER 10DWC.EM.) 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.C.). HEATING UNIT(TO 100,000 B.T.U.) 8.00
Lender's Name
Lender's Address HEATI NG UN IT(OV ER 100,000 B.T.U.)9.50 ELECTRIC w
I certify that 1 have read this application and state that the oVENTILATION FAN (SINGLE) 4.00
information correct I agree tcomply with all city and countyunty PLUMBING
ordinances and store 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 In enter upon the BOILER-COMP(OWI,100,000 BTUI SEE F EE SCH. MECHANICAL
above-mentioned property for inspection purposes.
(We) agree to Save, indenmit'y and keep harndess the City of MISC.- REFER TO ORD.
Cupertino against liabilities,judgments, costs and expenses which PERMIT ISSUANCE 10.00 CONST.TAX
may in any way acer a against said City in coijisequence of the
granlingof[h' p i O MECH.CONT. LIC.NO. MECH.
TOTAL TOTAL G
Signature of Applicant/Contractor A Date
' OFFICE COPY